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Optimizing Patient Safety in the Obese Parturient with an Interdisciplinary Planning Team: A Case Report
Abstract Number: 67
Abstract Type: Case Report/Case Series
A 29 year old G2 P0 woman with super obesity was followed by an interdisciplinary OB team during her pregnancy. The patient had a medical history significant for super obesity (540 lbs, BMI = 86 kg/m2), obstructive sleep apnea, chronic hypertension, Type II diabetes mellitus, thyromegaly with a large left-sided goiter, and a panic disorder. On physical examination the patient had a MP class III airway, adequate mouth opening, good neck extension, thyromental distance greater than 6 cm, and a large goiter. Her neck circumference above the goiter was measured at 56 cm. In addition, the patient described symptoms of airway compression when she turned her head to the side. An ENT consult confirmed our airway assessment, and noted that surgical management of the airway would likely be difficult.
The patient was admitted to the antepartum unit at 32 weeks of gestation for compliance with medical management. The initial OB plan was to induce labor at 37 weeks of gestation, with anticipation of vaginal delivery. Because the patient was unable to breathe easily in the supine position, the obstetricians agreed that a cesarean delivery (if necessary) could be performed in the semi-recumbent position. At one of the interdisciplinary OB team meetings for this patient, detailed plans were discussed for management of a "stat" situation. The team members were concerned about the safety of the mother and the fetus, as well as possible staff injuries during emergency patient transport and positioning of this very obese patient. Due to potential airway management problems and the significant risk of maternal death, the consensus was to avoid general anesthesia in an emergency setting. Neuraxial blockade would be attempted for emergency cesarean delivery, even if the potential time delay resulted in fetal morbidity or mortality. The anesthetic plan for labor analgesia or non-emergent cesarean delivery was a continuous lumbar epidural block. These plans were discussed extensively with the patient and she agreed. At 37 weeks of gestation, a lumbar epidural analgesic was placed, labor was induced and a vigorous newborn was born vaginally without complications.
This case illustrates several points:
1. Parturients with super obesity have additional risks for maternal and fetal safety, and require additional planning for safe peripartum care.
2. An interdisciplinary team with members from OB, OB anesthesiology and OB nursing is useful in formulating, communicating and implementing these plans.
3. The team approach to planning allowed input from all of the clinical constituencies and the patient, resulting in an excellent acceptance of the plan.
4. Although an Ethics Consult was available, it was not deemed necessary by the patient or any member of the health care team.