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Keywords:

  • Caesarean delivery;
  • mode of birth;
  • obesity;
  • pregnancy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

Please cite this paper as: Homer C, Kurinczuk J, Spark P, Brocklehurst P, Knight M. Planned vaginal delivery or planned caesarean delivery in women with extreme obesity. BJOG 2011;118:480–487.

Objective  To compare the outcomes of planned vaginal versus planned caesarean delivery in a cohort of extremely obese women (body mass index ≥ 50 kg/m2).

Design  A national cohort study using the UK Obstetric Surveillance System (UKOSS).

Setting  All hospitals with consultant-led maternity units in the UK.

Population  Five hundred and ninety-one extremely obese women delivering in the UK between September 2007 and August 2008.

Methods  Prospective cohort identification through UKOSS routine monthly mailings.

Main outcome measures  Anaesthetic, postnatal and neonatal complication rates.

Results  After adjustment, there were no significant differences in anaesthetic, postnatal or neonatal complications between women with planned vaginal delivery and planned caesarean delivery, with the exception of shoulder dystocia (3% versus 0%, P = 0.019). There were no significant differences in any outcomes in the subgroup of women who had no identified medical or antenatal complications.

Conclusions  This study does not provide evidence to support a routine policy of caesarean delivery for extremely obese women on the basis of concern about higher rates of delivery complications, but does support a policy of individualised decision-making on the mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

Obesity is a growing global public health problem and a major contributor to the global burden of chronic disease and disability.1 Obesity has significant implications for the provision of maternity care, both in relation to increased risks and complications for both mother and baby, and its association with an increased risk of caesarean delivery. A recent systematic review of 11 cohort studies reported that the risk of caesarean delivery was increased by 50% in women with a body mass index (BMI) of 30–35 kg/m2 and was more than doubled in women with BMI > 35 kg/m2 compared with women with a normal BMI (20–25 kg/m2).2 Factors associated with a higher risk of caesarean delivery in obese women may include medical and pregnancy complications, such as diabetes and pre-eclampsia, as well as poor uterine contractility3 and concerns regarding the challenges of both general and regional anaesthesia in the emergency situation.4,5 There appears to be an increasing move to recommend planned caesarean delivery to avoid the perceived risks of emergency caesarean delivery in this group of women. However, earlier studies have highlighted increased morbidity and mortality associated with caesarean delivery in obese women,6 longer operative times and length of hospital stay, with blood loss and postoperative infective morbidity being greater.7,8 Recent consensus standards on the management of women with obesity in pregnancy make no recommendations concerning caesarean delivery because of a lack of evidence to inform advice.9 Thus, there is an urgent need for evidence to inform the development of clinical policy on the planned mode of delivery in this group of high-risk women.

The aim of this study was to investigate, using data from a UK national cohort of pregnant women with BMI ≥ 50 kg/m2,10 the factors associated with mode of birth, and to compare the outcomes in women planned to deliver vaginally with those planned to deliver by caesarean section.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

The cohort of extremely obese women was identified through the UK Obstetric Surveillance System (UKOSS)11 between September 2007 and August 2008, and the methods of identification have been described fully elsewhere.10 The study included pregnant women who at any point in their pregnancy had BMI ≥ 50 kg/m2 and had data available on mode of birth and urgency of caesarean delivery (Figure 1). Women were divided into two groups based on the planned mode of delivery. Women who laboured or who had an induction of labour were included in the planned vaginal group, and women who were delivered by caesarean section without labour were included in the planned caesarean group. The characteristics were compared between the two groups using chi-squared and Fisher’s exact tests.

image

Figure 1.  Reporting of women with extreme obesity and completeness of data collection.

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A multivariable logistic regression model was used to examine predictive factors for caesarean delivery. We developed a pragmatic model by including factors known from the literature to be associated with caesarean delivery, particularly in obese women. The factors included were age, ethnicity, socioeconomic status based on occupation, previous caesarean delivery, diagnosed diabetes including current gestational diabetes, multiple pregnancy and BMI. Continuous variables were tested for departure from linearity by the inclusion of quadratic terms in the model and subsequent likelihood ratio testing on removal. Potential interactions between each variable and every other variable in the model were tested by the addition of interaction terms and subsequent likelihood ratio testing on removal. P < 0.05 was considered as evidence for significant interaction or departure from linearity. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated.

