Part 2 of 2: Delivery and postpartum concerns in the obese gravida

Prophylaxis is warranted

Preoperative prophylactic antibiotics (weight-based) and prophylaxis for venous thromboembolism using sequential compression devices are recommended prior to surgery.

Choose the incision wisely

Data do not indicate whether vertical or transverse skin incisions for cesarean delivery are associated with higher infectious morbidity. In general, a Pfannenstiel incision is associated with less postoperative discomfort, allowing earlier mobilization and better respiratory function. A vertical incision allows optimal exposure, especially in the case of a macrosomic infant, and may thereby limit operating time and blood loss.^7,8

A vertical supraumbilical incision is another option. If the lower uterine segment is not accessible, a fundal uterine incision can be made ( FIGURE 3 ). The advantage of this method is increased exposure as well as access to the incision for wound care. However, because this method may necessitate a classical uterine incision, counseling must be given regarding future pregnancy.

FIGURE 3 Pair incisions strategically to ease cesarean delivery

In an obese patient, a supraumbilical skin incision paired with a classical uterine incision may simplify the surgery.

Other intraoperative considerations

If the surgery is prolonged, consider administering another dose of antibiotics.

If the subcutaneous tissue is thicker than 2 cm, it should be reapproximated to minimize the risk of hematoma and seroma formation and wound infection.^8,9

A subcutaneous drain should also be considered.

Postpartum care

Be aware of special risks

One retrospective study showed an increased risk of postpartum hemorrhage in women who had a BMI above 25, compared with women of normal weight. This risk increased as BMI increased. Knowledge of this complication and early use of uterotonic agents can minimize the morbidity associated with postpartum hemorrhage.

Postpartum infection is more likely in obese women, with three times the risk of endometritis of women of normal weight, and increased risks of wound infection, urinary tract infection, septic pelvic thrombophlebitis, and pneumonia.¹⁰ Early recognition of infection and administration of antibiotics can minimize morbidity.

Venous thromboembolism is more likely throughout pregnancy in obese women. Risk is heightened, however, during the postpartum period, when it is four times as high as the risk in women of normal weight.¹¹ Early ambulation and use of venous compression devices are encouraged. Consider heparin in the immediate postpartum period, when mobility is compromised for a longer period, particularly for women undergoing cesarean delivery who have comorbidities.

Suggest breastfeeding, weight loss

Women who breastfeed longer than 1 month have a 22% reduction in the risk of developing metabolic syndrome later in life, compared with women who do not. It also appears that a longer duration of breastfeeding reduces the risk of diabetes.¹²

Weight loss should be strongly encouraged. Women who retained their pregnancy weight at 6 months were 18 lb heavier after 10 years than women who lost their pregnancy weight.

The risk of metabolic syndrome increases with parity, probably because of the tendency of many obese women to retain their pregnancy weight.¹²