Managing anesthesia  for cesarean section in obese patients: current perspectives

Abstract

Obesity is a worldwide epidemic. It is associated with increased comorbidities and increased maternal, fetal, and neonatal complications. The risk of cesarean delivery is also increased in obese parturients. Anesthetic management of the obese parturient is challenging and requires adequate planning. Therefore, those patients should be referred to antenatal anesthetic consultation. Anesthesia-related complications and maternal mortality are increased in this patient population. The risk of difficult intubation is increased in obese patients. Neuraxial techniques are the preferred anesthetic techniques for cesarean delivery in obese parturients but can be technically challenging. An existing labor epidural catheter can be topped up for cesarean delivery. In patients who do not have a well-functioning labor epidural, a combined spinal epidural technique might be preferred over a single-shot spinal technique since it is technically easier in obese parturients and allows for extending the duration of the block as required. A continuous spinal technique can also be considered. Studies suggest that there is no need to reduce the dose of spinal bupivacaine in the obese parturient, but there is little data about spinal dosing in super obese parturients. Intraoperatively, patients should be placed in a ramped position, with close monitoring of ventilation and hemodynamic status. Adequate postoperative analgesia is crucial to allow for early mobilization. This can be achieved using a multimodal regimen incorporating neuraxial morphine (with appropriate observations) with scheduled nonsteroidal anti-inflammatory drugs and acetaminophen. Thromboprophylaxis is also important in this patient population due to the increased risk of thromboembolic complications. These patients should be monitored carefully in the postoperative period, since there is increased risk of postoperative complications in the morbidly obese parturients.

A randomized trial of phenylephrine infusion versus bolus dosing for nausea and vomiting during Cesarean delivery in obese women

“…Obese women have reduced lumbar cerebrospinal fluid (CSF) volume which can be inversely related to cephalad spread of local anesthetics. 14 Carvalho et al 7 and Lee et al 15 found no association with BMI and the height of spinal anesthesia for obese women undergoing a CD. However, the study sizes are small and use methods that assume large sample properties.…”

The Effect of Different Doses of Intrathecal Hyperbaric Bupivacaine Plus Sufentanil in Spinal Anesthesia for Cesarean Sections

“…However, by adding opioids such as sufentanil to bupivacaine, the required dose of local anesthetic is decreased. This may result in lower side effects and improved quality of spinal anesthesia and postoperative analgesia ( 7 , 8 ). Earlier studies have examined the effects of adding various amounts of sufentanil to a fixed dose of local anesthetic to find the optimum dose of adjuvant ( 9 - 12 ).…”

Maternal Diet Quality, Body Mass Index and Resource Use in the Perinatal Period: An Observational Study

“…For example, complications from anaesthesia are higher in obese patients compared to normal weight patients [ 36 ]. There is increased risk of incorrectly placing an epidural in obese patients as the distance to the epidural space is greater with increased BMI [ 36 , 37 ], risk of difficult intubation is increased in obese patients, monitoring and positioning obese patients under anaesthesia can also pose specific challenges [ 36 ]. Obesity is also associated with an increased risk of maternal mortality and anaesthesia-related maternal mortality [ 37 ].…”

“…There is increased risk of incorrectly placing an epidural in obese patients as the distance to the epidural space is greater with increased BMI [ 36 , 37 ], risk of difficult intubation is increased in obese patients, monitoring and positioning obese patients under anaesthesia can also pose specific challenges [ 36 ]. Obesity is also associated with an increased risk of maternal mortality and anaesthesia-related maternal mortality [ 37 ]. From a midwife’s perspective, a 2011 study of midwives and other health professionals caring for obese childbearing women in NSW, Australia, found midwives were concerned about the rapid impact of the obesity epidemic on maternity services and that study participants felt increased pressure in the management of obese pregnant women and the complications associated with their BMI [ 38 ].…”