Outcomes were compared between the two groups in a further multivariable model, adjusting for potential confounders identified from the literature (pre-existing: diabetes, asthma, hypertension or endocrine disorder; current: gestational diabetes, pre-eclampsia or a thromboembolic event in this pregnancy, previous delivery by caesarean section). Neonatal outcomes were also adjusted for preterm delivery. A sensitivity analysis was conducted to explore the outcomes in the group of women who had no reported antenatal or medical complications (pre-existing: diabetes, asthma, hypertension or endocrine disorder; current: gestational diabetes, pre-eclampsia or a thromboembolic event in this pregnancy) by repeating the comparison of outcomes excluding women with any of these known complications.

All analyses were carried out using STATA 10 software (StataCorp, College Station, TX, USA).

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

This analysis included 591 women who met the study inclusion criteria (Figure 1). The median BMI was 55 kg/m2 with a range from 50.0 to 80 kg/m2. Of the 591 women, 174 (29.4%) were in the planned caesarean group and 417 (70.6%) were in the planned vaginal group. Of those who planned a vaginal delivery, 30.5% (n = 127) went on to have a caesarean delivery. The characteristics of women according to planned mode of delivery are shown in Table 1. Women in the planned caesarean group were significantly older, of higher parity and more likely to have essential hypertension, previous hypertensive disorders of pregnancy, previous caesarean delivery, a multiple pregnancy or current gestational diabetes. In a logistic regression model, after controlling for age, ethnicity, socioeconomic status and the other variables in Table 1, the factors associated with a significantly higher odds of actual caesarean delivery were a previous caesarean delivery and pre-existing diabetes or gestational diabetes (Table 2). Of the 26 women in the planned vaginal delivery group who had a previous caesarean delivery, only 9 (35%) delivered vaginally. There was a three-fold increase in the risk of caesarean delivery associated with multiple pregnancy; this was not statistically significant, but it should be noted that, because of the small numbers, this comparison has limited power to demonstrate statistical significance.

Table 1.   Demographic characteristics, pregnancy events and complications by planned mode of birth
  1. *Percentages of those with data.

  2. **Composite antenatal medical risk factor: one or more of the following: pre-existing diabetes, asthma, hypertension or endocrine disorder and/or current gestational diabetes, pre-eclampsia or a thromboembolic event in this pregnancy.

 Planned vaginal delivery (n = 417) (%)*Planned caesarean delivery (n = 174) (%)*P value
Parity
Primiparous162 (38.9)40 (23.1)<0.001
Multiparous255 (61.1)54 (76.9)
Age
<35 years322 (77.2)112 (64.4)0.001
≥35 years95 (22.8)62 (35.6)
Ethnicity
White366 (88.6)147 (87.0)0.579
Black and other minority groups47 (11.4)22 (13.0)
Socioeconomic group
Managerial/professional288 (83.2)112 (80.0)0.397
Other58 (16.8)28 (20.0)
Body mass index
50–54 kg/m2278 (66.7)108 (62.1)0.423
55–59 kg/m290 (21.6)40 (23.0)
60–64 kg/m235 (8.4)15 (8.6)
≥65 kg/m214 (3.4)11 (6.3)
Previous medical conditions
Hypertension19 (4.6)19 (11.1)0.004
Asthma51 (12.2)21 (12.1)0.956
Endocrine disorders13 (3.1)9 (5.1)0.229
Diabetes17 (4.1)12 (6.9)0.148
Mental health problems41 (9.8)19 (10.9)0.690
Polycystic ovarian syndrome22 (5.3)4 (2.3)0.108
Previous obstetric conditions
Gestational diabetes (GDM)14 (3.4)8 (4.6)0.468
Pre-eclampsia or pregnancy-induced hypertension (PE/PIH)39 (9.4)26 (14.9)0.048
Composite antenatal medical risk factor**139 (33.3)86 (49.4)<0.001
Current obstetric conditions
Previous caesarean section26 (6.2)74 (42.5)<0.001
Multiple pregnancy6 (1.4)11 (6.3)0.001
PE/PIH88 (21.1)47 (27.0)0.119
GDM37 (8.9)32 (18.4)0.001
Thrombotic event3 (0.7)0 (0)0.265
Table 2.   Factors associated with actual delivery by caesarean section (CS) in extremely obese women, irrespective of planned mode of delivery
 Vaginal deliveryCSUnadjustedAdjusted*
n = 29 (%), 0n = 30 (%), 1OR (95% CI)OR (95% CI)
  1. CI, confidence interval; OR, odds ratio.

