**5. Preparation for cesarean delivery in the obese patient**

Performing a cesarean delivery, primary or repeat, in an obese patient poses certain challenges to the obstetrician and the operative team. These challenges are amplified in the super-obese patient, where maternal weight requires particular preparation for routine surgical issues, such as physical plant or space preparation, and informed consent.

#### **5.1 Physical plant preparation**

Hospital equipment is often not designed for super-obese women. Operating tables, delivery beds, and even scales may have an upper limit weight rating that is lower than the weight of a super obese woman [44]. It is reasonable for a labor and delivery hospital unit to prepare a sufficient number of rooms with the equipment needed to safely labor and deliver a super-obese women, based on the characteristics of the population they serve and the number of deliveries performed. Our institution maintains one room capable of laboring a patient in excess of 500 pounds. The bed has a higher weight rating and is wider, and has hydraulics to assist in mobility should a move to the operating room be indicated. The room also has a lift on the ceiling above the labor bed, which has been instrumental for aiding the super-obese woman in positioning – for example to lift a leg during placement of a Foley catheter. The room is stocked with equipment and supplies necessary to care for an obese patient.

Since obese women carry a higher risk for cesarean delivery and up to a 50% chance of emergency cesarean delivery, preparation of an operating room even when trial of labor is attempted is necessary [44, 45]. If a wide operating room bed is not available, two standard 50-cm width tables can be secured together [44, 46].

**71**

**Table 1.**

*Obesity: Unique Challenges at the Time of Cesarean Delivery*

Transferring the patient from a labor and delivery bed to an operating table and then back to a medical bed or gurney can be difficult and lead to staff injury. Air-assisted mattresses can be placed underneath obese patients to facilitate bed transfers (e.g., Hovermatt®, HoverTech International, Bethlehem, PA, USA). Some of these mattresses can also provide lateral turns to help position patients to prevent aortocaval

Practical considerations for preparation of the operating room for scheduled or emergency cesarean of an obese patient should be part of labor and delivery policy. Supplies, such as extra-large blood pressure cuffs, clothing, and large pneumatic compression devices should be available. Consideration of adequate surgical supplies including long instrument trays and accessible self-retaining retractors (see Section 6.3), as well as pre-operative preparation for anesthetic administration (see Section 6.1) may improve patient safety [48]. A checklist for physical plant prepara-

Nursing care requires particular attention to support the delivery of an obese patient. Nurses require knowledge of how to use specialized equipment, how to

tion for cesarean delivery in the obese patient is presented in **Table 1**.

Bariatric operating table, or two standard 50-cm width tables strapped together securely

Bariatric bed with frame and trapeze (motorized to improve mobility)

Continuous positive air pressure (CPAP) equipment

Extra-large wheelchairs (motorized to improve mobility)

Adhesive straps / Elastoplast tape for pannus management Self-retaining retractors (Alexis-O cesarean, Doyen)

*Physical plant preparation checklist for labor and cesarean delivery in obese patients.*

Large or extra-large blood pressure cuffs Extra-large clothing (gowns, panties) Extra-large pneumatic compression devices

Large or extra-large blood pressure cuffs Extra-large pneumatic compression devices

Emergency cricothyroidotomy kit

Toilet to exceed 500 lb. capacity

**Operating room**

Air assisted mattress

Long instrument tray Large OR strap Long spinal needles Difficult airway cart

Laryngeal mask airway Video guided laryngoscopes

Glide scope

*DOI: http://dx.doi.org/10.5772/intechopen.86085*

compression [47].

