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 Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 1  |  Page : 22-26

Anesthetic technique for elective cesarean section in obese parturients: A cross-sectional study

Department of Anaesthesia, Prince Sultan Military Medical City, Riyadh, KSA

Date of Submission15-Jan-2020
Date of Acceptance16-Jan-2020
Date of Web Publication3-Oct-2020

Correspondence Address:
Dr. Sadaf Malik
Department of Anaesthesia, Prince Sultan Military Medical City, Riyadh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SJL.SJL_1_20

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Context: A pregnant obese is at an increased risk of several serious adverse outcomes. Anesthesia-related morbidity and mortality are increased in this patient population.
Aims: The primary aim of this study was to find the incidence of obesity in parturients presenting for elective cesarean section (CS) and the anesthesia technique offered to these obese parturients.
Materials and Methods: A cross-sectional study of patients presenting for elective CS was done over 2 months. The data included patients' age, height, weight at the first antenatal visit and at term, parity, and type of anesthesia. The percentage of obese parturients was determined by calculating the body mass index from the data.
Results: Data were calculated from 109 patients. The percentage of obese parturients was 60% and 16.5% were overweight. Spinal anesthesia was employed in 60% of obese parturients for elective CS.
Conclusion: The increasing number of obese parturients is alarming and among the highest in the region. The percentage of spinal anesthesia for elective CS is below the recommended international guidelines.

Keywords: Cesarean section, obesity, regional anesthesia, spinal block

How to cite this article:
Malik S, Anwari JS, Alotaibi RA. Anesthetic technique for elective cesarean section in obese parturients: A cross-sectional study. Saudi J Laparosc 2020;5:22-6

How to cite this URL:
Malik S, Anwari JS, Alotaibi RA. Anesthetic technique for elective cesarean section in obese parturients: A cross-sectional study. Saudi J Laparosc [serial online] 2020 [cited 2022 May 19];5:22-6. Available from: https://www.saudijl.org/text.asp?2020/5/1/22/296779

  Introduction Top

Obesity is an endemic worldwide.[1] A similar trend is reflected in the pregnant population. It is estimated that over 50% of pregnant females in the USA are obese.[2] Saudi Arabia is no exception with multifactorial reasons to this international trend of obesity.[3] The increasing number of obese parturients and the unique challenges they offer to the involved physicians in their health care has led to specific guidelines for the management of obese parturients in labor and delivery.[4] This cross-sectional study was conducted to see the percentage of obese parturients presenting for elective cesarean section (CS) and to audit the type of anesthesia offered to the obese parturients.

  Materials and Methods Top

One hundred and twenty-one women undergoing elective CS at Prince Sultan Military Medical City from October 01, 2017, to November 30, 2017, were prospectively studied. Approval for this study was obtained from the Hospital Ethics Committee (Project No. 972, approved in July 2017). Women undergoing elective CS with American Society of Anesthesiologists physical status score 1 or 2 were included in the study. Exclusion criteria were contraindications to spinal anesthesia, known previous spinal pathology, history of antepartum hemorrhage, allergy to local anesthetic agents, patients with any psychiatric illness, and all emergency CS.

Demographic data collected were age, weight, and height. Weight at the first antenatal visit was recorded from the antenatal follow-up card. Weight and height at term were recorded from the preoperative anesthesia assessment chart. Anesthetic data obtained were the type of anesthesia technique employed for the procedure. Data were entered into the Statistical Package for the Social Sciences Sciences 16.0 (SPSS, IBM, ARMONK, USA) for Windows Product. Body mass index (BMI) was calculated from the available data of weight and height. The percentage of normal weight, overweight, obese, and morbid obese was calculated. Normal weight was defined as BMI 18.9–24.9 kg/m2 at the first antenatal visit (up to 9 weeks) or <28.4 kg/m2 at term and overweight as BMI 25–29kg/m2 at the first antenatal visit or 30–32 kg/m2 at term. Obesity was defined as having BMI >30 kg/m2 at the first antenatal visit (up to 9 weeks) or having BMI >33 kg/m2 at term. Morbid obese was classified as having BMI >40 kg/m2 at first visit or BMI >43 kg/m2 at term.

