Anaesthetic management of obese parturients: what is the evidence supporting practice guidelines?
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/m2and 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?".
Anaesthetist, Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, School of Medicine, The University of Queensland, Brisbane, Queensland.
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Eley
Professor, Department of Anaesthesia and Perioperative Medicine, The Royal Brisbane and Women's Hospital, School of Medicine, Professor and Chairman, Discipline of Anaesthesiology, Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland.
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van Zundert
Director, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, School of Medicine, The University of Queensland, Faculty of Health, Queensland University of Technology, Brisbane, Queensland.
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Lipman
Obstetric Physician, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital, School of Medicine, The University of Queensland, Brisbane, Queensland.
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Callaway
D015360:Analgesia, Epidural; D000773:Anesthesia, Obstetrical / Q000379:methods*; D015992:Body Mass Index; D005260:Female; D006801:Humans; D009765:Obesity / Q000150:complications*; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011295:Prenatal Care; D012017:Referral and Consultation
epidural, obstetric anaesthesia, guidelines, obesity