Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: [Link]/locate/bpobgyn

Intrapartum care and management of

complications in women with obesity
Namiko Aleker, BBiomed Sci, MBBS, FRANZCOG, MPH/TM a,
Boon H. Lim, MBBS, FRCOG, FRANZCOG b, *
a
Staff Specialist in Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin Northern Territory, Australia
b
Senior Staff Specialist in Obstetrics and Gynaecology, Canberra Health Services, Clinical Associate Professor,
Australian National University, Canberra, Australian Capital Territory, Australia

a b s t r a c t
Keywords:
Obesity Pregnant women with obesity are at considerable risk during their
Post-term pregnancy labor and delivery. The aim of obstetric care is the safe delivery of
Intrapartum the baby and the maintenance of good health of the mother while
Induction providing an ongoing support for the family unit. The awareness
Macrosomia and mitigation of risks associated with caring for women who are
BMI
obese is vital in ensuring continued good outcomes. Transfer of
women for labor care, presence of senior staff, bariatric resources,
understanding of the progress of labor with an increase in body
mass index, and preparation for complications are covered in this
chapter.
© 2023 The Author(s). Published by Elsevier Ltd. This is an open
access article under the CC BY-NC-ND license (http://
[Link]/licenses/by-nc-nd/4.0/).

* Corresponding author.
E-mail address: boon.lim1@[Link] (B.H. Lim).

[Link]
1521-6934/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
[Link]/licenses/by-nc-nd/4.0/).
N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

Multiple Choice Questions and Answers

1. Induction of labor in women with obesity

a. Is more common because medical co-morbidities such as pre-eclampsia and diabetes are
more difficult to manage, necessitating delivery
b. Is more at risk of resulting in a Cesarean section compared to a woman of normal weight
who has also undergone an induction
c. Should be undertaken for the same medical and obstetric indications as induction of labor in
a woman without obesity
d. Is more likely to fail in a nulliparous woman compared to a multiparous woman with no
previous normal vaginal deliveries
e. Should be re-considered in favor of an elective cesarean section in a nulliparous woman
with an unfavorable cervix and at 42 weeks gestation

2. Preparation for intrapartum care in a woman with morbid obesity

a. Involves planning for delivery at a tertiary level center from as early as possible in a
pregnancy
b. Should involve consultation with an anesthetist as a general anesthetic will be required for
Cesarean section delivery
c. Does not necessarily need to involve an obstetric consultant as long as the clinical team is
happy with the care provided
d. Transfer to specialist centers for intrapartum care ensures the availability of appropriate
expertise, facilities and equipment
e. Where inter-facility transfer is necessary, this may involve road or air transport depending
on the woman's weight and distance to travel

3. Preparation to care for pregnant women with obesity includes

a. Staff training in manual handling only if required, depending on the woman's weight
b. Operating tables able to support weights above 160 kgs
c. All staff knowing weight limits of equipment
d. Caring for women based on their booking BMI and not re-weighing in the third trimester
e. Ensuring the availability of senior obstetric medical and midwifery staff

4. In pregnant women with obesity

a. Progress of labor may be dysfunctional because of altered uterine contractility

b. Weight gain in pregnancy rather than her pre-pregnancy weight has the greatest influence
on fetal birth weight
c. There is clear evidence to show that obesity is a good predictor of the risk of shoulder
dystocia
d. Only those with gestational diabetes are at risk of having large for gestational age babies
e. Increased anesthetic complications occur because the physical changes in pregnancy are
combined with the limitations associated with obesity

Introduction

The worldwide prevalence of obesity has nearly tripled in the last 40 years. The World Health
Organization (WHO) estimates that in 2016, more than 1.9 billion adults aged 18 years and older had a
Body Mass Index (BMI) greater than 25.0 kg/m2. In these estimates, 40% of women (18 years and over)
were categorized as those with obesity (BMI
30 kg/m2) [1e3].
Once considered a problem for populations in high-income countries, there is increasing data
showing that the prevalence of people with overweight and obesity are now dramatically on the rise in
low- and middle-income countries (LMIC), particularly in the urban setting [1,4]. Worryingly for future

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generations, the vast majority of children with overweight and obesity live in LMIC where the rate of
increase has been more than 30% higher than that in developed countries [1].
A number of observational studies have shown a higher incidence of intrapartum complications
among women with obesity, compared to those with a normal BMI [5]. Ikedionwu et al. showed that
the rate of fetal macrosomia was nearly double in pregnant women who had obesity compared with
those who were in the normal-weight category. This then corresponded to an increased risk of stillbirth
for women who had obesity [6]. The gravity of the situation is highlighted by the 2015 MBRRACE-UK
(Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) review
into maternal deaths, which reported that 30% of women who died had obesity and 22% were over-
weight [7].
There is an assumption that the pregnancy risks associated with excessive Gestational Weight Gain
(GWG) (as defined by the Institute of Medicine, 2009) are similar to those associated with increased
pre-pregnancy BMI. This is not the case as shown by Fayed et al. [8] who demonstrated that although a
larger proportion of women with overweight and obesity had excessive GWG compared to women
with a normal weight, maternal pre-pregnancy obesity compared with excessive GWG was indepen-
dently associated with more pregnancy risks [7]. This chapter focuses on the risks of obesity with most
evidence focused on obesity as measured at pre-pregnancy or early pregnancy time points.
Preparation for labor involves a multidisciplinary approach to care of women with obesity.
Awareness of risks and up to date evidence-based clinical practice are essential in ensuring safe out-
comes and cost-effective use of resources.