  2. *Adjusted for all other factors in the model.

Age
<25 years59 (20.3)38 (12.6)1.01.0
25–34 years170 (58.7)167 (55.5)1.52 (0.96–2.41)1.20 (0.68–2.13)
≥35 years61 (21.0)96 (31.9)2.44 (1.45–4.10)1.50 (0.78–2.86)
Ethnic group
White253 (87.9)260 (88.4)1.01.0
All other groups35 (12.1)34 (11.6)0.95 (0.57–1.56)0.86 (0.46–1.60)
Socioeconomic status
Nonmanagerial199 (85.0)201 (79.8)1.01.0
Managerial35 (15.0)51 (20.2)1.44 (0.90–2.31)1.65 (0.99–2.76)
Previous CS
No281 (96.9)210 (69.8)1.01.0
Yes9 (3.1)91 (30.2)13.5 (6.67–27.46)16.7 (7.06–39.7)
Past or current diabetes (including gestational diabetes in this pregnancy)
No258 (89.0)240 (79.0)1.01.0
Yes32 (11.0)61 (20.3)2.05 (1.29–3.25)2.08 (1.20–3.59)
Body mass index
<60 kg/m2256 (88.3)260 (86.4)1.01.0
>60 kg/m234 (11.7)41 (13.6)1.19 (0.73–1.93)1.14 (0.63–2.06)
Multiple pregnancy
No286 (98.6)288 (95.7)1.01.0
Yes4 (1.4)13 (4.3)3.23 (1.04–10.02)3.42 (0.85–13.79)

Admission to a neonatal intensive care unit was more likely in infants born to women undergoing a planned caesarean delivery on univariate analysis. However, after adjustment, there were no significant differences in anaesthetic, postnatal or neonatal complications between women with planned vaginal delivery and planned caesarean delivery (Table 3), with the exception of shoulder dystocia. None of the 13 infants born following shoulder dystocia were reported to have suffered permanent injury. The sensitivity analysis showed that there were no significant differences in any outcomes in the subgroup of women who had no identified medical or antenatal complications (Table 4), although it should be noted that there was a 66% lower risk of major maternal morbidity in the planned vaginal group (not statistically significant).

Table 3.   Anaesthetic, postnatal and neonatal complications by planned mode of birth
  1. CI, confidence interval; NA, not applicable; NC, not calculable because of zero cells; OR, odds ratio.

  2. *Adjusted for the presence of one or more of the following: pre-existing diabetes, asthma, hypertension or endocrine disorder and/or gestational diabetes, pre-eclampsia or a thromboembolic event in this pregnancy, previous delivery by caesarean section. Neonatal outcomes also adjusted for preterm delivery (gestation <37 completed weeks at birth).

  3. **Denominator is women who had a caesarean delivery.

  4. ***Composite score including one or more of the following: intraoperative or postpartum haemorrhage, thromboembolic event, septicaemia, septic shock and/or admission to an intensive care unit.

 Vaginal (n = 417) (%)Caesarean (n = 174) (%)Unadjusted OR (95% CI)Adjusted OR (95% CI)*
Caesarean delivery127 (30.5)174 (100)NANA
Anaesthetic
Failure or problems with regional anaesthesia35 (8.4)18 (10.3)0.79 (0.44–1.44)0.72 (0.37–1.39)
General anaesthetic for delivery22 (5.3)15 (8.6)0.59 (0.30–1.17)0.55 (0.26–1.16)
Maternal postnatal
Postoperative wound infection or other wound complication**33 (26.2)38 (22.4)1.23 (0.72–2.11)1.20 (0.68–2.13)
Intensive care unit admission9 (2.2)6 (3.5)0.61 (0.22–1.75)0.62 (0.19–2.07)
Major maternal morbidity***18 (4.3)11 (6.3)0.67 (0.31–1.45)0.53 (0.23–1.24)
Neonatal
Birth weight 4500 g or greater35 (8.4)22 (12.7)0.63 (0.36–1.11)0.60 (0.32–1.12)
Shoulder dystocia13 (3.1)0 (0)∞ (1.44–∞)NC
Neonatal Intensive care unit admission34 (8.3)27 (15.5)0.49 (0.29–0.84)0.67 (0.34–1.30)
Neonatal death2 (0.5)1 (0.6)0.85 (0.08–9.4)1.08 (0.09–13.2)
Table 4.   Sensitivity analysis to examine anaesthetic, postnatal and neonatal complications by planned mode of birth, excluding women with known antenatal complications*
  1. CI, confidence interval; NA, not applicable; NC, not calculable because of zero cells; OR, odds ratio.

