Anaesthetic Management of Obese Parturients: What is the Evidence Supporting Practice Guidelines?

Abstract

Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant women. Various governing bodies have published clinical guidelines for the care of obese parturients. These guidelines refer to two components of anaesthetic care: anaesthetic consultation in the antenatal period for women with a body mass index (BMI) ≥ 40 kg/m 2 and the provision of early epidural analgesia in labour. These recommendations are based on the increased incidence of obstetric complications and the predicted risks and difficulties in providing anaesthetic care. The concept behind early epidural analgesia is logical-site the epidural early, use it for surgical anaesthesia and avoid general anaesthesia if surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the management of labour epidurals in obese women is complicated and that women with extreme obesity require higher rates of general anaesthesia. Anecdotally, anaesthetists view and apply the early epidural recommendation inconsistently and the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies addressing epidural extension ('top-up') in obese parturients would help inform practice, audit of local practice may better answer the question "is early epidural analgesia beneficial to obese women in my practice?".

Obesity and Complications from Neuraxial Analgesia – We Need to Know More

“…The authors report that women with class III obesity were more likely to have regional anaesthesia, with 60.9% of primiparous women with BMI 40–49.9 kg/m 2 receiving epidural analgesia. The significance of this is complex, and likely to be influenced by the practice patterns of the treating anaesthetists, the epidural usage rate in the underlying population, obstetrical, maternal and fetal indications for regional anaesthesia, and preferences of treating obstetricians . Practice guidelines internationally refer to the early insertion of epidurals in women with BMI >40 kg/m 2 , a practice which is supported by expert opinion and known to be adopted by anaesthetists in Australia .…”