Evidence Based Approach to Cesarean Delivery in the

Evidence Based Approach to Cesarean Delivery in the Obese Gravida

Objectives • • • Name 3 comorbidities associated with obesity in the general population and 2 additional comorbidities associated with obesity in the pregnant population. Name 3 measures that can be taken preoperatively to decrease morbidity during a C-Section Name 2 measure that can be taken intraoperatively to decrease morbidity during a C-Section

Definition of Obesity • • • Definition Obesity Class BMI (kg/m 2) Underweight BMI<18. 5 Normal BMI 18. 5 -24. 9 Overweight BMI 25. 0 -29. 9 Obese BMI 30. 0 -34. 9 Class I BMI 35. 0 -39. 9 Class II Extreme Obesity Class III BMI >40

Epidemiology of Obesity

Epidemiology of pregnant population • • • In one 2007 Californian study (Kim et al) it was found that >40% of women are overweight or obese when initiating pregnancy A 2006 study (Johnson et al) looking at a US database showed 25% incidence of obesity when initiating pregnancy In a 1999 study (lu et al) 25% of women >200 lbs at first PNV o 10% >250 lbs o 5% >300 lbs o

• • • Risks of Obesity in General Population CAD, HTN, hyperlipidemia DM Type II Obesity hypoventilation syndrome, OSA, Asthma GERD Fatty Liver, Cholelithiasis, NASH, Cirrhosis Stress urinary incontinence Venous stasis, DVTs, PEs Hernias Infection (cellulitis, post-op wound infections)

• • • Risks of Obesity in Pregnancy Increased miscarriages GDM GHTN, Pre. E Prolonged hospitalization UTIs Dysfunctional Labor Hemorrhage Increased rates of C-sections Perioperative Risks

Fetal Risks • • Preterm Deliveries Post Term Pregnancy Lower Apgar Scores IUGR Macrosomia & shoulder dystocia NICU admissions neonatal and childhood obesity Congenital malformations (spina bifida, omphalocele, heart defects)

Increased incidence of C/S • • • European prospective study with more than 200, 000 deliveries a BMI >40 was associated with 4 times risk of C/S. Cedergren MI et al Another study C/S for nonobese was 20. 7%, compared with 33. 8% for obese (BMI 3034. 9) and 50% for extremely obese (BMI>35) Wiess JL et al. Increase in Emergent C-Sections. Poobalan AS et al. o Overwieght OR 1. 53

Perioperative morbidities • • Prolonged operative time Increased Blood Loss Fe in PNC o T&C o H/H before OR o • • • Increased risk of thromboembolism o Thrombopyphylaxis Aspiration/Failed intubation Anesthetic Morbidities

Anesthesia Considerations • 75% of all anesthesia-related maternal deaths happened in obese pts o Difficult placement of IV access o Difficult achieving endotracheal airway § Pts more quickly desaturate o Difficulty placing epidural/spinal § Pt can't flex back as well § More tissue to go through § Importance of prophylactic CSE o Aspiration Prophylaxis § Bicitra § Consider NPO in labor

Prophylactic antibiotics • Review of 66 trials showed prophylactic abx reduces risk of infection up to 75%. Smaill et. al (Level A) o Study with bariatric pts showed inadequate abx levels in obese pts receiving 2 g of ancef (Edmiston et al)

Thromboembolic prophylaxis • • • One of the leading causes of maternal death o Occurs more frequently in obese pts SCDs Pre and postoperatively (Level C) If BMI>40 Unfractionated Heparin 500010000 u q 8 -12 hrs o No well designed RTCs to assess risk reduction therefore recommendations is expert opinion (Level C)

Importance of team approach • • • Appropriately trained OR staff Surgical assistant(s) Anesthesiology staff trained in fiberoptic intubation

Equipment • • Bariatric set Alexis retractor Vacuum elastoplast tape or Montgomery straps

What to do with the Pannus?

• • Incision Choice Lack of randomized control studies. Vertical incision 12 fold greater risk of wound complications compared to transverse o Rapid, Easy to extend o • Transverse Incision o Low § warm moist area under pannus • § Cephalad retraction of pannus • o thought to increase risk of infection May lead to cardiopulmonary comprimise Perumbilical/Supraumbilical § Avoid button hole § Avoid using the umbilicus as a landmark

Intraoperative Considerations • • Self retaining retractor o Alexis retractor Fundal pressure often difficult and limited o Have vacuum available

Closure • 1 or 2 delayed absorbable monofilament suture on facia. Fascial stitch should incorporate >1 cm of facia and stitch interval no <1 cm apart o Consider Mass closure (Smead Jones Technique) o • • • Subcutaneous Suture o In a 2004 metanalysis (Chelmow et al)34% decrease in risk of wound complications with subcutatneous sutures when subcutaneous tissue >2 cm (Grade A) Drains o No additional benefit (Grade A) Staples vs subcuticular

Smead Jones Closure

Post operative morbidities • • 10 fold increase in post-operative endometritis Higher rates of wound infection Close inspection of wound o Consider removing staples after discharge in office esp with vertical incision o • • Increased risk of thromboembolism o Encourage early ambulation Postpartum weight retention Encourage breast feeding o Nutrition counseling o Consider bariatric consult o • Higher rates of PP depression o 40% with Class III obesity

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