Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery

Abstract

Objective To assess the influence of body mass index (BMI) on the performance of epidural analgesia in labour and the subsequent mode of delivery.Design A retrospective audit of prospectively collected quality assurance data.Setting The delivery suite of Leeds General Infirmary, Leeds, UK. This is a 4500-delivery teaching hospital unit.Population All women receiving epidural analgesia during labour in our unit between April 1997 and December 2005.Methods Epidural recipients were divided into BMI groups according to World Health Organization (WHO) categories and compared for indices of epidural performance and mode of delivery.Main outcome measures Midwife and patient satisfaction scores with epidural analgesia, epidural resite rates, and mode of delivery.Results Data from 13 299 epidural recipients were analysed. Using WHO definitions, 22.8% were of normal body mass, 41.9% were overweight, 31.9% obese, and 3.4% morbidly obese. Epidurals were more likely to fail as BMI increased, as judged by midwife satisfaction scores (P < 0.001) and epidural resite rates (P < 0.01). This trend was not seen for maternal satisfaction scores using the WHO BMI categories. However, if women with BMI below 30 kg/m 2 were grouped together, a significant trend was found (P < 0.01). BMI had no influence on vaginal instrumental deliveries, but caesarean section rates rose from 11.5% in women of normal BMI to 29.2% in the morbidly obese women (P < 0.001).Conclusions Obesity increases the incidence of analgesic failure and the need for resite of epidurals. The caesarean section rate among epidural recipients increases dramatically as BMI rises.Keywords Caesarean section, epidural analgesia, labour, obesity, pregnancy.Please cite this paper as: Dresner M, Brocklesby J, Bamber J. Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery.

Anaesthetic outcomes in obese parturients: the effect of assessment in the high-risk clinic

“…In our series, general anaesthesia was required for only one elective caesarean section in which regional anaesthesia was contraindicated and none for emergencies. In our series, the primary failure rate was 15% which falls in the middle of the range of 2.4-42% reported in the international literature [17][18][19]. The use of epidural analgesia, while high at 69% is, however, not universal and the reason for this is not known.…”

“…This contemporary anaesthetic strategy for obese patients focuses appropriately on minimization of the potential morbidities associated with general anaesthesia by provision of regional anaesthesia but this approach is made challenging by the increased rates of technical difficulty and failure of neuraxial techniques widely reported in this population [17][18][19]. General anaesthesia has been reported in up to 11.7-26% of obese patients requiring caesarean section and increases with greater levels of obesity [17,20].…”

The surgical management of obesity in young women: consideration of the mother’s and baby’s health before, during, and after pregnancy

“…Any anesthesia required for cesarean section is likely to be more difficult for an obese woman because of pathophysiologic changes resulting in decreased functional reserve [51], technical difficulties siting a spinal needle for regional block, and difficult or failed endotracheal intubation for general anesthesia [1,13,48,52]. Obesity also increases the likelihood of failed epidural among women attempting vaginal delivery, with failure rates according to midwife satisfaction scores and need for resite increasing in a linear fashion with increasing BMI [48].…”

“…The increased likelihood of fetal macrosomia (infant birth weight C 4,000 g) in this population [5,28,32,33,36] makes failure to progress in labor due to cephalopelvic disproportion a common indication for emergency cesarean section [5], although findings show fetal distress to be equally responsible in obese women [48].…”

Management of obese pregnancies

“…Bu nedenle hastanın beklentilerine ve mevcut hasta hâli ve doğum yapılacak merkez şartlarına uygun bir doğum planı yapılmalıdır (Tablo 2). Doğum sırasında spinal ve epidural anestezi desteklenmeli fakat obezite nedeni ile anestezinin uygulanmasındaki güçlük ve ağrıyı istenilen düzeyde indirememe gibi zorluklar da göz önünde bulundurulmalıdır (21) . Postpartum zorluklar arasında hemoraji, sezaryen doğumda daha sık görülen yara yeri ayrılması ve enfeksiyonu, artan venöz tromboemboli oranı yer almaktadır (22) .…”