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Obesity and Pregnancy

1 Contact Hour
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN)
This course will be updated or discontinued on or before Monday, January 24, 2022
Course Description
Registered nurses working in labor and delivery should know how to provide evidence-based care to pregnant obese women.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Outcomes

Participants will understand how to care for the obese pregnant woman.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Identify why maternal obesity is a pregnancy risk.
  2. List ways that obesity can impact the woman during pregnancy.
  3. Identify how obesity can impact the fetus during pregnancy and delivery.
  4. Identify how obesity can affect the woman and child after birth.
  5. List ways the woman can improve her health outcomes.
  6. Plan care of the obese woman in labor and delivery.

Background

According to the National Health and Nutrition Examination Survey, 33.4% of women 20 to 34 years of age are obese and 58.4% are overweight.1 Obesity is a commonly overlooked medical problem in pregnant women. Obese women have increased risks for maternal and perinatal complications.2 Up to 25% of all pregnancy complications such as gestational hypertension, preeclampsia, gestational diabetes, and preterm birth may be related to maternal obesity.2

Risks During Pregnancy

Overall severe maternal morbidity and mortality (SMM) rates increase with increased body mass index (BMI). The higher the BMI, the greater the rate of SMM.3 Once pregnant, there are risks associated with obesity. Obese women have a significant increase in early pregnancy loss. Diabetes is another complication that can affect a pregnant woman. An obese woman who has not had recent testing may have undiagnosed type 2 diabetes. Gestational diabetes (diabetes that has an onset during pregnancy) is significantly higher in obese women. Gestational diabetes and type 2 diabetes can lead to additional maternal and fetal complications.1 Obesity is a risk factor for gestational hypertension and preeclampsia. Preterm birth is also a risk of obesity. This is not usually due to spontaneous preterm labor but medically indicated preterm delivery due to maternal medical reasons.2 Obstructive sleep apnea is worsened with obesity and weight gain in pregnancy, which can lead to increased complications.

Risks During Labor and Delivery

Obesity may lead to longer inductions of labor, longer labor times, and increased rates of c-sections. Obese women are also less likely to have a successful trial of labor after cesarean section. An obese woman has a higher risk of having a macrosomic infant (weight >4000 grams). Macrosomia can cause many delivery complications, including shoulder dystocia, an operative vaginal delivery, perineal lacerations, or a c-section. All of these complications can cause trauma to the mother or the fetus.2 Obese women may also have complications with anesthesia. The epidural or spinal may be more challenging to place in an obese woman.

Risks to the Fetus

As previously discussed, macrosomia is a problem that can affect the mother and fetus during delivery. Infants born to obese women also have an increased risk of hyperinsulinemia and hypoglycemia. As children of obese mothers age, they are more prone to childhood obesity and metabolic disorders. Some studies even show a link between obese mothers and children with neuropsychiatric and mood disorders.4 Congenital deformities such as neural tube defects, cardiovascular anomalies, and cleft palate all have an increased risk of occurring in a child delivered to an obese woman.

Risks After Delivery

Obese, postpartum women, especially women who have had a c-section, are at an increased risk for venous thromboembolism (VTE). These women are also at an increased risk for infection and postpartum depression.2 Women who have had a c-section are more likely to have repeat c-sections, which then can increase risks of placental abnormalities, adhesions, and complications from c-sections. Obese women and women with diabetes may have trouble with infection and wound healing. Women with preeclampsia have an increased risk of cardiovascular disease in the future.

How to Improve Outcomes

Weight loss is the most important factor in improving outcomes. Diet and exercise before getting pregnant can improve reproductive outcomes and pregnancy outcomes, and improve the woman’s overall health.5 A 10% reduction in pre-pregnancy BMI can have a positive impact on outcomes. Weight loss surgery prior to pregnancy may also be beneficial. Weight loss drugs should not be used during pregnancy. Weight gain should be less and varies depending on the severity of obesity.2 Early screening for diabetes is recommended and close surveillance of the woman and fetus during pregnancy is important.

Nursing Care of Obese Women

When caring for obese, pregnant women it is important not to judge the woman or make her feel guilty for being overweight, but instead teach the woman about ways that she can make small, easy changes to improve her health outcomes.6 The nurse can help the woman to identify barriers and find motivators to lead the woman to healthier eating and exercise. During labor and delivery, the nurse should be prepared for a longer labor with possible complications, such as shoulder dystocia, vacuum, forceps, or c-section delivery. Once the woman has delivered, the nurse should watch for signs of infection and VTE. The nurse should encourage breastfeeding, which can lead to more weight loss for mom and decreased risk of obesity for the infant. These women also need proper long-term medical care, such as screening for diabetes, hypertension, and heart disease.

Case Study

Patient M.S. is a 22-year old woman who presents to the prenatal clinic at 18 weeks gestation for her 1st prenatal visit. She is 5’4,” and her pre-pregnancy weight was 290, making her BMI 50. She has not had regular preconception medical care. She has not received any screenings at this point. She has gained 15 pounds since getting pregnant. Her vital signs are BP 108/68, HR 78, Resp 16, temp 98.5. She is complaining of excessive thirst, a urinary tract infection, and fatigue.

What risks does M.S have?

M.S. is at risk for all complications associated with obesity. She may be a type 2 or gestational diabetic considering her symptoms. She is at risk for gestational hypertension or preeclampsia, although her BP is currently fine.

What care is needed for M.S.?

M.S. needs a full exam and screening for diabetes. She needs education on diet, exercise, and a healthy weight gain for obesity. She needs to be taught the importance of keeping her appointments and having close surveillance of the pregnancy for her health and the health of her baby. She needs to know how important all of these things are and find the motivation to follow her plan of care.

Conclusion

Obesity is a serious problem in the United States. It is not a problem that can be fixed overnight. Obesity can cause severe complications to the mother and fetus. Women need education on the risks and how to decrease these risks before they get pregnant. It is important that all nurses and healthcare providers know these risks and educates their patients.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  1. ACOG Practice Bulletin No 156: Obesity in Pregnancy. Obstet Gynecol 2015; 126:e112. essential.
  2. Ramsey PS, Schenken RS. Obesity in Pregnancy: Risks and Management. UpToDate. Updated June 7, 2019. Accessed December 27, 2019. Visit Source.
  3. Lisonkova S, Muraca GM, Potts J, et al. Association Between Prepregnancy Body Mass Index and Severe Maternal Morbidity. JAMA 2017; 318: 1777.
  4. Howell KR, Powell TL. Effects of maternal obesity on placental function and fetal development. Reproduction. 2017;153(3). doi:10.1530/rep-16-0495. Visit Source.
  5. Practice Committee of the American Society for Reproductive Medicine. Obesity and reproduction: a committee opinion. Fertil Steril 2015; 104: 1116.
  6. Mccloud MB. Health Behavior Change in Pregnant Women With Obesity. Nursing for Womens Health. 2018;22(6):471-480. doi:10.1016/j.nwh.2018.09.002. Visit Source.