Preterm birth (PTB)

Preterm birth is associated with significant neonatal mortality, morbidity and long-term disability
[10]. Obesity increases the risk of iatrogenic preterm delivery related to co-morbidities, such as pre-
eclampsia and gestational diabetes [10e13]. The evidence is not so clear in regards to the risk of
spontaneous preterm delivery in women with obesity. Whilst there is an increased risk of preterm
delivery, mostly due to associated co-morbidities, they are iatrogenic, rather than due to spontaneous
onset of labor [11,13]. Spontaneous onset of labor in women with obesity has been shown to be
associated with an increased risk of premature pre-labor rupture of membranes (PPROM) [10,11]. The
mechanism behind this is hypothesized to be related to the up-regulation of inflammatory cytokines
and the increased risks of genital and urinary tract infections pre-disposing to chorioamnionitis in
women with obesity [14].
More recently, Liu et al. [15] have demonstrated that the risk of PTB differs according to age and
racial/ethnic make-up. Their informative study could explain the inconsistent and inconclusive asso-
ciations in previous study populations. In their study, which looked at over 7 million singleton preg-
nancies in the US between 2016 and 2017, the study populations were analyzed according to age
(<20e24, 25e29, 30e34, 35e39, >40 years) and race/ethnicity (Hispanic, non-Hispanic white, non-
Hispanic-black, other) and then the results were presented according to BMI group (healthy weight
vs obese).
From these analyses, there is no doubt that further research is needed to understand the underlying
mechanisms behind the differing associations between maternal pre-pregnancy obesity and the risk of
preterm birth. There is also the potential to develop risk prediction models for preterm birth, which
consider refined categories of maternal age and race/ethnicity, especially in diverse populations [15]
(see Fig. 1).

Post-term pregnancy

A progressive relationship between increasing BMI and prolonged gestation was demonstrated in a
retrospective study analyzing 9336 births. A total of 28.5% of women with obesity progressed beyond
41 weeks' gestation, compared with 21.9% of women with normal weight (P < 0.001). Women with
obesity also had an increased risk of reaching 42 weeks’ gestation compared with women of normal
pre-pregnancy BMI, with an adjusted odds ratio of 1.69 (95% confidence interval, 1.23e2.31) (Fig. 2) [5]
(see Fig. 3).

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

Fig. 1. Joint association of maternal race or ethnicity and pre-pregnancy obesity status with risk of preterm birth among women
aged younger than 20 years (A), 20e24 years (B),25e29 years (C), 30e34 years (D), 35e39 years (E), and 40 years or older (F).
Reprinted from original article. Liu B, Xu G, Sun Y, Du Y, Gao R, Snetselaar LG, Santillan MK, Bao W. Association between maternal
pre-pregnancy obesity and preterm birth according to maternal age and race or ethnicity: a population-based study. Lancet Diabetes
Endocrinol. 2019 September; 7(9): 707e714. doi:10.1016/S2213-8587(19)30193-7. With permission from Elsevier.

Fig. 2. Survival curves for BMI categories, with delivery as the failure event P < 0.001 for log-rank test.
Reprinted from Am J Obstet Gynaecol, Vol 197 edition 378, Stotland, N. E., Washington, A. E., and Caughey, A. B. Prepregnancy body
mass index and the length of gestation at term. e1-378.e5 with permission from Elsevier

Similar results have been found in other large population-based observational studies [16,18,20].
The results are significant even considering the vast number of women with obesity whose deliveries
are performed electively, either by induction of labor or elective cesarean section, before they reach 40
weeks or beyond (Table 1) [17,20].

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

Fig. 3. Labour curve by obesity status and parity. BMI, body mass index.
Norman SM, Tuuli MG, Odibo AO, Caughey AB, Roehl KA, Cahill AG. Effect of Obesity on the Labour Curve. Obstet Gynecol2012.
Reprinted with permission from Elsevier

The mechanism behind the prolongation of gestation in women with obesity is unclear. Some
authors have postulated that endocrine factors, which may have a role in the initiation of labor, are
altered in women with obesity due to an excess of hormonally active adipose tissue [4].

Preparation prior to labor

Antenatal care of a pregnant woman with obesity involves the preparation of the woman, staff, and
family for the intrapartum and postpartum periods. Accurate documentation of weight at the booking
visit is essential and re-weighing in the third trimester of women with morbid obesity is recommended
to allow appropriate intrapartum planning. The UK guidelines for the management of women with
obesity in pregnancy recommend that women with a booking BMI of 30 kg/m2 or greater should have
an informed discussion about the plan for their labor and birth with a consultant obstetrician, which is
documented in the antenatal notes prior to 36 weeks gestation. The multidisciplinary approach in-
volves not only good obstetric and midwifery care, but careful screening for co-morbidities, such as
gestational diabetes and hypertensive complications, dietary advice and a possible review by the
specialist obstetric anesthetist to identify potential difficulties during the intrapartum period.
Antenatal care for women who are obese should be collaborative and can be integrated into all
levels of antenatal care as long as there are clear guidelines and protocols in place for early referral to
consultant obstetrician led care. For women with a BMI >35 kg/m2, a recommendation should be made
to deliver in a consultant obstetrician led unit although local staffing and resources may not make this
feasible. All maternity units should have a documented environmental risk assessment regarding the
availability of equipment required to care for pregnant women with a booking BMI >/ ¼ 30 kg/m2.
Manual handling assessment in the third trimester using validated scoring tools is helpful for planning

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Table 1
Adjusted odds ratios and 95% confidence intervals calculated for prolonged pregnancy or preterm delivery according to maternal
BMI category at pregnancy booking in comparison to a normal BMI of 20e24.9 kg/m2.

