guideline for management of pregnancy of women with raised bmi · 3.0 (final) November 2009...

Mangement of women with raised body mass index (BMI) in pregnancy

Raised BMI, Obesity, Pregnancy

Version: 7.0 Authorised by: Clinical Governance Group Date authorised: May 2019 Next review date: May 2022 Document author: Reviewing author:

Dr B Hammersley & Dr Biza Akbar Dr V Hall

Tameside and Glossop Integrated Care NHS Foundation Trust

GUIDELINE FOR MANAGEMENT OF PREGNANCY OF WOMEN WITH RAISED BMI

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VERSION CONTROL SCHEDULE Management of women with raised body mass index (BMI) in pregnancy

Version Number Issue Date Revisions from previous issue

1.0 (final) Sept 2006

1.1 (draft) June 2008 Review and amendment following CNST pilot standards

2.0 (final) August 2008 Ratified

2.1 (draft) January 2009

3.0 (final) November 2009 Ratified

4.0(final) August 2010 Ratified

4.1 (draft) July 2012 Review and amendments following CNST standards

5.0 August 2012 Ratified

5.1 January 2013 Audit Proforma Added

5.2 April 2015 Indications for routine serial growth scanning and new thromboprophylaxis guidance post delivery for BMI>40

6.0 August 2015 Ratified

6.1 October 2016 Review and amendmended to reflect change in practice

6.2 February 2018 Review to reflect change in national guidance

7.0 December 2012 Review following new RCOG Greentop.

8.0 May 2019 Review following new RCOG Greentop.



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INDEX/ TABLE OF CONTENTS INTRODUCTION ........................................................................................................ 4 PURPOSE/RATIONALE/OBJECTIVES ...................................................................... 4

SCOPE ....................................................................................................................... 4 DEFINITIONS ............................................................................................................. 4 DUTIES ....................................................................................................................... 4 GUIDELINE STATEMENT .......................................................................................... 4 THE GUIDELINE ........................................................................................................ 4

GUIDELINE DEVELOPMENT & CONSULTATION .................................................... 8 IMPLEMENTATION .................................................................................................... 8 MONITORING ............................................................................................................ 8 REFERENCES ........................................................................................................... 9 REVIEW ...................................................................................................................... 9

Appendix 1 Antenatal Checklist for women with BMI > 40 or WEIGHT > 120KG ..... 10

Appendix 2 Audit Proforma ........................................................................................... 12



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INTRODUCTION This guideline aims to assist all staff involved in providing care for the pregnant woman with a raised Body Mass Index (BMI). Obesity in women can cause serious pregnancy related complications, but it is a risk factor that can be modified and mitigated to improve birth outcomes.

PURPOSE/RATIONALE/OBJECTIVES This guideline is intended to inform the practice of all midwives and medical staff involved in providing care to the pregnant woman with a raised BMI.

SCOPE This guideline is of relevance to all midwives, medical staff and support workers with involvement in providing care to the pregnant woman with a raised BMI in the outpatient, community and acute hospital setting.

DEFINITIONS Obesity in pregnancy is defined as Body Mass Index (BMI) greater than 30kg/m2 at booking.

BMI NICE Classification

Under 18.5 Underweight

18.5-24.9 Healthy weight

25.0-29.9 Overweight

30.0-34.9 Obese class I

35.0-39.9 Obese class II

40 and above Obese class III

BMI Body mass index FBC Full blood count GDM Gestational diabetes IV Intravenous LMWH Low molecular weight heparin PICO Negative pressure wound therapy dressing VBAC Vaginal birth after caesarean VTE Venous thromboembolism

DUTIES Chief Executive- is responsible for ensuring that guidelines are in place. Director of Nursing- is responsible for ensuring that guidelines are developed. Head of Midwifery/ Lead Clinician- have responsibility for implementation and monitoring of guidelines. All Midwives/ Medical staff are responsible for their own practice, including adherance to guidelines which inform practice and ensure quality of care, and safe practice.

GUIDELINE STATEMENT This guideline will influence the practice of all staff involved in the care of the pregnant woman with a raised BMI. The guideline outlines what is acceptable and appropriate care for these patients.

THE GUIDELINE Pre-Pregnancy Care

All women planning a pregnancy with a BMI > 30 should be advised of the risks



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of pregnancy associated with obesity and encouraged to lose weight before pregnancy.

Women with a BMI > 30 should be advised to take 5mg folic acid supplementation daily starting at least one month before conception and continuing throughout the first trimester

Women with a BMI > 30 should be informed the weight loss between pregnancies to reduce the risk of still birth, hypertensive complications and fetal macrosomia.

