2/9/2015 1 Presented by Stacy Evans, MSN, RN, CMSRN Discuss the prevalence of obesity in the US, affecting our patients, both women and children Identify challenges and potential complications obesity in pregnancy presents Discuss considerations for the pregnant women post Bariatric surgery <10% 10-14% 15-19% 20-24% 25-29% >30 Percentage of Obese people
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Bariatric Considerations in labor and delivery€¦ · Labor dystocia Women who are obese are more likely to go past the normal 40 weeks of gestation Once in labor tend to have slower
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2/9/2015
1
Presented by Stacy Evans, MSN, RN, CMSRN
Discuss the prevalence of obesity in the US, affecting our patients, both women and children
Identify challenges and potential complications obesity in pregnancy presents
Discuss considerations for the pregnant women post Bariatric surgery
<10% 10-14% 15-19% 20-24% 25-29% >30
Percentage of Obese people
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19-25 Healthy
25-30 Overweight
30-40 Obese
> 40 Morbidly Obese
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Multiple influencing factors Balance of calories in vs calories burned
1. Bhoyrul S., Lashock J. The Physical and Fiscal Impact of the Obesity Epidemic: The Impact of Comorbid Conditions on Patients and Payers. .JMCM. 2008 :11(4): 10-17.
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• Studies show society has low respect for morbidly obese.
• Society is not tolerant of obese people--especially women
• 80% of obese individuals report being treated disrespectfully by the medical community
References to weight should be informative, not judgmental
Be aware of your own feelings when caring for these patients
Right size cuff =accurate B/P
Knee-high Compression Devices
Med-Large-Bariatric=
Measure calf for accurate sizeMultiple sizes of adult gowns=
Chose the one that fits
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One Size does NOT fit everyone
300 lbs750 lbs
500 lbs
1000 lbs
Patient Room Chairs
Wall Mounted Toilet 300 lbs
Floor Mounted Toilet: Unlimited
Shower Bench: 300 lbs
Step stool 300 lbs
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To widen bed
-Turn toggle switch,
-Pull out 4 shelves,
-Buckle and zip the
extender mattresses to
sides.
Bed needs to be in
narrowest position to
fit through the doors
Weight Capacity of other EquipmentSt. Luke’s commodes St. Luke’s Walkers St. Luke’s Wheel chairs
Rapid sequence induction, with a rapid-acting muscle relaxant
Fiber optic laryngoscope may be needed
Have difficult airway carts available
LMA or combi tube may be used if unable to intubatein an emergent situation
Trach sizes
External monitoring
Obstructive sleep apnea
Nursing acuity
Moving patient
Equipment
Breastfeeding complications
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Anticipate active management of the third stage of labor:◦ Oxytocin administration
◦ Controlled cord traction
◦ Fundal palpation
Women with a BMI of 30 or more are at greater risk (10x more likely) of postpartum infection such as endometritis (3.4% of obese moms)
Teach your patient to monitor their incision for signs and symptoms of infection or dehiscence
DVT, PE
Hemorrhage
PROS Less fat to transect Less OR time Less wound
breakdown Less post-op pain Less post-op resp
issues
CONS Intertriginous Area
(where skin rubs together)
Less upper abdaccess
More difficult delivery
Pannus retraction
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Pregnant women who are obese have a VTE incidence of 2.5% whereas a non-obese pregnant women has an incidence of .6%
Women who are obese also face a increased risk of recurrent VTE
Macropghages infiltrate the adipocytecauses secretion of inflammatory factors
•Tumor Necrosis Factor α (TNFα)
•C-Reactive Protein (CRP)
•Haptoglobin
•Interleukin-6 (IL-6) Increases with obesity (predictor of T2DM &MI)o Contributes to insulin resistance o Activates hypothamic-pituitary-adrenal axis o Increases lypolysiso Promotes release of endothelial adhesion moleculeso Effects fibrinogen and platelet
Leads to Hypercoaguablity
Blood Clots
PE Symptoms • Shortness of Breath• Chest Pain/ or No Pain
• ↑Pulse
• ↑ Respirations
• Anxiety•↓O2 sats
Prophylaxis• Anticoagulants•Ankle Flexions q 2 hr•SCDs while in bed•Early ambulation
Express the importance for women with a BMI of 30 or more to take additional folic acid to prevent neural tube disorders. 400mcg is recommended
The risk of delivering an infant weighing over 4,000g, or above the 90th percentile (macrosomia) is 1.7-2 times higher for women who are obese or morbidly obese
More than a third of infants weighing over 4,500g have shoulder dystocia, whereas normal weight pregnant women have a 0.2-3% occurrence of this complication
Women who are obese have lower prolactin levels making breastfeeding difficult
Early initiation is important
Refer to a lactation consultant if needed
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Discuss weight loss strategies
Discuss prevention interventions if planning another baby
The IDEAL time for intervention is preconception
Medications
Lifestyle Changes
Physical Activity
Nutrition
Surgery
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Depression55% resolved
Obstructive sleep apnea74-98% resolved
Asthma82% improved orresolved1,
Cardiovascular disease82% risk reduction
Hypertension52-92% resolved
GERD72-98% resolved
Stress urinaryincontinence44-88% resolved
Degenerativejoint disease41-76% resolved
Gout72% resolved
Migraines57% resolved
Pseudotumor cerebri96% resolved
Dyslipidemia, hypercholesterolmia63% resolved
Non-alcoholicfatty liver disease90% improved steatosis37% resolution of inflammation20% resolution of fibrosis
Metabolic syndrome80% resolved
Type II diabetes mellitus83% resolved
Polycystic ovarian syndrome79% resolution of hirsutism100% resolution of menstrual dysfunction
Most deficiencies can be avoided with good compliance to:•Dietary guidelines •Vitamin and mineral supplements
•Yearly blood levels should be evaluated•Adjustments to supplements recommended Chewable supplements
Delay pregnancy 12-36 months following bariatric surgery
Some studies suggest to delay pregnancy based on weight loss instead of a timeframe (i.e. if the patient is able to make it to their goal weight and maintain a stable nutritional balance they may be able to conceive earlier)
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Avoid oral contraception 2 months post surgery due to risk for DVT
Breastfeeding-infants should be monitored closely due to potential for nutritional deficits in post bariatric patients
For patients with a lap band, it is suggested they make an appointment early with their surgeon to discuss removing fluid from their band to allow for normal weight gain and favorable maternal outcomes
Some surgeons do so automatically when a patient is pregnant, others do it based on the need of the patient
Evidence does not suggest a strong relationship between c-section rates and a history of bariatric surgery
If the patient is still obese at the time of delivery, it is the obesity that puts them at risk for a c-section, not the history of bariatric surgery
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Complications related to bariatric surgery have been report in subsequent pregnancies
Surgical complications should be considered in women presenting with nausea, vomiting, epigastric discomfort, abdominal pain, and uterine cramping
Low threshold for surgical intervention if abdominal pain develops in labor
Post partum depression is always something to consider
Patients post bariatric surgery may experience some mood swings due to the extreme lifestyle changes
Always keep post partum depression in mind with this patient population
Sensitivity is critically important with obese patients
Obesity and pregnancy creates various challenges
Patient’s history is important in addition to thorough assessment and evaluation
If your patient is post bariatric surgery, keep in mind the potential complications and considerations