Maternal BMI group at pregnancy booking

Underweight Normal weight Overweight Obese Very obese Morbidly obese

(n ¼ 2087) (n ¼ 9530) (n ¼ 5294) (n ¼ 2051) (n ¼ 707) (n ¼ 303)

Preterm 1.33 1.00 0.81 0.92 0.84 1.25

(n ¼ 907) (1.09e1.62)* (0.68e0.97)* (0.72e1.17) (0.56e1.28) (0.72e0.19)
Term Ref 1.00 Ref Ref Ref Ref
(n ¼ 14 229)
Prolonged 0.75 1.00 1.24 1.52 1.75 2.27
(n ¼ 4836) (0.66e0.85)* (1.14e1.34)* (1.37e1.70)* (1.48e2.07)* (1.78e2.89)*

Values are adjusted odds ratio (AOR) with 95% CI in parentheses. Analyses controlled for the following variables: maternal age,
maternal race, parity, hypertension (pregestational or gestational), diabetes mellitus (pregestational or gestational) and smoking
status. Normal weight and term pregnancy were used as the reference categories.
*An AOR>1 indicates a significantly increased risk of prolonged pregnancy or preterm delivery whereas an AOR<1 indicates
significantly less risk compared with women of normal weight (P < 0.05).
Reprinted from BJOG, Vol 118, Arrowsmith S, Wray S, Quenby S, Maternal obesity and labor complications following induction of
labor in prolonged pregnancy, pp578-588, 2011, with permission from John Wiley & Sons.

prior to admission. Tissue viability issues should also be assessed for women with a BMI >/ ¼ 40 kg/m2
to reduce the risk of pressure sores development. These antenatal preparations, although resource
intensive, ensure effective communication between staff involved in care as well as inform the woman
well and minimize the chances of adverse outcomes [21].

Induction of labor

There is limited data on the outcomes of induction of labor (IOL) in women with obesity in the
preterm setting. On the other hand, there are several large studies, which have shown a relationship
between obesity and an increased incidence of IOL [20,21,25,26,32]. IOL is required more often due to
both the strong association of medical co-morbidities with obesity, such as diabetes mellitus and
hypertension, and increased rates of post-term pregnancies seen in women with obesity. Even when
the presence of pre-eclampsia is adjusted for, compared with normal-weight women, women with
morbid obesity are more likely to be induced, with an adjusted odds ratio of 2.38 (95% confidence
interval 2.17e2.60) [17].
Arrowsmith et al. in a retrospective cohort study of 29,224 women, found that high maternal BMI at
booking was associated with an increased risk of prolonged pregnancy and IOL, and 8,497 women
(29.1%) had their labors induced. As maternal BMI increased, so did the number of women requiring IOL
e 26.2% for normal-weight women, 30.5% for women with overweight, and 34.4% for women with
obesity (Table 2) [21].

Table 2
Mode of labor onset for deliveries at all gestations tabulated according to maternal BMI category at booking (n ¼ 29 224).
Reprinted from BJOG, Vol 118, Arrowsmith S, Wray S, Quenby S, Maternal obesity and labor complications following induction of
labor in prolonged pregnancy, pp578-588, 2011, with permission from John Wiley & Sons.

BMI group Mode of labour onset

Spontaneous Elective cesarean Emergency cesarean Induction

(n ¼ 17 417) section (n ¼ 2568) section (n ¼ 742) (n ¼ 8497)

Underweight (%) (n ¼ 2831) 69.0 4.7 2.1 24.2

Normal (%) (n ¼ 13 231) 64.1 7.4 2.4 26.2
Overweight (%) (n ¼ 7989) 56.9 10.1 2.5 30.5
Obese (%) (n ¼ 3303) 50.5 11.7 3.4 34.4
Very obese (%) (n ¼ 1267) 43.7 13.3 3.0 40.0
Morbidly obese (%) (n ¼ 603) 35.5 16.7 4.1 43.6
Overall (%) (n ¼ 29 224) 59.6 8.8 2.5 29.1

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

Similar experiences were noted in the UK, where less than half of the women with obesity (47%)
were noted to have labored spontaneously and one-third (33%) underwent an IOL. The spontaneous
labor and induction rate in the general maternity population at the same time were 69% and 20%,
respectively [7].
Obesity is associated with high rates of failure of induction, with 5.7% of women with obesity with a
BMI of 30.0e39.9 kg/m2 and 3.9% of women with a BMI greater than 40.0 kg/m2 requiring cesarean
section for a failed induction of labor in one study [30]. In a population-based cohort study of 80,887
women by Wolfe et al. the rate of failed IOL (as determined by delivery by cesarean section) was 29% in
women with a BMI >40 kg/m2, compared with 13% for women with a normal BMI. Factors associated
with failure of induction included nulliparity, lack of a previous successful vaginal delivery, and the
presence of macrosomia [30]. Maged et al. found a higher risk of failure of induction (with resultant
delivery by cesarean section) in women with obesity who had prolonged pregnancies (>41 weeks
gestation) with an odds ratio (OR) of 2.02 relative to women with a normal BMI [25].
As in the non-obese parturient, IOL may be carried out by various methods, such as using prosta-
glandins, cervical ripening balloon catheter, artificial rupture of the membranes, oxytocin infusion, or a
combination of these methods. Ellis et al. in their meta-analysis found that women with obesity
needed higher doses and a longer duration of exposure to prostaglandins to complete labor initiation
as well as higher doses of synthetic oxytocin to complete birth compared with women of normal BMI
[23]. Interestingly, BMI at the time of hospital admission for labor correlated well with unsuccessful
cervical ripening for women with obesity and may reflect a woman's metabolic condition for labor.
The high rate of cesarean section and the morbidity associated with emergency cesarean section in
women with obesity have led to the discussion regarding the consideration of elective cesarean section
in women with morbid obesity who do not labor spontaneously. Wolfe et al. [31] demonstrated the risk
of cesarean delivery increased with elective labor induction at term in nulliparous women with obesity
and unfavorable cervix. It supports the assertion that labor induction is an intervention that each
patient should be fully informed of. In addition, the favorability of the cervix needs to be ensured to
increase the chances of a vaginal delivery following induction [31]. For some women, taking into ac-
count individual co-morbidities, history, and environmental factors, the balance of risks may favor an
elective cesarean section.
The decision regarding mode of delivery should be a multidisciplinary one, taking into account each
individual's obesity class, cervical examination, prior obstetric and medical history, and estimated fetal
weight [30].