**Labor and delivery room**

Bariatric chair Hydraulic lift Air assisted mattress

#### *Obesity: Unique Challenges at the Time of Cesarean Delivery DOI: http://dx.doi.org/10.5772/intechopen.86085*

*Recent Advances in Cesarean Delivery*

Neonatal outcomes also appear to be influenced by maternal obesity at cesarean delivery. Neonatal morbidity, including low 5-minute Apgar scores (<7), umbilical cord arterial pH < 7.2, base excess ≤8 mmol/L, and neonatal intensive care unit admissions are seen more often in obese women who undergo cesarean delivery. Hypotension during spinal anesthesia, and prolonged puncture time for regional anesthesia is more pronounced in obese women, and has been shown to cause lower umbilical cord pH in obese women undergoing scheduled cesarean delivery [40, 41]. Women who are super-obese at the time of delivery have a 20% chance of neonatal intensive care unit admission [26]. There is a twofold odds increase of adverse neonatal event (low 5 min Apgar score, cardio-pulmonary resuscitation and ventilator support <24 h, neonatal injury, or transient tachypnea of the newborn, grade 3, 4 intraventricular hemorrhage, necrotizing enterocolitis, seizure, respiratory distress syndrome, hypoxic ischemic encephalopathy, meconium aspiration, ventilator support >2 days, sepsis and/or neonatal death) in women with super obesity compared to their normal weight controls [42]. Despite the tendency towards earlier cesarean delivery, the inherent delays and slower decision-to-incision and incision-to-delivery times involved in moving obese women to the delivery suite, and in getting the baby out when marked fetal distress is evident may contribute to adverse neonatal outcomes in some cases [43]. However, planned cesarean delivery is not protective against these risks, and suggests an underlying poorly understood biologic etiology may be the source of the increase in adverse neonatal outcomes

**4.3 Neonatal outcomes**

seen in obese women.

and informed consent.

for an obese patient.

**5.1 Physical plant preparation**

**5. Preparation for cesarean delivery in the obese patient**

Performing a cesarean delivery, primary or repeat, in an obese patient poses certain challenges to the obstetrician and the operative team. These challenges are amplified in the super-obese patient, where maternal weight requires particular preparation for routine surgical issues, such as physical plant or space preparation,

Hospital equipment is often not designed for super-obese women. Operating tables, delivery beds, and even scales may have an upper limit weight rating that is lower than the weight of a super obese woman [44]. It is reasonable for a labor and delivery hospital unit to prepare a sufficient number of rooms with the equipment needed to safely labor and deliver a super-obese women, based on the characteristics of the population they serve and the number of deliveries performed. Our institution maintains one room capable of laboring a patient in excess of 500 pounds. The bed has a higher weight rating and is wider, and has hydraulics to assist in mobility should a move to the operating room be indicated. The room also has a lift on the ceiling above the labor bed, which has been instrumental for aiding the super-obese woman in positioning – for example to lift a leg during placement of a Foley catheter. The room is stocked with equipment and supplies necessary to care

Since obese women carry a higher risk for cesarean delivery and up to a 50% chance of emergency cesarean delivery, preparation of an operating room even when trial of labor is attempted is necessary [44, 45]. If a wide operating room bed is not available, two standard 50-cm width tables can be secured together [44, 46].

**70**

Transferring the patient from a labor and delivery bed to an operating table and then back to a medical bed or gurney can be difficult and lead to staff injury. Air-assisted mattresses can be placed underneath obese patients to facilitate bed transfers (e.g., Hovermatt®, HoverTech International, Bethlehem, PA, USA). Some of these mattresses can also provide lateral turns to help position patients to prevent aortocaval compression [47].

Practical considerations for preparation of the operating room for scheduled or emergency cesarean of an obese patient should be part of labor and delivery policy. Supplies, such as extra-large blood pressure cuffs, clothing, and large pneumatic compression devices should be available. Consideration of adequate surgical supplies including long instrument trays and accessible self-retaining retractors (see Section 6.3), as well as pre-operative preparation for anesthetic administration (see Section 6.1) may improve patient safety [48]. A checklist for physical plant preparation for cesarean delivery in the obese patient is presented in **Table 1**.

Nursing care requires particular attention to support the delivery of an obese patient. Nurses require knowledge of how to use specialized equipment, how to


#### **Table 1.**

*Physical plant preparation checklist for labor and cesarean delivery in obese patients.*

adapt ergonomics to prevent staff and patient injury, and preparation for known risks in order to safely care for obese patients undergoing planned or unplanned cesarean delivery [44, 48]. It may even be reasonable to increase nurse to patient ratios in some situations [48].

#### **5.2 Informed consent**

Informed consent for cesarean is best initiated well before the operative day, because of the known increase chance of cesarean in obese women, as well as the particular risks described in section 4. Informed consent obtained during labor is known to be particularly brief, and it is unlikely that obstetricians are able to adequately counsel obese patients about their specific risks at time of cesarean delivery [49]. Lack of informed consent can reinforce a claim of medical malpractice [50]. Discussion that includes culturally sensitive and tailored review of the patients' beliefs about her weight may help improve the environment and her delivery experience, and perhaps even impact her health outcomes [51]. It may be reasonable to address and document informed consent during her routine obstetric care visits, and/or at time of admission to the hospital, well in advance of the actual surgery.