Women with BMI > 30 should be advised weight loss will increase chance of successful vaginal birth after caesarean (VBAC).

The role of pre-conceptual vitamin D remains uncertain and should be considered on a case by case basis.

In the Clinic

The antenatal clinic should have a documented environmental risk assessment regarding the facilities to care for women with a BMI > 30

At the Community Booking Appointment

All primiparous women with BMI >30 should be advised to book for shared care and hospital delivery

All multiparous women with BMI < 40 who have no other risk factors can be offered choice of setting for their birth with referal to a consultant unit if complications arise.

Venous thromboembolism (VTE) risk assessment should be performed. At Booking Visit At Hospital

Commence the high BMI checklist for all women booking with BMI over 40 or weight over 120kg.

All women should have their BMI calculated at the booking visit and documented in antenatal notes, the electronic record and on the BMI checklist.

All obese women should be informed of the risks of obesity in pregnancy and given the RCOG patient information leaflet. This should be documented in the case notes.

Advise healthy diet, regular exercise and consider referral to dietician as per the healthy weight protocol.

All women with BMI > 30 either consultant or midwifery led care should be referred to Be Well Tameside (Appendix 1) for healthy lifestyle and weight management advice. An automatic referral form will be generated on Euroking once height, weight and BMI have been calculated and inputted.

All women with a BMI > 30 should be informed that this is an opt out service and if they have any queries regarding the service or referral they should contact the Be Well team directly. Contact details will be provided when the referral is made.

An information leaflet “Looking after Mum and Baby” (Appendix 2) will be provided to all women by the community midwife at the first booking appointment and the patient should be informed about the possible referral if they have a BMI >30 at their hospital booking appointment

Women should be counselled that some forms of chromosomal screening are slightly less effective with a raised BMI.

Transvaginal ultrasound should be considered in women where it is difficult to obtain nuchal translucency measurements.

Women with BMI > 30 should be screened for mental health problems as they are at increased risk.



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If BMI exceeds 40 send a faxed referral to obstetric anesthetists using standard proforma.

All women with BMI > 30 should be offered glucose tolerance test (GTT) at 26 wks.

Consider aspirin 150mg until delivery if any additional risk factors for pre-eclampsia.

Perform thromboembolic risk assessment: If BMI> 30 and three additional risk factors for venous thromboembolism prior to 28 weeks or two additional risk factors after 28 weeks then recommend LMWH. If BMI > 40 this counts as 2 VTE risk factors

If BMI >35 book growth scans at 28/32/36/40 weeks.

If BMI exceeds 50 then transfer antenatal care to the consultant with a special interest in care of women with a high BMI in pregnancy (unless diabetic).

At 20 week visit

Anomaly scan - If on two occasions suboptimal views are obtained for anomaly scan, women should be informed of limitations of scanning with high BMI and no further scans arranged. Do not refer for specialist scan unless additional high risk factors that could raise the risk of fetal abnormality eg family history of cleft lip and face not see.

Advise that all forms of screening are more limited in obese pregnant women. 28 week visit (if BMI >35)

Routine bloods, FBC and Antibody screen.

Growth Scan

VTE risk assessment and prescibe low molecular weight heparin (LMWH) if indicated

Mental Health check 32 week visit (if BMI>35)

Growth scan

VTE risk assessment and prescibe LMWH if indicated

Confirm woman has appointment for anaesthetic review. 36 week visit

Growth/presentation scan

Assess mobility and risk assess for manual handling

Re-weigh if booking BMI >40 – assess need for bariatric equipment (see appendix 2) and manual handling requirements

Discuss anaesthetic care plan with woman and document discussion.

VTE risk assessment and prescibe LMWH if indicated

Mode of delivery should be individualised and should be discussed with consultant obstetrician.

Discuss infant feeding and advise additional benefits of breast feeding if BMI > 30.

Women with a booking BMI 40 kg/m2 for whom moving and handling are likely to prove difficult should have a moving and handling risk assessment carried out in the third trimester of pregnancy to determine any requirements for labour and birth.



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Bariatric Surgery

Women should wait 12-18 months after bariatric surgery before attempting pregnancy

Women who have had bariatric surgery should have consultant led care

Women who have had bariatric surgery should be referred to a dietician for specialist advice

Women who have had bariatric surgery should have a nutritional profile (1 brown bottle) to screen for deficiencies at booking and 28 weeks.

Induction of Labour

Elective induction of labour at term in obese women may reduce the chance of caesarean birth without increasing the risk of adverse outcomes. This should be discussed with each woman on an individual basis.