Location of intrapartum care

With the increased risks of intrapartum complications, the additional care that can be provided by
delivery in a facility where senior obstetric staff and access to theatre are immediately available should
be considered. Although there is no consensus that pregnant women with class I and II obesity should
deliver in a consultant obstetrician led facility, a further discussion of appropriate birthing facility
should be considered. A policy of planning delivery in a regional specialist or tertiary center, rather than
in a small, rural maternity unit has been recommended [33], as access to appropriate care in labor and
timely assessment by midwives, obstetricians and anesthetists should lead to the prevention of delays
in performing any necessary interventions and improvement of outcomes [8,40].
The Royal College of Obstetricians and Gynaecologists (RCOG) Guidelines on the Care of Women
with Obesity recommends that women with a BMI greater than 30 kg/m2 should be given the op-
portunity to make an informed choice about the place of birth acknowledging that birth in a
consultant-led obstetric unit would facilitate the immediate interventions needed for managing ob-
stetric emergencies [22]. This is supported by the NICE Clinical Guideline, which also recommends
women with a BMI between 30.0 and 34.9 kg/m2 have an individual risk assessment regarding planned
place of delivery [34]. The CMACE report further recommended that women with obesity with a BMI
greater than 35 kg/m2 may not be suitable for entirely midwifery-based care and that these women
give birth in a consultant-led setting [7]. Analysis of worldwide prevalence of obesity indicate that rural
areas and resource poor settings carry the greatest burden [1,35] with low-income households and
poor education status linked to rising trends in obesity [36]. This creates a dilemma that whilst

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recommendations for centralization of care are based on concentration of expertise and physical re-
sources to cater for the women with morbid obesity, the social and financial upheavals associated with
this need to be considered. Although re-location for intrapartum care is a significant burden on the
woman, safety in pregnancy is paramount and appropriate support should be put into place to
minimize this disruption from home life. If a woman is to re-locate for confinement, the timing of this
should be guided by local capacity and arrangements. Inter-facility transfer is best conducted prior to
the onset of labor, in the antenatal period. Transfer can be problematic once labor has established due
to the increased need for, and the difficulties with, monitoring both the maternal and fetal status, as
well as the technical difficulties in arranging appropriate transport for the woman with morbid obesity.

Transfer of obese women for intrapartum care

The rise of obesity in rural and regional settings means that increasingly, medical transport teams
are involved in the transfer of patients with obesity to tertiary-level care. This is an important
consideration for countries like Australia where transfers may involve vast distances. A 2021 cohort
study looking at characteristics of pregnant patients retrieved by the Australian Royal Flying Doctor
Service (RFDS) found that there were higher rates of obesity in this cohort compared to pregnant
patients who didn't require retrieval [32]. Pregnant women with obesity provide especially challenging
logistical and manual handling issues associated with transfers. Beebe et al. [37] identified various
difficulties ambulance crews face when transporting patients with obesity and illustrated methods
used in the US to transport patients with obesity using modified equipment. In Australia, where road
transport may be especially prolonged in remote regions, air ambulance services require referring
centers to document an accurate weight, width at greatest diameter, and mobility status for their
bariatric patients. A patient will fulfill the bariatric criteria if their weight is greater than 110 kgs or they
are 60 cm or more at their greatest diameter. Irrespective of total weight, a patient's width may be the
determining factor in deciding on appropriate transport type. The maximum weight that an aircraft can
carry depends on flying time and other necessary equipment. Depending on the mobility status of the
patient, a case-by-case assessment of the appropriate vehicle and resources used may be needed as
these would be different for stretcher bound patients versus ambulatory patients. With road transport,
difficulties can be experienced even with simple care procedures, such as the use of bedpans, insertion
of indwelling catheters, pressure care, and respiratory care [38]. The importance of early assessment
and planning for early inter-facility transfer is stressed by many studies and guidelines
[21,22,37,39e41]. Extra equipment that may need to be on hand includes the Bariatric Equalizing
Abdominal Restraint (BEAR) device, which aids transport by stabilizing mass and minimizing the side
to side shift of a large mass.

Resources required for obese women in the intrapartum period

Occupational as well as patient health and safety requirements mean that care of women with
obesity necessitates specialized equipment. The implementation of a ‘bariatric protocol’ to identify and
mobilize the necessary equipment and resources is suggested for maternity units caring for the
parturient with obesity [42]. Appropriate delivery suite beds, lateral transfer equipment and hoists for
patient bed transfers, and an operating table with appropriate safe working load are required for the
safe care of such women [22]. When special beds for women with morbid obesity are required, staff
familiarity with these is vital in case a woman needs to be laid flat urgently for resuscitation [7].
The Obstetric Anesthetic Association and the Association of Anesthetists of Great Britain and Ireland
recommend that operating tables in all maternity theatres be able to support a weight of at least
160 kgs with alternative provision for women who exceed this. It also states the maximum weight of
the operating tables available must be made known to all staff involved [43]. The standard modern
operating table can support a weight of 130e160 kgs. Specialized tables available can support weights
ranging from 225 kgs to 360 kgs which also include lithotomy stirrups of appropriate size [44]. Other
equipment such as appropriately sized thromboembolic deterrent stockings (TEDS), large BP cuffs,
large wheelchairs and appropriate ward, bathroom facilities and delivery beds should be available.
Patient positioning and transfer are affected by obesity [40]. Weight limitations of some equipment,