These terms were classified as per the World Health Organization, using BMI at the first antenatal visit (up to 9 weeks) to define normal weight (<25 kg/m2), overweight (25–29 kg/m2), obese (>30 kg/m2), and morbid obese (>40 kg/m2).[5] Maternal pregnancy BMI was calculated from maternal weight and height at term with the following cutoff values as suggested by Catalano et al.: normal weight <28.4 kg/m2, overweight 28.5–32.9 kg/m2, and obese >33 kg/m2.[6] The type of anesthesia employed for these groups was expressed as percentage.

  Results Top

One hundred and twenty-one women who underwent elective CS in the abovementioned period were included in the study. Twelve patients were later dropped due to incomplete or missing data. The mean age of parturients was 32 years (± standard deviation [SD] 5.35). The mean weight at term was 87 kg (± SD 16 kg), and the mean height was 1.57 m (± SD 0.06 m). The percentage of obese parturients was 60.5% (66). The number of morbidly obese patients was 11 (10%). About 16.5% (18) of all the patients were overweight [Figure 1].
Figure 1: Distribution of patients according to the body mass index

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Of 109 patients, 58.7% (64) had spinal block and 41.3% (45) had general anesthesia (GA) [Figure 2].
Figure 2: Anesthesia technique for the study group

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The percentage of obese parturients receiving spinal anesthesia for CS was 60.6% (40 out of 66). The rest of the obese pregnant patients (39.3%, 26) received general anesthesia for CS [Figure 3].
Figure 3: Flowchart of the cross-sectional study

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  Discussion Top

Obesity is an epidemic worldwide. For different socioeconomic reasons, both developed and underdeveloped parts of the world have an alarming rate of increase in the obese population. In 2016, more than 1.9 billion adults, 18 years and older, were overweight. Of these, over 650 million were obese.[1] Saudi Arabia is no exception to this international trend of obesity. The impact of trending westernized culture, increased influx of fast food, hostile weather for exercise, and outdoor sports are few reasons attributable in making Saudi Arabia one of the leading countries having a high percentage of obese population.[3] According to Forbes, Saudi Arabia ranks 29 on a 2007 list of the fattest countries with a percentage of 68.3% of its citizens being overweight.[7] Data on obesity from Saudi Arabia are scarce and lack national-level representation. One research survey done in 2013 by interviewing 10,735 Saudis aged 15 years or older revealed that 28.7% were obese. The prevalence of obesity was higher among women.[8]

Obesity in pregnancy is hence becoming a global burden and poses unique challenges to the physicians involved in health care. The prevalence of obesity in women of childbearing age is highest in Saudi Arabia among the Middle Eastern region.[9] There is no agreed definition of obesity specific to pregnancy, and BMI classifications have limitations in certain populations such as those with advanced age, athletes, and in pregnancy. BMI should be calculated from prepregnancy height and weight. Those with a BMI greater than 30 kg/m2 before getting pregnant or at the first antenatal visit (up to 9 weeks) are considered obese.[10] However, many parturients present later than the first trimester in the antenatal clinic, and subjective assessment of antenatal weight based on memory is not accurate. Therefore, maternal pregnancy BMI was calculated from maternal weight and height at term as suggested by Catalano et al.[6] This audit indicates an alarming percentage of obese parturients (60.5%) and overweight (16.5%) in the study group. A large cohort study conducted in Riyadh showed comparable results to our audit on percentage of obese among pregnant females. This cohort study included 14,658 pregnant females and showed that more than 68% of the participants were either overweight or obese when BMI was calculated according to self-reported prepregnancy weight.[11]