Where macrosomia is suspected induction of labour may be considered. The woman should have a discussion of the risks and benefits of induction of labour versus expectant management.

Elective Caesaerean section

The decision for a woman with maternal obesity to give birth by planned caesarean section should involve a multidisciplinary approach, taking into consideration the individual woman’s comorbidities, antenatal complications and wishes.

When Admitted In Labour If BMI >40;

Inform Obstetric Registrar on call and anaesthetist on call.

Gain IV access and send Full Blood Count & Group & Save. Consider need for second cannula.

If any doubt regarding presentation perform a portable scan.

If weight > 120kg advise theatre staff that there is a bariatric patient in labour

Women with BMI >40 should have continuous midwifery care with consideration of additional measures to prevent pressure sores.

Give ranitidine 150mg orally 6 hourly

Active management of 3rd stage should be encouraged especially if BMI> 30 If Caesarean Section is performed

If most recent weight greater than 115kg use the hover mattress not the pat slide.

Traxi retractor should be used where there is a large pannus

The fat layer should be closed as a separate layer

If BMI>35 or where there is concern regarding wound infection (GDM, Previous wound infection, poor quality skin or where clinically indicated) a PICO negative pressure dressing should be used with interrupted skin sutures.

Postnatal care

Assuming no contraindications all women with BMI >40 should be offered postnatal thromboprophylaxsis in doses appropriate for their weight for a minimum of 10 days regardless of mode of delivery.

All women who have received ante-natal thromboprophylaxis should continue for at least 6 weeks post natally.

Women > class 1 obesity should be supported to lose weight with appropriate post natal referral where indicated.

Breast feeding rates are low in obese women. Women with BMI > 30 should



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receive advice and support regarding the benefits of breastfeeding Bariatric Equipment Antenatal clinic

5 examination couches with a working load of up to 160kg

1 examination couch with a working load of 225kg

1 standard BP cuffs for arms up to 36.5cm and 2 large BP cuffs for arms up to 46cm

1 bariatric chair with a working load of 160kg, additional bariatric chairs are stored in the basement of the Charlesworth building

Maternity ward (27)

28 Huntleigh 390 electric profiling beds with a working load of 230 kg, 26 have a Huntleigh soft form mattress with a working load of 114kg, 2 have a Huntleigh soft form plus mattress with a working load of 247kg. Additional soft form plus matrresses can be obtained from the store in the Charlesworth basement on request

1 standard BP cuffs for arms up to 36.5cm and

2 large BP cuffs for arms up to 46cm

1 bariatric chair with a working load of 160kg, additional bariatric chairs are stored in the basement of the Charlesworth building

Labour ward

5 Huntleigh Birthrite beds with a working load of 180 Kg, each has a mattress which also have a working load of 180kg

5 Huntleigh 390 electric profiling beds with a working load of 230 kg, 4 have a Huntleigh soft form mattress with a working load of 114kg, 1 has a Huntleigh soft form plus mattress with a working load of 247kg. Additional soft form plus matrresses can be obtained from the store in the Charlesworth basement on request

Theatre table with working load of 450kg and a working load of 275kg in lithotomy

5 standard BP cuffs for arms up to 36.5cm and 3 large BP cuffs for arms up to 46cm

Bariatric chairs are stored in the basement of the Charlesworth building

GUIDELINE DEVELOPMENT & CONSULTATION This guideline has been developed in consultation with members of the Obstetrics & Gynaecology Governance Group, all O&G Consultants and Clinical Leads and other interested parties. National guidance and recommendations have been considered in the development of this guideline.

IMPLEMENTATION A copy of this guideline will be available to all staff in all relevant clinical areas. The guideline will also be available on the Trust intranet site. The relaunch of this policy will coincide with awareness raising sessions for staff within the relevant clinical areas.

MONITORING The guideline will be monitored by governance processes through Committees and Groups outline in the policy as having responsibilities for risk management and through their terms of reference. Where monitoring identifies deficiencies or gaps in the



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implementation or in the policy actions will be taken and improvements made.

REFERENCES National Institute for Health and Clinical Excellence. (2008) Antenatal Care:

Routine care for healthy pregnant women. Clinical Guideline Number 6. London: NICE.

The Association of Anaesthetists of Great Britain and Ireland, Obstetric Anaesthetists’ Association (2005). Guideline for Obstetric anaesthetic services OAA/AAGBI Revised edition 2005. London, OAA/AAGBI. Available at www.aagbi.org and www.oaa-anaes.ac.uk.