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such as lithotomy poles, may preclude the ready use of lithotomy in some circumstances. Suitable
alternatives, such as Yellofins® Stirrups, Yellofins Elite® Stirrups and the Ultrafins (Allen Medical
Systems, Acton, MA) have a patient weight capacity of 159 kg, 227 kg, and 363 kg respectively and
should be readily available for this reason. Extra staff may also be required to assist in achieving the
lithotomy position, either in the labor ward, or in theatre, especially if a regional anesthetic is being
used. An inflatable air transfer system, such as the HoverMatt® (HoverTech International, Bethlehem,
PA) should be available for use prior to the placement of epidural anesthesia on the labor ward, and in
operating theatres for safe patient transfer [40].
The availability of an ultrasound machine is recognized as a good practice point in caring for the
women in labor who are obese [22]. Due to abdominal adiposity, adequate palpation of the maternal
abdomen to determine fetal presentation can be technically challenging. Determination of the fetal
presentation by the use of ultrasound can itself be difficult in cases of extreme obesity. Ultrasound may
also be required to assist in the visualization of veins in cases of difficult cannulation and is increasingly
being used in the placement of epidural catheters. For regional anesthesia, extra-long spinal and
epidural needles are also necessary. Appropriately sized graduated compression stockings should be
employed at a minimum. Inflatable sequential compression devices should also be considered for use
intraoperatively [42]. When planning for cesarean sections in the patient with obesity, bariatric sur-
gical equipment must be available and various methods to retract a large pannus should be considered.
Consideration of postpartum thromboprophylaxis regardless of the mode of delivery is essential in the
obese parturient [22].
It is a recommendation that senior obstetric, midwifery, and anesthetic staff are available for the
care of women with a BMI greater than or equal to 40 during labor and delivery [22].

Intrapartum monitoring and assessment

Women with BMI greater than 40 kg/m2 should receive one-to-one continuous midwifery care in
established labor [22]. Two attendants should be present for vaginal delivery with consideration to
deliver in the lithotomy position to allow adequate access should maneuvers become necessary [45].
Senior obstetric and anesthetic staff should be informed of all women with class III obesity admitted for
labor management to ensure early assessment and identification of potential difficulties [22]. The
operating theatre staff should also be alerted. Regular review by senior clinicians may help to identify
any intrapartum complications as they arise, and to guide management accordingly [22]. Senior ob-
stetric and anesthetic staff should be present for operative deliveries, due to the increased difficulty
encountered in both abdominal and vaginal deliveries in the morbidly obese woman [8,22].
Due to the increased risk of adverse events, including pre-eclampsia, gestational diabetes, stillbirth
and the potential for undiagnosed growth restriction [46,47], it is recommended that pregnancies
complicated by maternal obesity should have continuous electronic fetal monitoring (EFM) in labor
[48,49]. The risk of stillbirth in the obese population is especially increased at term gestation, with the
highest risk in the morbidly obese [47].
External monitoring may become impossible in labor due to abdominal adiposity and the pannus.
There is no evidence to support the routine use of internal fetal monitoring in this population, but
application of the fetal scalp electrode should be considered if a satisfactory recording is not obtained
by external monitoring [40,50]. On occasions where application of a fetal scalp electrode is contra-
indicated prolonged monitoring with a portable ultrasound machine may become necessary if the fetal
heart rate pattern is not reassuring and needs further observation [51]. With a large pannus or with
gross central obesity, palpation and detection of uterine contractions may also be difficult and inac-
curate. The use of an intrauterine pressure catheter to assist with better assessment of uterine activity
and thus aid in the assessment of fetal well-being has been described. This is especially pertinent in the
setting of IOL, oxytocin augmentation or vaginal delivery after Cesarean section [45,52]. This has not
been described in contemporary practice and merits further research into its value in monitoring
contractions in women with a high degree of obesity.
Vaginal examination and abdominal palpation in the obese woman are more challenging due to
physical obstruction by adipose tissue and decreased mobility. Ray et al. [45] found a higher incidence
of difficult vaginal examinations in obese women due to poor access to the perineum. Accurate and

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timely vaginal examinations are essential in labor especially in a subgroup of women already at risk of
dysfunctional labor.

