How High BMI Can Affect Your Care During Labor and Delivery

As a South Shore Hospital physician specializing in anesthesia, a key aspect of my role is informing patients about the kind of care they can expect when delivering a baby.

In this blog, I want to specifically address how an increased body mass index (BMI) can impact how we administer anesthesia during labor and delivery.

A quick disclaimer, before getting into the details of the discussion: this information is not intended to scare patients or make them feel badly about themselves, their weight, or their decision to have a baby.

Unfortunately, studies show those things do happen to women with high BMI when they visit their health care provider. One study completed in 2014 found that 53% of the patients with high BMI reported being “fat-shamed” by their doctor.

This kind of experience can have dangerous consequences, as a 2016 report showed that 45% of women with high BMI said they postponed preventative care, including annual physicals and mammograms, because their health care providers humiliated them about their weight.

We strive to provide compassionate, judgment-free care to all patients, and that doesn’t change due to high BMI.

But it’s also important for us to ensure that patients with high BMI are informed about what to expect on the day of their delivery, particularly when it comes to anesthesia.

Why deliveries may be different for patients with high BMI

In some pregnancies, patients with a high BMI may have a delivery that is different than they anticipated. This is because higher BMI is associated with increased obstetric and anesthesia risks, which may require a different approach.

Our goal as anesthesiologists is to both alleviate pain and to keep the patient and baby safe. We need to anticipate any complications that could jeopardize the safety of the patient and baby on the day of delivery (as well as on the days leading up to and after delivery).

We also want patients to be aware of these potential challenges in advance so they are not caught by surprise if something changes during delivery. 

What are the obstetric and anesthesia risks for patients with high BMI?

Increased difficulty in obtaining intravenous placement

Because it is sometimes difficult to obtain intravenous placement, we may place one early or obtain multiple IVs in patients with higher BMIs.

IVs are necessary for administering medications and fluids in a timely manner and are integral to keeping patients safe.

Increased difficulty monitoring

Because of the increased risk of gestational diabetes and a large baby, high BMI patients can have longer and more complicated labor. Some of the seemingly mundane aspects of care can be more challenging.

Because of this, we may have to take more time to obtain lab tests and to monitor the patient and baby before, during, and after the birth.

This can be frustrating, but please know that everything we do is with patient safety in mind.

We will do our part to take patient needs into account, by having everything from the right-sized gowns and blood pressure cuffs, to furniture in the offices and birthing rooms.

Increased obstetric risks

Patients with high BMI have an elevated risk of preeclampsia, macrosomia, shoulder dystocia, meconium aspiration, and a complicated delivery.

There is also an increased risk of having a caesarian delivery (C-section) and the baby requiring care in the neonatal intensive care unit.

Patients with high BMI also have a greater risk of bleeding, both during and after delivery.

Because of this, we recommend an early epidural not only to alleviate labor and birth pain, but also as a tool that the team can use to provide anesthesia in the event of an emergent or urgent C-section or a surgery to control bleeding throughout your birth.

Epidural or spinal placement

Because epidural and spinal placement are reliant on feeling the back and spine, these procedures can be difficult with patients with a high BMI.

There have been instances where we have been unable to obtain an epidural or a spinal and we have had to alleviate pain through IV medication (in the case of laboring patients) or by general anesthesia (in patients requiring a C-section).

Because it may take longer to provide an epidural or spinal, we recommend an early epidural, which allows more time for the anesthesia team to place the epidural and the patient to sit in the proper position for epidural placement before positioning becomes a challenge due to labor pain.

Risk of intubation

There are situations in which a C-section or other surgical procedure is so emergent that we must institute a general anesthesia with a breathing tube, known as intubation.

Intubating patients with high BMIs can be more difficult for a variety of physiologic reasons.

Higher BMI patients also have a higher likelihood of aspiration during intubation, which is when stomach contents gain entrance into a patient’s lungs.

We have a number of tools that can minimize the risks of intubation and will attempt to use an epidural or spinal whenever feasible, as it has a superior safety profile to general anesthesia in high BMI patients.

Risk of blood clots

Patients with high BMI are at risk of developing a blood clot in blood vessels that could travel to the lungs. This is a rare event, but it may require additional use of blood thinning medications during and after the delivery.

When delivery at another hospital is recommended

The obstetrics and anesthesia teams at South Shore Hospital are cognizant of the risks mentioned and tailor patient care to keep patients safe and make the birth experience a positive one.

But there are some conditions that warrant transferring patients to a tertiary center that specializes in high-risk pregnancy for the delivery.

Patients with certain cardiac conditions, prior obstetric difficulties, or extremely elevated BMI are often referred to a hospital with specialized care for complex pregnancies.

If a provider recommends delivering at a tertiary center, please know that it’s not that they don’t want to deliver your baby – they have the best interests and the safety of patient and baby at heart. 

Our obstetric and anesthesia teams want your birth to be a collaborative and inclusive process that culminates in a successful delivery.

Please speak with your provider if you have further questions regarding anesthesia or other aspects of your care and delivery.

Kristen C. Stadtlander, MD, is an obstetric anesthesiologist at South Shore Hospital.

Learn more about OB/GYN care and Maternal Fetal Medicine at South Shore Health.