  2. *The presence of one or more of the following: pre-existing diabetes, asthma, hypertension or endocrine disorder and/or gestational diabetes, pre-eclampsia or a thromboembolic event in this pregnancy.

  3. **Adjusted for previous delivery by caesarean section. Neonatal outcomes also adjusted for preterm delivery (gestation <37 completed weeks at birth).

  4. ***Denominator is women who had a caesarean delivery.

  5. ****Composite score including one or more of the following: intraoperative or postpartum haemorrhage, thromboembolic event, septicaemia, septic shock and/or admission to an intensive care unit.

 Vaginal (n = 288) (%)Abdominal (n = 88) (%)Unadjusted OR (95% CI)Adjusted OR (95% CI)**
Caesarean delivery76 (27.3)88 (100)NANA
Anaesthetic
Failure or problems with regional anaesthesia19 (6.8)8 (9.1)0.73 (0.31–1.74)0.67 (0.25–1.78)
General anaesthetic for delivery13 (4.7)6 (6.8)0.67 (0.25–1.82)0.62 (0.20–1.92)
Maternal postnatal
Postoperative wound infection or other wound complication***19 (25.0)15 (17.7)1.56 (0.73-3.33)1.43 (0.64-3.22)
Intensive care unit admission5 (1.8)3 (3.5)0.51 (0.12–2.19)0.29 (0.07–1.25)
Major maternal morbidity****10 (3.6)5 (5.7)0.62 (0.21–1.86)0.34 (0.11–1.04)
Neonatal
Birth weight 4500 g or greater21 (7.6)11 (12.6)0.45 (0.26–1.22)0.19 (0.32–1.05)
Shoulder dystocia5 (1.8)0 (0)∞ (0.40–∞)NC
Neonatal Intensive care unit admission18 (6.5)7 (8.0)0.81 (0.33–2.00)0.79 (0.28–2.25)
Neonatal death2 (0.5)0 (0)∞ (0.16–∞)NC

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

This study did not identify any statistically significant differences in anaesthetic, maternal postnatal or neonatal complications according to planned mode of delivery in a national cohort of extremely obese women in the UK after adjusting for maternal medical and antenatal complications, other than in the occurrence of shoulder dystocia. None of the infants suffered permanent injury. All the other complications examined, with the exception of postnatal wound complications, occurred less frequently in the planned vaginal group than in the planned caesarean group, although again the differences were not statistically significant, possibly because of the limited study power even in this national cohort study. When we examined the subgroup of women with no identified medical or antenatal complications, we were unable to identify any differences in any of the complications examined.

Other studies addressing this issue are few and have focused particularly on the planned mode of delivery in obese women who have undergone a previous caesarean delivery, reporting poorer outcomes amongst those undergoing a trial of labour compared with elective repeat caesarean delivery.12,13 In contrast, we studied the entire group of extremely obese women, not a selected group, and after adjusting for potential confounders, did not demonstrate any differences in outcomes, with the exception of shoulder dystocia without permanent injury. In our analysis of women without any documented medical or antenatal complications, there were no significant differences, although it should be noted that even large national studies such as this have limited power to detect differences in rare outcomes. This study does not provide any evidence to support a policy of routine caesarean delivery for extremely obese women on the basis of concern of higher rates of delivery complications, but does support a policy of individualised decision making on mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes. Such a policy would be supported through guidance, such as that available to inform the care of women undergoing birth after previous caesarean birth.14

The definition and accuracy of reporting of shoulder dystocia are important factors when interpreting the incidence of shoulder dystocia. In practice, some clinicians only report a birth as involving shoulder dystocia if they have had to employ specific manoeuvres to deliver the baby’s anterior shoulder. Others will record shoulder dystocia if there is any delay in the emergence of the shoulder following delivery of the head. In this cohort, it is possible that the existence of the women’s extreme obesity ensured a high index of concern in the minds of the clinicians for shoulder dystocia, and any difficulties delivering the baby were defined as shoulder dystocia. Nevertheless, 2.2% of babies were born following shoulder dystocia. This is higher than many other reported rates, although studies have reported a wide variation in incidence. Unselected population studies in North America and the UK found a 0.6% incidence.15–17