Progress of labor and labor dystocia

There is a greater incidence of prolonged labor in obese women [52e54]. There is evidence that
uterine contractility in obese women may be altered or impaired [55,56]. Fat deposition in the maternal
pelvis and fetal macrosomia may also contribute to labor dystocia [16,52,53] leading to an increased
risk for cesarean delivery. There is overwhelming evidence that obesity is significantly associated with
both elective and emergency cesarean section [10,16,18,19,21,24,27e29,54,55,60].
In vitro studies of human myometrium at elective cesarean section at term confirmed that the
strength and rate of myometrial contraction was lower in obese women compared to women of normal
weight. It was hypothesized that this decreased contractility was due to altered cholesterol levels in the
obese which detrimentally affected myometrial cells [55]. Myometrial smooth muscle contraction
occurs in response to rising intracellular calcium [58]. The coordinated action of uterine contraction is
orchestrated by catecholamines which produce the progression in both frequency and amplitude of
contractions necessary in labor [58,59]. In the study reported by Zhang et al. [55], the effects of
cholesterol were dose dependent and reversible with the removal of cholesterol from the in vitro
environment. Moynihan et al. [56] showed that leptin concentrations were increased in obesity and
their in vitro studies demonstrated this reduction in myometrial contractility was related to the
inhibitory effect of leptin. Chu et al. [60] in their study looking at the risk of stillbirth in a patient with
obesity found that the prevalence of fetal macrosomia (birthweight >4 kgs) was increased in a woman
with obesity compared to a woman of normal weight. Fetal macrosomia can result in cephalo-pelvic
disproportion manifesting as arrested or obstructed labor. Thus, from the outset, fat deposition
contributing to disproportion, reduced and uncoordinated uterine contractility due to inhibitory ef-
fects of leptin and cholesterol as well as fetal macrosomia resulting in cephalo-disproportion may
together mean that labor progress in women with obesity is different to that in women who do not
have obesity.
Norman et al. [74] conducted a retrospective cohort study looking at 5204 singleton term preg-
nancies comparing duration of first stage of labor between women with a BMI less than 30 to women
with a BMI of greater than 30. The study found that women with a BMI greater than 30 had a longer
median duration of labor as well as a slower progress to get to 6 cm of cervical dilatation. The duration
of labor and the slower progress increased with increasing obesity class. They concluded that women
with obesity took a longer time to get to the active phase of labor and that active labor for these women
began at 6 cm.
This is supported by other smaller sets of data. Vahratian et al. found that after adjusting for
maternal height, pregnancy weight gain, labor induction, membrane rupture, oxytocin use, epidural
analgesia and fetal size, slow progression in labor occurred mostly between 4 and 6 cm in overweight,
and in active labor under 7 cm in women with obesity. No noticeable differences were seen after
cervical dilatation of 7 cm in either group. The authors concluded that differences in labor progression
seen among women with increasing BMI should be taken into account before additional interventions
are performed [53]. As maternal weight increased, the rate of cervical dilatation slowed, and the mean
duration from oxytocin initiation to delivery increased. In nulliparous women, a difference of 5 h in
labor duration was seen between those in the highest weight quartile, compared with those in the
lowest quartile (Fig. 4) [54]. This study, along with others, also demonstrated that as maternal weight
increased, so did oxytocin requirements, and irrespective of parity, increasing weight was associated
with a decreased rate of cervical dilatation and an increased labor duration [29,54]. In a retrospective
cohort study conducted by Adams et al. [75], 4284 sets of birth data were analyzed and showed that
women with obesity were more likely to require oxytocin rates more than 20 mU/min, higher doses of
oxytocin, and greater duration of oxytocin exposure to achieve a vaginal delivery.
The prolongation of labor duration appears limited to the first stage of labor only [28,53,61].
Increasing maternal BMI was not associated with a difference in second-stage duration, regardless of
whether the labor was induced or spontaneous [28,76]. A large population-based study also demon-
strated no difference in failure to progress in the second stage of labor between women with obesity

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

Fig. 4. Labour curves in nulliparas by body mass index category.

Reprinted from Am J Obstet Gynecol, Vol 205 Edition 244, Kominiarek MA, Zhang J, VanVeldhuisen P, Troendle J, Beaver J, Hibbard JU,
Contemporary labour patterns: the impact of maternal body mass index, e 1-8., 2011 with permission from Elsevier

and normal-weight women [61]. A prospective trial of 71 women did not demonstrate a difference in
second-stage intrauterine pressure between women with obesity and those with a normal BMI [62].
This study also found that though women with obesity had longer labors overall and required oxytocin
augmentation more often, the duration of second stage was similar among all weight groups. These
studies support the finding that the increased risk for cesarean section in women with obesity is mostly
confined to the first stage of labor [16,64].
Increasing BMI is associated with reduced rates of spontaneous vaginal delivery [64]. The chance of
a spontaneous vaginal delivery in women with a BMI over 35 kg/m2 is 55% [7] and this rate reduces to
36.7% in women with morbid obesity [11]. Data regarding instrumental delivery in the second stage is
conflicting, with the majority of studies showing lower operative vaginal delivery rates in women with
obesity compared to those in the normal BMI range. This is thought to be due to the high rate of ce-
sarean sections, and perhaps added to by a reluctance of practitioners to perform instrumental vaginal
deliveries in women with obesity [8,14,51].
Prolonged labor also puts women at risk of chorioamnionitis, operative deliveries, postpartum
endometritis and wound infections [65]. This must be taken into consideration in the intrapartum as
well as the postpartum period.

Macrosomia and shoulder dystocia

Pre-pregnancy weight is the most important factor influencing birth weight of babies in women
with obesity [67]. Women with obesity are two to three times more likely to give birth to a large for
gestational age (LGA) infant (birth weight greater than 4000 g), even after adjustment for diabetes

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

mellitus [8,16,19,30,42,62,66e68]. Complications associated with LGA include malpresentation, oper-

ative vaginal delivery, shoulder dystocia, cesarean section, postpartum hemorrhage, perineal trauma,
low Apgar scores, and admission to neonatal intensive units [42,62].
Data regarding shoulder dystocia is conflicting. Population-based cohort studies have shown that
the use of shoulder dystocia was significantly increased in women with obesity, with an odds ratio
ranging from 1.61 (95% CI 1.04e2.51) to 3.0 (odds ratio 3.14, 95% CI 1.86e5.31) [17], with obesity as an
independent risk factor [68]. On the contrary, in a study of women with a BMI greater than 50 kg/m2 an
increased risk was not demonstrated. The authors hypothesized that this may be due to the extremely
high rate of cesarean delivery in this group [57]. In another large population-based study, after ac-
counting for diabetes, Sheiner et al. failed to demonstrate obesity as an independent risk factor for
shoulder dystocia, despite the high incidence of fetal macrosomia [61]. These findings were supported
by a case-control study by Robinson et al. They demonstrated that maternal obesity was not an in-
dependent risk factor for shoulder dystocia, when the confounding effects of macrosomia, diabetes and
mid-pelvic instrumental delivery were controlled for, and fetal macrosomia remained the strongest
predictor [69]. The obstetric care provider should be prepared in any event to manage this obstetric
emergency when it arises.

