The perioperative care of a super morbidly obese pregnant woman: a case study.
With over two million people classified as obese in Australia (Grant & Newcombe 2004), the incidence of obese patients is increasing. Furthermore, this figure has more than doubled in the past two decades, and is increasing at a rate unparalleled in the United States of America and the United Kingdom (Grant & Newcombe 2004). Obesity can be defined as a body mass index, or BMI, of >30kg/[m.sup.2], morbid obesity as a BMI of >40kg/[m.sup.2] (Grant & Newcombe 2004) and super morbid obesity as a BMI of >50kg/[m.sup.2] (Abir & Bell 2004). The perioperative care of a super morbidly obese patient presents significant challenges, and these challenges are greatly increased when the patient is pregnant.
A super morbidly obese pregnant woman presented to our hospital, a tertiary referral obstetric and gynaecology centre in Perth, Western Australia. Her weight at booking with the hospital was 230kg (507lbs), giving her a BMI of 75. She was spontaneously pregnant with twins, an occurrence which is not uncommon in obese women (Morin 1998). Due to the breech presentation of twin one, the patient agreed to an elective caesarean. However, she presented at 35 weeks' gestation with preterm premature rupture of membranes, meconium liquor, and in early labour, thus requiring an emergency caesarean. This article will detail the processes and procedures which had to be implemented in order to safely care for the patient during her perioperative experience.
The perioperative process
As our hospital is the only tertiary referral hospital in Western Australia, the patient, to whom I have given the alias of Sally, was obliged to present here for obstetric care. Women who are over the weight of 100kg (220lbs) are automatically referred to our hospital for obstetric or gynaecology care. A multidisciplinary working party was set up in order to discuss how to safely and responsibly care for Sally and her babies. The working party consisted not only of obstetricians, but also anaesthetists, perioperative nursing staff, paediatricians and midwives.
Much of the planning was led by the anaesthetic and theatre nursing staff. A comprehensive care plan was drawn up for Sally. Sally agreed to have an elective caesarean, under epidural anaesthesia. By establishing a controlled manner of delivery, it was envisaged that a safe outcome for Sally and her babies could be achieved. A date was selected. A surgical list was cancelled, in order to have the greatest number of consultant anaesthetists available for Sally's surgery. There were also no other elective caesareans booked on this date, thus ensuring that all necessary obstetric staff would be available. Then, at 35 weeks' gestation, late at night, Sally presented in early labour and with meconium liquor, thus requiring an emergency caesarean.
The staffing in theatre at night comprises only three nurses, an anaesthetist, an anaesthetic technician, and an orderly. Extra staff were therefore required on the night Sally came in. The extra staff comprised two orderlies, the on-call theatre nurse, the clinical nurse manager, two extra anaesthetists (one a consultant), and the on-call anaesthetic technician. The consultant obstetrician on call came in for the surgery. Assisting her were two obstetric registrars, and an oncology consultant surgeon, as progress during the surgery was expected to be slow and difficult.
Sally was transferred from our labour and birth suite to theatre on a bed that accommodates weights of up to 267kg (588lbs). The midwifery staff had inserted a urinary catheter while Sally was on the ward bed, as this would be a difficult procedure to perform once Sally was on the narrow operating table. In theatre, Sally climbed off the ward bed and walked to the operating table, where staff helped to position her for the insertion of the epidurals, the arterial line and the two peripheral intravenous lines. Usually, the women have their epidurals inserted in the anaesthetic rooms while on a trolley, but staff were keen to minimise any necessity to transfer Sally once her epidurals were in situ, hence the need for Sally to be positioned straight onto the operating table. Two epidurals were required because Sally was to have a midline abdominal incision, as this would allow the greatest ease of access during the surgery. The anaesthetic process took almost two hours, and involved all three anaesthetists. An ultrasound machine was necessary to identify the upper level of the iliac crests and the midline of Sally's back, as palpation of the relevant landmarks was difficult.
Once the regional blocks had been tested, Sally was assisted in lying down in the supine position with the help of four theatre staff. An Eschmann T20 operating table had been set aside and placed on charge, in preparation for Sally's surgery. The T20 takes patient weights of up to 300kg (661lbs). The table is only 564mm (22inches) in width, so four side extensions were attached to the table; these were of sufficient width to accommodate the patient, but did not impede access for the surgeons. A specially constructed padded bar was also attached to the left side of the operating table. To prevent aortic compression in pregnant patients the operating tables are tilted to the left, and the patients' legs are strapped securely. For patients of normal weight, the leg strap is sufficient to prevent them from rolling off the table. In the case of Sally, however, this risk was increased. The padded bar prevented this from happening.
The positioning of Sally on the operating table took 10 to 15 minutes. Time was also taken up with careful, safe placement of the surgeons around the operating table. In order to have a good view of the surgical area, the surgeons needed to be standing on two wide platforms, one on top of the other. The instrument nurse had set up her trolley in an adjacent room, so as not to distract the anaesthetists in the theatre. Extra linen was needed in order to adequately provide a sterile field, as the large disposable drape normally used was not big enough. Extra equipment, such as a large Deaver retractor and a deep-bladed Doyen, were also required. The surgery was relatively uneventful but slow, lasting two hours, due to the difficult access. Two live male babies were delivered through a lower uterine segment incision, and transferred to midwifery and paediatric care. Besides using three packets of fat stitch, the closure of the wound was routine.
Postoperatively, Sally was transferred from the operating table to a ward bed with the aid of an AirMatt[R]. This device, which tolerates weights of up to 300kg (661 lbs), had been loaned from Air Movement Technologies, Inc. The AirMatt, once inflated, reduces the need for excessive manual handling of patients, as they can be more easily moved from one bed to another. Sally was taken to the recovery room, where two staff members succeeded in attending to the usual post-caesarean observations. She was then transferred to the Adult Special Care Unit.