Keeping in view the increased rate of multiple complications associated with obesity in pregnancy, both the American College of Obstetricians and Gynecologists (ACOG)[12] and the Royal College of Obstetricians and Gynaecologists (RCOG) in conjunction with the Centre for Maternal and Child Enquiries published guidelines recommending a multidisciplinary team approach when caring for the obese parturients.[4] The major maternal complications prevalent in obese parturients are hypertension (chronic hypertension and preeclampsia), diabetes mellitus (pregestational and gestational), respiratory disorders (asthma and sleep apnea), thromboembolic disease, and infections (primarily urinary tract infections, wound infections, and endometritis). The rate of labor complications is also increased in obese pregnant patients such as intrapartum fetal distress, meconium aspiration, failure to progress, abnormal presentation, shoulder dystocia, and increased rate of instrumental and CS. Obese pregnant patients have an increased risk of intraoperative blood loss and postpartum hemorrhage.[13] Maternal obesity is associated with large for gestational age infants. There is an increased risk of a macrosomic fetus, infant birth defects, and stillbirth. Obesity is also a risk factor for anesthesia-related maternal morbidity and mortality.[14] These patients present with technical difficulties of airway management and regional blocks. No anesthetic technique is without special hazards in grossly obese patients. The obese parturients need thorough preoperative assessment for difficult airway as the incidence of failed intubation is eight times higher than in nonobese patients. It is also associated with an increased difficulty in mask ventilation. This is related to the short neck, fat deposition in the neck and shoulders increasing the difficulty for optimal position for laryngoscopy, breast hypertrophy as well as enlarged tongue, and excessive palatal and pharyngeal soft tissues. Neuraxial techniques are the preferred anesthetic techniques for CS in obese parturients but can be technically challenging. The appropriate positioning of the patient and identification of the midline can be difficult. Multiple attempts of spinal anesthesia and epidural catheter placement are common.[15]

Our study is one of the first to assess the type of anesthesia offered to the obese parturients of the community. The Royal College of Anaesthesia sets a standard of proportion of regional anesthesia of greater than 95% for category elective CS. It is recommended that a similar percentage should be ideally present for the obese parturients.[4] These recommendations are based on the benefits of regional anesthesia over general anesthesia for obstetric population.[16] Obesity is identified as a risk factor for anesthesia-related maternal mortality by the past two Confidential Enquiry into Maternal and Child Health (CEMACH) reports. In the last CEMACH report, of the six direct deaths attributable to anesthesia, four patients were obese, and of these, two were morbidly obese, with a BMI of greater than 35.[17]

The percentage of pregnant females receiving spinal block for cesarean is 58.7% in the whole group and approximately 60% in the obese parturients in our study group. This percentage is well below the recommended international guidelines. The reasons for low proportion of regional anesthesia are multifactorial. There are multiple myths in general population about spinal block like spinal block causes permanent headache and spinl block causes damage to spinal cord. Being influenced by these trending myths many females are reluctant to opt for spinal block for elective c section and hence receive general anaesthesia by choice. Back pain is the most common misconception related to spinal anesthesia. Many females have a firm belief that “a needle in the backbone” will result in permanent and continuous back pain and this myth runs in the family.[18]

Another reason is a lack of appropriate antenatal counseling. There is a strong need to implement a system of antenatal counseling of the parturients, especially the obese ones. ACOG and RCOG strongly recommend that all obese parturients, particularly with BMI >40 kg/m2, get an anesthesia consultation during their third trimester. During this meeting, the patients should be briefed about the anesthesia choices available and merits and demerits of both GA and regional. The importance of regional anesthesia and analgesia should be explained well and also the fact that neuraxial techniques might be technically difficult and time-consuming; therefore, patients should be encouraged to request neuraxial analgesia early in labor.