Instrumental delivery

Instrumental vaginal delivery can be particularly challenging in a woman with obesity due to as-
sociations with fetal macrosomia and shoulder dystocia [60,61] which contribute to perineal injury,
perinatal morbidity and postpartum hemorrhage [42,70]. A higher incidence of second-degree, but not
third-degree perineal tear has been seen in primiparous women with obesity [66]. An attempted
operative vaginal delivery in a woman with obesity must therefore take these factors into consider-
ation, and senior obstetric staff should be present to perform or supervise operative deliveries in
women with a BMI over 40 kg/m2 [22].

Cesarean section

The risk of cesarean delivery is more than double for women with obesity compared to women with
a normal BMI [16,43,60,71]. The adjusted odds ratio for women with the most morbid obesity (BMI
over 50 kg/m2) from UKOSS data was 3.50 (95% confidence interval 2.72e4.51) [57]. The risk of ce-
sarean section increases with increasing BMI, as shown in the CMACE report on maternal obesity,
where the cesarean section rate was 37% among singleton pregnancies in women with a BMI over
35 kg/m2, and 46% in women with a BMI over 50 kg/m2 [7].

Postnatal management

Admission to the Intensive Care Unit occurs more commonly among women with a BMI greater
than 50 kg/m2 compared with women of normal weight [adjusted odds ratio 3.86 (95% CI 1.41e10.6)]
[57]. Obesity and its complications are also associated with longer hospital stays and higher costs
[11,30]. Hospital admissions longer than 5 days are seen increasingly in women with a BMI over 30 kg/
m2: OR 1.49 (95% CI 1.21e1.86) and over 40 kg/m2: 3.18 (2.19e4.61) [64].
Women with obesity are more at risk of suffering a significant postpartum hemorrhage [18,63].
Although the increased cesarean section rate can contribute to the higher incidence of PPH, Sebire et al.
[16] demonstrated that women with obesity were more at risk of PPH even after correcting for con-
founders such as mode of delivery. Active management of the third stage reduces the risk of PPH
[22,72,73]. Fyfe et al. [63] found that women with obesity had a two-fold increase in risk of major PPH
(greater than 1 L) regardless of mode of delivery. The significance of BMI in the risk of PPH is
demonstrated further by Vinayagam et al. [9] who found that women with a BMI of greater than 40 had
nearly three times the risk of a PPH compared to women of normal weight.
Obesity is an added risk factor for venous thromboembolism and risk assessments should be carried
out throughout the antenatal, intrapartum and postpartum period and appropriate thromboprophy-
lactic measures instituted.

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

Caring for women with obesity in a non-judgmental manner is important

Jensen et al. in their study looking at qualitative insights from women who experienced care as a
parturient with obesity showed that experiences of weight stigma and moral accusations in the
healthcare setting, further contributed to a woman's sense of vulnerability [77]. A number of quali-
tative studies have supported this view with women reporting negative experiences that were con-
fronting, judgmental and generally unhelpful [78]. It is important that women feel supported in their
pregnancy care and access non-judgmental equitable services regardless of their BMI.

Conclusion

Caring for women with obesity in pregnancy places significant demands on healthcare resources.
Specialized equipment and well-trained staff are required to manage the specific requirements of such
women and the potentially significant complications that may arise for the mother, fetus and neonate.
Good multidisciplinary care needs to be formulated and communicated to all stakeholders, including
the woman herself. A policy of networked care and plans for centralization of care for women with
morbid obesity should be considered in order to ensure safe outcomes for the mother and baby as well
as cost-effective allocation of resources.

Practice points

 Care of the parturient who has obesity should be multidisciplinary and collaborative.
 Case-by-case assessment should be made in the transfer of the parturient with obesity.
 Women with obesity took a longer time to get to the active phase of labor.

Research agenda

 What endocrine factors in women with obesity put them at risk of prolonged pregnancy.
 Elective cesarean section in women with morbid obesity who do not labor spontaneously.
 Ideal timing and form of induction of labor in women with obesity.

Answers
a. F b. T c. T d. F e. T

a. Induction of labor in women with obesity is more common because of a combination of two
factors, the strong association of medical co-morbidities with obesity (such as pre-eclampsia
and diabetes) and the increased incidence of post-term gestations (12, 14, 16, 18, 20). The
risk for induction increases with increasing BMI (16).
b. Women with obesity are more at risk of failed induction (21, 22). The high rate of cesarean
section in the population with obesity combined with the increased risk of failure with in-
duction means that elective cesarean section can be a consideration in the right clinical
situation.
c. Despite the higher rate of failure of induction in the population with obesity and the risks of
an emergency cesarean section, at this time the recommendation is that in the absence of
medical or obstetric indications, labor and vaginal delivery should be encouraged for
women with obesity (5).
d. Obesity is already an independent risk factor in itself for failed induction (9). Factors asso-
ciated with failed induction are nulliparity, the lack of a previous vaginal delivery and a
macrosomic fetus (22).