The 1999-2000 Australian Diabetes, Obesity and Lifestyle study (AusDiab) has shown that the prevalence of obesity is higher in women than in men (Cameron et al 2003). It is therefore obvious that the incidence of patients presenting to our hospital with elevated BMIs will increase. Obesity is an independent risk factor for adverse obstetric outcomes (Weiss et al 2004). Obese pregnant women have more primary caesarean births and repeat caesarean births than do non-obese women (Morin 1998). There is also an increased risk of epidural failure (Dresner et al 2006). Delivery and operative times are longer, and there is an increased incidence of preterm births (Morin 1998). Postnatally, there are more wound, endometrial and urinary tract infections (Morin 1998).
Despite all this data, there is little documentation regarding the healthcare costs relative to obesity in pregnancy. One French study estimated the cost to be 3.2 times higher for massively obese women than for women of normal weight (Galtier-Dereure et al 1995). In the case of Sally, the cost to our hospital of providing quality obstetric care was significant. As detailed above, nine extra staff members were called in for her operation. Extra equipment, such as the padded bar and side extensions, was purchased or loaned to ensure Sally's safety. Extra instruments were also required for the actual surgery. Postoperatively, Sally stayed longer than normal in the Adult Special Care Unit and the postnatal ward. Her babies required intensive neonatal care in the Special Care Baby Unit. She was also readmitted for 24 hours. Sally's anaesthetic procedures took five times longer, and the operative procedure was over an hour longer than normal.
There is also little data regarding the perioperative care of a morbidly obese pregnant woman in Australia. The clinical nurse manager attempted to acquire information on how other hospitals accomplish satisfactory care of morbidly obese patients or morbidly obese pregnant women. There were extensive searches for adequate hoists that would prevent our nursing staff and orderlies having to manually move Sally once she had had the epidurals inserted. The clinical nurse manager even contacted animal zoos, in order to exhaust all possibilities, to find out how heavy animals are moved. No suitable equipment was found. Manual shifting of morbidly obese patients and large animals appears to be the norm in Australian hospitals and zoos.
There were no TEDS stockings or calf compressors large enough to provide anti-embolic prophylaxis for Sally. As her postnatal care progressed, other logistical considerations arose. Most hospital toilets only support weights up to 160kg (352lbs). Only one room in each postnatal ward at our hospital has a pedestal toilet that is able to accommodate a weight over 160kg. None of the shower chairs would take Sally's weight. The wheelchairs only accommodate a weight of up to 200kg (440lbs). Thus, Sally had to walk to the neonatal nursery to visit her babies. None of the hospital nightgowns would fit Sally--she had to wrap a cotton sheet around her body in order to provide privacy while in theatre.
A de-brief session was held once Sally had been discharged from our hospital. While the staff were happy with the successful outcome of Sally's surgery and hospital stay, many queries were raised regarding the future care of morbidly obese women. It was agreed that written guidelines regarding the morbidly obese need to be set in place, so that there will be no doubts as to how best to care for such women. The team recognised the importance of early bookings of obese women, so that adequate preparation can be made for them and their babies. It was also noted that increased and good communication and collaboration among all team members had contributed to the responsible care of Sally and her babies. The team had also learnt where to access all the necessary equipment, or that which is available in Australia, for the care of an obese pregnant woman. These points, among others, were important ones to include in the written guidelines.
The perioperative care of the morbidly obese pregnant woman is not well documented, despite the huge logistical adjustments that a theatre may have to make in order to accommodate such a patient. This case study details such adjustments, made at our hospital theatre. With these changes, we can now describe a successful outcome for our first morbidly obese pregnant patient, and adequately plan for future such admissions.
Sally has graciously given her permission for her information to be used in this paper. I would like to acknowledge the dedication of all the theatre staff at King Edward Memorial Hospital in Perth, Western Australia, to the task of ensuring a safe and happy outcome for Sally and her babies. I particularly acknowledge the valuable contribution to this article of the following nurses (in alphabetical order): Holly Carney, Jenny Cogin, Pat Davis, Caroline Dufton, Sylvia Hall, Wendy Leeson, Lesa Mackay and Maureen Myles.
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Abir F, Bell R 2004 Assessment and management of the obese patient Critical Care Medicine 32 (4 Suppl) S87-91
Cameron AJ, Welborn TA, Zimmet PZ, et al 2003 Overweight and obesity in Australia: the 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab) Medical Journal of Australia 178 (9) 427-432
Dresner M, Brocklesby J, Bamber J 2006 Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery British Journal of Obstetrics and Gynaecology 113 (10) 1178-1181
Galtier-Dereure F, Montpeyroux F, Boulot P, et al 1995 Weight excess before pregnancy: complications and cost International Journal of Obesity and Related Metabolic Disorders 19 (7) 443-448
Grant P, Newcombe M 2004 Emergency management of the morbidly obese Emergency Medicine Australasia 16 (4) 309-317
Morin KH 1998 Perinatal outcomes of obese women: a review of the literature Journal of Obstetric, Gynecologic and Neonatal Nursing 27 431-440
Weiss JL, Malone FD, Emig D, et al 2004 Obesity, obstetric complications and caesarean delivery rate--a population-based screening study American Journal of Obstetrics & Gynecology 190 (4) 1091-1097
Sheena McChlery, RN, BSc(Hons)
Perioperative Nurse, King Edward Memorial Hospital, Perth, Western Australia
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|Title Annotation:||CLINICAL FEATURE|
|Publication:||Journal of Perioperative Practice|
|Article Type:||Clinical report|
|Date:||Nov 1, 2007|
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