Shoulder dystocia is known to increase with fetal macrosomia. For example, an incidence of 14.3% has been reported in babies with a birth weight of 4500–4750 g, and 21.1% in those with a birth weight of 4750–5000 g, in a population-based study in California.18 In this cohort, nearly 10% of babies weighed 4500 g or more at birth; over 60% of these were in the planned vaginal delivery group, suggesting that more accurate assessment of fetal weight may be beneficial. Unfortunately, the estimation of fetal weight is particularly challenging in women with a high BMI as conventional methods, such as ultrasound scanning in late pregnancy, are likely to be difficult, inaccurate and, in some cases, not possible at all. Abdominal palpation and fundal height measurement are also not likely to be helpful in predicting the size of the baby. Other measures, such as magnetic resonance imaging, are also limited by the size of the machine and the cost and availability.

One of the main concerns about caesarean delivery for women with extreme obesity is the risk of anaesthetic complications in the emergency situation. A recent study of difficult and failed intubation in obstetric anaesthesia found that women whose tracheas proved difficult to intubate had a weight range of 50–140 kg (median, 80 kg), whereas those in whom intubation was straightforward ranged from 50 to 73 kg (median, 57 kg).19 In their logistic regression analysis, however, a weight of 100 kg or more was not an independent predictor of a difficult intubation. This may have been a result of the small sample size in the difficult intubation group (36 of 1095 patients) and the sole use of weight, rather than BMI. A study of failed intubation for obstetric anaesthesia is currently being conducted to investigate further the role of BMI in failed intubation.20 Anaesthetic complications were rare in our cohort, and there were no differences between the planned vaginal and planned caesarean groups.

Randomised controlled trials in the context of uncommon pregnancy conditions, such as extreme obesity, are challenging. National cohort studies, such as this, provide high-quality evidence in the absence of randomised controlled trials, as they are free from most of the biases of centre-based observational studies. Nevertheless, the study design does have limitations. We identified clear differences between the group planned to deliver vaginally and that planned to have a caesarean delivery, reflecting the clinical decision making which underlies the choice of mode of delivery, and we therefore adjusted for these in our analysis. It is likely, however, that there are other differences between the two groups which we have not identified and therefore have not been able to adjust for. UKOSS was also the only source of data used in the absence of any other available source; however, previous studies using this system have suggested a high rate of case ascertainment.21–23 The study was conducted in a well-developed health system and, as such, the results cannot be generalised to less developed health systems. It is likely that the health care for this group of women in countries such as the USA, Australia and many European countries will be similar, and therefore the results are likely to be generalisable to these settings.

Disclosure of interest

We do not have any interests to declare in relation to this study.

Contribution to authorship

CH undertook this particular analysis and wrote the first draft of the paper. JJK assisted with the design of the study and supervised the data collection and analysis, and contributed to writing of the paper. PB had the original idea for the surveillance system, provided advice at every stage of the study and contributed to the writing and editing of the paper. PS assisted with data coding, conducted validation of the data and contributed to writing of the paper. MK is the lead investigator on UKOSS and is responsible for the overall design and conduct of the study, as well as leading this analysis and working on subsequent drafts of the paper. All authors provided comment and approved the final version of the paper and the submission. MK will act as study guarantor.

Details of ethics approval

The UKOSS general methodology (04/MRE02/45) and this study (06/MRE02/77) were approved by the London Research Ethics Committee.

Funding

This paper reports on an independent study which was funded by the Policy Research Programme in the Department of Health. The views expressed are not necessarily those of the Department. MK is funded by the National Coordinating Centre for Research Capacity Development of the National Institute for Health Research. The funding sources played no part in the design, data collection, analysis and interpretation in the writing of the paper, or the decision to submit the paper for publication. The first author is a Chief Investigator on the Australasian Maternity Outcomes Surveillance System (AMOSS), a study similar to UKOSS. This work was undertaken when she was a Visiting Academic at the National Perinatal Epidemiology Unit as part of the AMOSS Project.