The failure rate of spinal block is high in the obese population as compared to the nonobese due to technical difficulties.[19] Although we have not calculated the incidence of failed spinal converted to GA in our study group, this can be a contributory factor to our observation. The failure rate of spinal anesthesia is also related to operator experience, trainees have a higher failure rate for spinal block in obese population. This warrants strict supervision of trainees to prevent morbidity and mortality in obese parturients.[16] With the high percentage of obese parturients in our population, it is even more important to refer the obese parturients for an early anesthetic consultation so that a proper preoperative assessment is done, and if required, a multidisciplinary team is involved.[20]

The high percentage of obese parturients requires us to look into the practical problems that these patients have in the operating theater. The presence of appropriate-sized blood pressure (BP) cuffs is very important as close monitoring of BP is mandatory, especially with regional block. The surgical beds should be appropriate for the adequate weight-bearing. There should be adequate personnel and proper equipment to transfer obese patients from bed to trolley.[21] The distance to the epidural and dural space is greater with increased BMI. Therefore, longer than standard spinal and epidural needles should be available. Adequate staffing is needed to ensure that the patient is properly and centrally positioned for neuraxial anesthesia. Obese parturients need to be in a ramped position on the operating table. These patients should be properly secured to the operating table first, and then, left uterine displacement should be initiated.[15]

The small study size and the inclusion of only urban population in the study group is one of the limiting factors of this study. This study depicts a strong need to address and audit further areas of concern for this group of population.

  Conclusion Top

The percentage of obese parturient is alarmingly high in the region. The study reflects that the percentage of regional anaesthesia for this group of population is below the recommended guidelines. There is a strong need to improve proper antenatal counselling of the obese parturient regarding the benefits of regional anaesthesia over general anaesthesia.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Obesity and Overweight, Fact Sheet. World Health Organization; 2017. Available from: http://www.who.int/mediacentre/factsheets/fs311/en. [Last accessed on 2018 Feb 25].  Back to cited text no. 1
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity among adults: United States, 2011-2012. NCHS Data Brief 2013:1-8.  Back to cited text no. 2
DeNicola E, Aburizaiza OS, Siddique A, Khwaja H, Carpenter DO. Obesity and public health in the Kingdom of Saudi Arabia. Rev Environ Health 2015;30:191-205.  Back to cited text no. 3
Modder J, Fitzsimons KJ. The Centre for Maternal and Child Enquiries (CMACE) and the Royal College of Obstetricians and Gynaecologists (RCOG). CMACE/RCOG Joint Guideline. Management of Women with Obesity in Pregnancy; 2010. Available from https://www.rcog.org.uk/en/guidelines-research-services/guidelines/management-of-women-with-obesity-in-pregnancy. [Last accessed 2018 Feb 25].  Back to cited text no. 4
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Catalano PM, McIntyre HD, Cruickshank JK, McCance DR, Dyer AR, Metzger BE, et al. The hyperglycemia and adverse pregnancy outcome study: Associations of GDM and obesity with pregnancy outcomes. Diabetes Care 2012;35:780-6.  Back to cited text no. 6
World's Fattest Countries Forbes; 08 February 2007. Available from: https://www.forbes.com/2007/02/07/worlds-fattest-countries-forbeslife.[Last Accessed on 2020 Feb 05].  Back to cited text no. 7
Memish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al. Obesity and associated factors-Kingdom of Saudi Arabia, 2013. Prev Chronic Dis 2014;11:E174.3.  Back to cited text no. 8
Al-Quwaidhi AJ, Pearce MS, Critchley JA, Sobngwi E, O'Flaherty M. Trends and future projections of the prevalence of adult obesity in Saudi Arabia, 1992-2022. East Mediterr Health J 2014;20:589-95.  Back to cited text no. 9
Davies GA, Maxwell C, McLeod L, Gagnon R, Basso M, Bos H, et al. SOGC clinical practice guidelines: Obesity in pregnancy. No. 239, February 2010. Int J Gynaecol Obstet 2010;110:167-73.  Back to cited text no. 10
Wahabi H, Fayed A, Esmaeil S, Alzeidan R, Elawad M, Tabassum R, et al. Riyadh mother and baby multicenter cohort study: The cohort profile. PLoS One 2016;11:e0150297.  Back to cited text no. 11
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Castro LC, Avina RL. Maternal obesity and pregnancy outcomes. Curr Opin Obstet Gynecol 2002;14:601-6.  Back to cited text no. 13
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