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

e. The favorability of the cervix prior to induction may be the best predictor of successful in-
duction (23) and in this case, there are 3 factors that make success of induction less likely, i.e.
nulliparity, unfavorable cervix and post-date gestation. Cesarean section is not without its
associated risks especially in a patient with obesity. The choice to offer an elective cesarean
section needs to be made in a multidisciplinary setting with senior medical staff involvement
and informed consent from the woman.

a. T b. F c. F d. T e. T

a. With the increased risk of intrapartum and anesthetic complications in patients with obesity,
intrapartum care should occur in a center where senior obstetric, anesthetic and midwifery
staff with experience caring for women with obesity are available. These centers are often
centralized and with the disproportionate distribution of women with obesity in rural and
regional areas, women with obesity often will have to re-locate to these centers to deliver
and have joint antenatal care. The RCOG recommends that women with a BMI greater than
35 kg/m2 give birth in a consultant led facility and are not suitable for midwifery led care (5,
17). Care in tertiary level centers for women with morbid obesity will ensure safe outcomes
for mother and baby as well as ensure cost effective allocation of resources.
b. The preferred method of analgesia in a patient with obesity is regional anesthesia although
this can be technically difficult to achieve with higher rates of failure, multiple attempts and
complications (37, 58e60). Because of the higher rates of failure to establish regional
anesthesia, a general anesthetic is more often necessary in the population with obesity (37).
Morbidity and mortality from general anesthetic is related to the difficulties in intubation
(58). It is recommended that women with a BMI greater than 40 kg/m2 be seen by a
consultant obstetric anesthetist in the antenatal period so that potential problems may be
anticipated (5).
c. The RCOG guidelines as well as recommendations from the CMACE state that women with a
BMI greater than 35 kg/m2 should give birth in a consultant led setting (5, 17). Timely
assessment and intervention by senior obstetric staff should lead to improvement in out-
comes. The UK guidelines recommend that women with a BMI greater than 30 kg/m2 should
have an informed discussion with an obstetric consultant in the antenatal period to discuss
potential intrapartum complications and their management (17). This should be docu-
mented in the antenatal record.
d. The care of a woman with obesity in pregnancy will involve medical staff (obstetric and
anesthetic), midwifery staff and allied health personnel (dietician, physiotherapist, occu-
pational therapist). Inter-facility transfer of women with obesity may also involve ambulance
officers and community counterparts. Liaison with theatre and ward staff will also facilitate a
woman's safe care in hospital. Patient focused multidisciplinary care is essential to ensure
safe outcomes.

Pregnant women with obesity are a logistical and clinical challenge for transfer teams (29). In
Australia, the RFDS require accurate weights of patients at the time of arranging transfer. The
maximum weight an airplane can carry depends on flying time and above 180 kgs, alternative
road transport may need to be arranged (30). In women with morbid obesity, air transfer may
not be an option thus preparation for road transfers should be made. Issues such as anti-
coagulation, pressure care and care of indwelling catheters or bedpans need to be thought
about. Resources including transfer equipment, beds able to support heavier weights and
monitoring devices need to be available.

a. F b. T c. T d. F e. T

a. Manual handling training should be provided to all staff involved in the care of women with
obesity. The implementation of a bariatric protocol’ is recommended in order to ensure
adequate resources and knowledge of care of women with obesity (34). Appropriate lateral
transfer equipment, hoists for bed transfers and operating tables with safe working loads
need to be available (17). In the obstetric setting, suitable lithotomy stirrups or alternatives
such as Yellofins® Stirrups and Yellofins Elite® Stirrups (Allen Medical Systems, Acton, MA)
may be needed as well as appropriate delivery suite beds, wheelchairs, BP cuffs and TEDS.

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N. Aleker, B.H. Lim Best Practice & Research Clinical Obstetrics and Gynaecology 91 (2023) 102404

An inflatable air transfer system, such as the HoverMatt® (HoverTech International, Beth-
lehem, PA) can be useful for transfer of patients with regional anesthesia or in theatre.
b. Operating tables should be able to support a weight of at least 160 kgs (35). Standard
operating tables can support weights of 130e160 kgs. All staff involved in the care of women
with obesity should be familiar with these limits. For women with morbid obesity, special-
ized operating tables that can support weights to 225 kgs and to 360 kgs are available (36).
c. Care of women with obesity involves specialized equipment and for safety reasons, all staff
should know about the different sizes available and weight limits recommended.
d. Reassessment with validated scoring tools in the third trimester will be helpful in planning
prior to admission for intrapartum care.
e. RCOG and the CMACE recommend the availability of senior obstetric and anesthetic staff in
the care of women with a BMI greater than 35 kg/m2. Immediate skilled intervention can
improve outcomes for both the mother and baby in the setting of shoulder dystocia,
emergency cesarean section, instrumental deliveries and PPH. The availability of senior
neonatal staff will also aid to improve outcomes for babies born to women with obesity.

a. T b. F c. F d. F e. T

a. Women with obesity have a longer duration of labor and this is mainly due to a prolonged
first stage of labor (12, 55). In vitro studies of human myometrium in pregnant women with
obesity have shown that contractility is decreased compared to women of normal weight and
this may be related to elevated cholesterol and leptin levels (47, 48). Cephalo-pelvic dispro-
portion may also contribute to the risk of arrested labor in the context of a macrosomia fetus
(52).
b,c and d. Pre-pregnancy weight is the most important predictor of fetal birthweight in women
with obesity (59). There is a higher incidence of LGA babies born to women with obesity
regardless of diabetic status (5,12,15,22,34,53,61,63). There are a number of intrapartum
complications associated with LGA babies thus presence of senior obstetric, anesthetic and
neonatal staff is recommended (17). There is no clear evidence to suggest that obesity is a good
predictor of the risk of shoulder dystocia. Fetal macrosomia is the best predictor of the risk of
shoulder dystocia (64) and in a population of women at increased risk of LGA babies, this
eventuality should be on every clinician's mind when caring for a woman with obesity in labor.
e. The anesthetic preparation for care of a pregnant woman with obesity can be timely and
costly. Obesity can distort anatomical landmarks and can affect positioning of a patient for
procedures. Soft tissue changes in pregnancy already make obstetric analgesia challenging.
Combined with the obese habitus (short neck, weight of breasts, increased tissue mass,
decreased mobility), providing safe analgesia is physically demanding for the clinician and
technically requires specialized resources and expertise (58).

Conflict of interest

I have no conflict of interest to declare with respect to this manuscript.

Appendix A. Supplementary data

Supplementary data to this article can be found online at [Link]

102404.

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