Royal College of Obstetricians and Gynaecologists. (2006). The growing trends in maternal obesity. RCOG Press release. Available at www.rcog.org

RCOG Green-top guideline No.72. Care of Women with Obesity in Pregnancy. November 2018.

REVIEW This guideline will be formally reviewed as stated on the title page, or earlier depending on the results of monitoring, audit results, new national guidance or recommended changes in practice.

http://www.aagbi.org/

http://www.oaa-anaes.ac.uk/

http://www.rcog.org/



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APPENDIX 1 ANTENATAL CHECKLIST FOR WOMEN WITH BMI > 40 OR WEIGHT > 120KG

Gestation Actions Signed/date

Booking If gestation is <13/40 increase folic acid to 5mg

Weigh and calculate BMI. If weight >150kg needs bariatric couch.

Discuss importance of weight neutral pregnancy

Give RCOG patient information leaflet

Give looking after mum and baby leaflet

Book GTT at 26 weeks

Refer to Dietician/ Be Well

Refer to Obstetric Anaesthetist if BMI>40

Serial growth scans from 28 weeks if BMI ≥ 35

VTE risk assessment (BMI>40 = 2 risk factors)

Assess for Aspirin 150 mg for PET prophylaxis

Advise screening for chromosomal problems is less accurate

Take blood for nutritional profile if bariatric surgery

Mental Health Screening

20/40

Repeat scan if incomplete, explain may not be complete on rescan.

28/40 VTE risk assessment (BMI>40 = 2 risk factors)

Routine bloods, including nutritional profile if bariatric surgery

USS for growth

32/40 USS for growth

VTE risk assessment

36/40 Reweigh and recalculate BMI

USS for growth, confirm presentation

Document discussion of anaesthetic opinion

VTE risk assessment

If booking LSCS put BMI and weight in theatre book

40/40 USS for growth, confirm presentation

Pre-Op Advise CDS of admission date and need for hover mattress

Confirm availability of mattress, gown, teds and flowtron boots

Booking weight kg 36/40 weight

kg

Antenatal & postnatal prophylactic dose of LMWH Weight <50kg = 2500 units dalteparin Weight 50-90kg = 5000 units dalteparin Weight 91-130kg = 7500 units dalteparin Weight 131-170kg = 10000 units dalteparin Weight > 170kg = 75 units/kg/day dalteparin (maximum dose 18,000 u/day)



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Booking BMI kg/m2 36/40 BMI kg/m2

Equipment Weight (Kg)

Suitable Yes

No

Scan couch scan room 1 180



ANC standard couch 160

ANC bariatriccouch 225

Standard bed 228

Standard mattress 120

Soft form plus mattress 247

Delivery bed 180

Pat slide 115

Theatre trolley 160

Bariatric theatre trolley 300

Standard wheel chair 120

Bariatric wheelchair 160

Management Plan when bariatric capacity of standard equipment is

exceeded.



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Appendix 2 Audit Proforma



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Appendix 3 looking after mum and baby information leaflet

Looking after mum and baby

Patient information Leaflet

January 2019



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It’s always a good idea to eat healthily and look after yourself. Now you’re pregnant, it’s important that you do. To help your baby to fully develop, your growing baby needs nutrients every single day. Choosing healthier foods and looking after yourself during this time will be good for you both. This leaflet will help you understand the things you can do to help you & your baby & lists available services that can support you. Healthy Start Vouchers You may be eligible for the Healthy Start scheme, which provides vouchers to pregnant women and families who qualify. The vouchers can be used to buy milk and fresh and frozen vegetables at local shops or exchanged for free vitamins locally. For more information, speak to your Health Visitor/Midwife or visit www.healthystart.nhs.uk Super Supplements Folic acid can reduce the risks of birth defects such as spina bifida. It is recommended to take 400 micrograms of folic acid each day from before pregnancy up to 12 weeks. If your body mass index is above 30 you should take a much higher dose of folic acid (5mg once a day), which can be obtained by a prescription from a doctor. Vitamin D may help boost both your and your baby's bone and muscle health. We advise taking 10 micrograms of vitamin D daily throughout pregnancy and breastfeeding. What you drink your baby drinks too Your baby’s liver isn’t fully developed until towards the end of pregnancy so even a little bit of alcohol can affect their development. Current guidance recommends not drinking any alcohol during pregnancy to protect your unborn baby. Baby on the way; quit today Giving up smoking is one of the best things you can do for your baby. To help reduce the risk of stillbirth, premature birth & sudden infant death syndrome. It can also lower the risk of ADHD and meningitis in children. It can be difficult to stop smoking, but it's never too late to quit and help is available. Be Well Tameside offer a FREE Stop Smoking service, Tel 0161 716 2000 Foods to Avoid There are some foods you should avoid eating during pregnancy because they could cause food poisoning. The possible presence of bacteria, chemicals or parasites in these foods could harm your unborn baby. Avoid raw or partially cooked eggs, some fish and certain meats. Wash fruit, vegetables and salads to remove all traces of soil. For more information visit the NHS Live Well website: www.nhs.uk/live-well/ Eating for two? It’s a myth that you need to ‘eat for two’ as energy needs do not change in the first six months of pregnancy. Only in the last three months do your energy needs increase by 200 calories per day e.g. 1 banana and fat free yoghurt or 2 slices of whole-grain toast. Baby pounds In the UK there are no formal guidelines to what is an appropriate weight gain during pregnancy. The NHS says most women gain between 22lb to 26lb during their pregnancy. Much of the extra weight is your baby growing, but your body will also be