Acknowledgements

The authors thank the UKOSS reporting clinicians who notified cases and completed the data collection forms. The authors also acknowledge the assistance of the UKOSS Steering Committee and the support of the Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Obstetric Anaesthetists Association, Faculty of Public Health, National Childbirth Trust and the Confidential Enquiry into Maternal and Child Health. ▮

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

The current obesity epidemic presents significant challenges to the obstetrician, midwife and obstetric anaesthetists. There have been numerous publications highlighting the increase in the caesarean section (CS) rate (Quenby et al., BJOG 2007;114:343–8), the use of National Health Service (NHS) resources (Heslehurst et al., Obes Rev 2008;9:635–83) and maternal and fetal morbidity and mortality rates (Guelinckx et al., Obes Rev 2008;9:140–50) in morbidly obese pregnant women. A consequence of this data is the frequently voiced opinion at midwifery, obstetric and anaesthetic conferences that the safest way to deliver a women with a body mass index (BMI) over 50 kg/m2 may be by elective CS. This elective option has been proposed as a way of avoiding the known risks of vaginal delivery and emergency CS in this population. Homer et al. (BJOG 2011; DOI: 10.1111/j.1471-0528.2010.02832.x.) challenge the assumption that elective CS is safer than planned vaginal delivery in these morbidly obese women. A large proportion, 70% of women with BMI > 50 kg/m2, who had a planned vaginal delivery did indeed deliver vaginally without the expected increase in neonatal and postnatal complication rates compared with those with planned elective CS. These data strongly indicate that elective CS in morbidly obese women cannot be justified, except for the usual obstetric indications. Only in very unusual circumstances should elective caesarean be performed if the requisite obstetric indications are not present.

The other issue driving the elective CS management option is uncertainty regarding the abilities of junior medical staff to deal with obese women in an emergency when out-of-hours consultant cover is from home. This issue is illustrated by the Centre for Maternal and Child Enquiries/Royal College of Obstetricians and Gynaecologists (CMACE/RCOG) guideline (Modder J, Fitzsimon K. CMACE/RCOG Joint Guideline: Management of Women with Obesity in Pregnancy. London: CMACE/RCOG, 2010) stating, ‘An obstetrician and an anaesthetist at Specialty Trainee year 6 and above, or with equivalent experience in a non-training post, should be informed and available for the care of women with a BMI ≥ 40 during labour and delivery’. The importance of the data from Homer et al. (BJOG 2011; DOI: 10.1111/j.1471-0528.2010.02832.x.) is that it was collected at a time in the UK when out-of-hours cover frequently involved consultants on call from home. Hence, it appears that the current on-call consultant cover was adequate to provide care for morbidly obese women in labour. Although it is optimal to have senior clinicians available at all times on labour and delivery units, the study by Homer et al. (BJOG 2011; DOI: 10.1111/j.1471-0528.2010.02832.x.) provides reassurance that morbidly obese women can be sufficiently cared for by trainee physicians in the current system.

As 30% of women with extreme obesity had a planned CS, another explanatory factor for the data is that UK obstetricians are good at assessing those women in whom planned vaginal delivery is more likely to result in complications. Hence, the conclusions by Homer et al. (BJOG 2011; DOI: 10.1111/j.1471-0528.2010.02832.x.) with regard to individualized decision making on the mode of delivery for women with extreme obesity in pregnancy are soundly supported and routine elective caesarean in these circumstances cannot be justified.

Conflict of interest

None

S Quenby Warwick Medical School, University of Warwick, Coventry, UK

Journal club

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. References
  8. Commentary on ‘Planned vaginal delivery or planned caesarean delivery in women with extreme obesity’
  9. Journal club

Discussion points

  1. Background: Describe the risks of extreme obesity in the antenatal, perinatal and postnatal periods.

Debate the advantages and disadvantages of vaginal versus caesarean delivery, specific to women with extreme obesity.

2. Methods: Discuss the general methodology of UK Obstetric Surveillance System (UKOSS) studies (npeu.ox.ac.uk/ukoss/methodology), as well as the advantages and disadvantages, with particular reference to response rates and bias. What about this specific study?

3. Results and implications: Discuss the (low) rate of successful vaginal birth after caesarean (VBAC) for women with extreme obesity, and the possible reasons.

Evaluate the risks associated with emergency caesarean for these women, in the light of the 30% incidence in this study.

What is your perception of the level of risk of shoulder dystocia for extremely obese women with planned vaginal delivery? What are the specific difficulties around the management of this emergency in extremely obese women? Discuss, if possible, in multiprofessional groups.

The authors conclude that a policy of individualised decision making is necessary concerning the mode of delivery for women with extreme obesity. Discuss the factors that would affect such decisions in your personal practice.

D Siassakos University of Bristol and Southmead Hospital, Bristol, UK Email jsiasakos@gmail.com