#### **6. Surgical considerations**

Challenges facing the obstetric team do not stop at preparation. The performance of a safe cesarean delivery in an obese patient starts with adequate anesthesia, continues with adaptations of surgical technique, and concludes with optimization of post-operative care.

#### **6.1 Anesthetic considerations**

General anesthesia, epidural anesthesia, and combined spinal-epidural anesthesia are all options for pain control during cesarean delivery in the obese patient. The choice of anesthetic largely depends on the indication for cesarean and the condition of the fetus at time of delivery.

Regional anesthesia puncture times for epidural and combined spinal-epidural may be prolonged in the obese patient, and may even contribute to delays in decision to delivery times seen in obese women [31, 52]. There is a higher chance of regional anesthesia failures needing conversion to general anesthesia, and a higher chance of high block during spinal anesthesia necessitating general anesthesia in super obese women (BMI ≥ 50 kg/m2)) [31, 53]. Still, dose reductions for spinal anesthesia have not been proven beneficial in obese patients [54]. The obese patient is at risk for a higher number of punctures at time of spinal placement, simply due to spinal cord distance from skin [41, 55]. Ultrasound guided regional anesthesia placement has been shown to reduce number of punctures in obese women [56].

The risk of regional anesthesia has to be balanced against the risks of general anesthesia in obese patients, which include an inherent difficult airway, transplacental passage of paralytic or sedating medication, and longer incision to delivery times. Pregnancy itself increases the chance of difficult intubation, and obesity appears to multiply this risk – noted to be as high as 33% [57]. The obese patient is also at risk for aspiration (especially if a difficult intubation is encountered), as well as earlier oxygen desaturation [58].

Surgical positioning with a maternal 10–15 degree left lateral tilt is very important in obese women, as their pannus may compress the aorta or vena cava leading

**73**

**Figure 1.**

*the pannus.*

*Obesity: Unique Challenges at the Time of Cesarean Delivery*

skin incision. A survey of women with BMI ≥ 40 kg/m<sup>2</sup>

**6.3 Surgical techniques unique to obese women**

to hypotension [44]. Obese women also experience more relative hypotension during spinal anesthesia [40]. In addition, the displacement of the pannus to allow

There is insufficient evidence to conclude a particular skin incision is superior in the performance of a cesarean delivery in obese women. Various choices have been reported including vertical supra-umbilical, vertical or transverse infraumbilical, and the traditional Pfannenstiel with taping of the pannus if necessary, see **Figure 1**. Vertical incisions are associated with a higher chance of vertical/classical uterine incision, but a lower chance of low 1 and 5 minute Apgar score in women

no difference in clinical outcomes between Pfannenstiel and vertical skin incisions, and suggested a larger study would have a low chance of finding a difference [61]. Surgeon preferences lean towards a Pfannenstiel skin incision. A study of surgeon preference of incision type on obese patients between Pfannenstiel with or without taping of the Pannus, and vertical in both emergent and non-emergent cesarean delivery, showed the majority preferred Pfannenstiel with taping of the pannus in both cases [62]. Women prioritize safety when it comes to choice of

maternal safety ranked higher in priority over cosmetic outcomes in selection of

Since a superior skin incision has not been clearly shown, it seems reasonable to choose the skin incision based on clinical characteristics of the maternal habitus, and surgeon preference. If a low vertical, or high transverse skin incision is selected in patients with a pannus, care must be taken to ensure the pannus is not transected.

Barrier self-retaining retractors, such as the Doyen or Alexis-O retractor shown in **Figure 2**, may be used to facilitate exposure and reduce the need for additional hands in surgery to provide retraction. This may be particularly helpful in women with a large pannus. The Hook and Doyen retractor apparatus uses hooks and an

*Surgical skin incision choices. A – Pfannensteil, B – Supraumbilical, and C – Infraumbilical. The Pannus is elevated using tape bilaterally on the upper abdomen with gentle cephalad traction and anchored to the operating table. Care must be taken when choosing a lower abdominal incision (A or B) to avoid transecting* 

[59, 60]. A randomized feasibility trial of 91 women showed

showed that neonatal and

for the surgical incision can increase the chance of respiratory distress [44].

*DOI: http://dx.doi.org/10.5772/intechopen.86085*

**6.2 Selection of the surgical skin incision**

with BMI ≥ 40 kg/m<sup>2</sup>

skin incision [63].

to hypotension [44]. Obese women also experience more relative hypotension during spinal anesthesia [40]. In addition, the displacement of the pannus to allow for the surgical incision can increase the chance of respiratory distress [44].