http://www.healthystart.nhs.uk/



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storing fat, ready to make breast milk after your baby is born. Is gaining too much weight a problem? Being overweight at the start of your pregnancy or putting on too much weight can affect your health. It can increase your blood pressure and increase your chance of other complications such as gestational diabetes and pre-eclampsia which can cause risks for you and your baby. Women with a body mass index (BMI) over 30 may be offered further screening to identify such risks. Strict or crash dieting during pregnancy is not recommended, improving your diet so you have a fit healthy baby and preventing excess weight gain is recommended. If you’re concerned about your weight or any aspect of your health while pregnant, ask your midwife or GP for advice What can I eat? The Eatwell Guide shows the quantities of foods we all should eat for a healthily balanced diet. Top tips include base meals on starchy foods (potatoes, bread, rice, pasta), choosing wholegrain where possible. Eat foods rich in fibre; this will help with digestion and constipation. Eat at least five portions of fruit and vegetables per day. They’ll provide you & your baby with lots of vitamins, minerals & fibre. Eat as little as possible of fried foods, and drinks and confectionery high in sugars and fats. These foods will play havoc with your energy levels. Try to eat 3 meals a day where possible. This bump is made for walking Being active when pregnant will prepare your body for labour. Keep up your normal daily activity or exercise (unless you’ve been advised by your midwife or GP not to exercise) be as active as possible but ensure you stay comfortably hydrated. Where possible try to get at least 30 minutes of moderate intensity activity each day. This can include activities such as swimming or walking. Something that gets you warm & breathing deeper but not breathless or sweating. Keep up a normal, daily routine. If you have not exercised routinely up to now, you



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should begin with no more than three 15-minute sessions a week, increasing gradually to daily 30-minute sessions. Don’t start any new strenuous activity during pregnancy. Time to make changes? Try not to make lots of changes at once. Focus on 1-2 things you can change easily, making further additional changes over time. Help available Be Well Tameside is a FREE service. Health & Wellbeing Advisors are located throughout Tameside to help support and motivate you to make lifestyle changes before, during or after your pregnancy. Ask your GP or Midwife to refer you. Alternatively, you can refer yourself. Tel: 0161 7162000 E-mail:[email protected] Facebook: Be Well Tameside Choose to Change runs a specialised weight management programme for pregnant women with a BMI of 30+. This FREE service is aimed at helping you choose healthy lifestyle choices throughout your pregnancy and beyond. Topics include: The removal of the myth of eating for two during pregnancy, a discussion of nutritional needs pre and post birth and tips for eating healthily on a budget. Speak to your Midwife or GP about a referral. Website: http://www.choose-to-change.co.uk/maternity-services. Alternatively Call: 01204 570 999 or Text: 'BABY' and 'Your Name' to 66777. Further Information This information leaflet has been produced using information from NHS Choices. The below websites will provide you with more information and guidance Start 4Life website: www.nhs.uk/start4life/mums NHS Breastfeeding: www.breastfeeding.nhs.uk NHS Choices www.nhs.uk/chq/Pages/917.aspx?CategoryID=54 NHS Live Well: www.nhs.uk/Livewell/Goodfood/Pages/the-eatwell-guide.aspx NHS Live Well: www.nhs.uk/conditions/pregnancy-and-baby/pages/foods-to-avoid-pregnant.aspx NHS Live Well: www.nhs.uk/conditions/pregnancy-and-baby/pages/pregnancy-exercise.aspx

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/pregnancy-exercise.aspx

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/pregnancy-exercise.aspx

guideline for management of pregnancy of women with raised bmi · 3.0 (final) November 2009...

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