Obese Women and Anesthesia..

GilaRRT · Sep 23, 2009

You walk a thin line. Per the TOS, we are not here to give you advice about your friend. With that, an anesthesia provider who is fearful of morbidly obese patients is a good provider IMHO. These patients are at risk for a multitude of problems such as respiratory, cardiac, and even the life ending failed airway. Then, add morbid obesity and pregnancy, and you have a very high risk situation.

You may think it's only an epidural, then you are staring at the face of an apneic, obese patient with no reserve and a mallampatti of IV who needs a C-section.

RescueGrrl211 · Sep 23, 2009

Wow.. This is why Im just a nursing student. The entirity of your last paragraph is way over my head. Gonna get out my handy dandy medical dictionary now..

Just to clarify.. Im not asking for advice, per se. I just hadnt considered and dont understand the complications involved with obese women and epidurals. I supposed I knew that anesthesia warrents airway issues (Im guessing difficult intebation? Others?) but I wasn't (in my head) putting anesthesia and epidurals in the same category..

roser13, ASN, RN · Sep 23, 2009

"a mallampatti of IV "

Could you tell me what this is?

ukstudent · Sep 23, 2009

in anesthesiology, the mallampati score, also mallampati classification, is used to predict the ease of intubation.[1] it is determined by looking at the anatomy of the oral cavity; specifically, it is based on the visibility of the base of uvula, faucial pillars (the arches in front of and behind the tonsils) and soft palate. scoring may be done with or without phonation. higher mallampati score (class 4) is associated with more difficult intubation as well as a higher incidence of sleep apnea.[2]

scoring is as follows:

class 1: full visibility of tonsils, uvula and soft palate

class 2: visibility of hard and soft palate, upper portion of tonsils and uvula

class 3: soft and hard palate and base of the uvula are visible

class 4: only hard palate visible

http://en.wikipedia.org/wiki/mallampati_score

this is how people can die, get anoxic brain injury, get nasal intubation and or emergency trached. that doctor your friend went to see who told her about a patient that died, did a good job. too many people think that just because they are coming to a hospital that nothing bad can happen to them. people die in hospitals and not because someone did anything wrong.

allnurses Guide · Sep 23, 2009

The safest thing for a morbidly obese pregnant woman would be to have an epidural placed early in her labor in order to evaluate its effectiveness and very slowly dose it up. The problem that you always have to think of when dealing with OB patients is that you may have to goto C-section with this patient. A morbidly obese patient is bad enough to intubate on the best days, but a morbidly obese patient that needs an emergent intubation can be just a plain nightmare. In general having a C-section under a general anesthetic vs. regional anesthetic carries a 16x greater risk of morbidity and mortality.

In no way is this to be considered medical advice! There is a lot more things to consider than just someones weight and pregnancy status when you are considering doing an epidural or spinal anesthetic.

bja.oxfordjournals.org/cgi/reprint/74/6/638.pdf (article on MP scores changing during pregnancy)

catshowlady · Sep 23, 2009

Also, re: epidurals, everyone thinks they are no big deal, but if the pt has a reaction, things can go downhill very quickly. I personally took care of a pt who had an epidural placed at bedside for postop pain control. Just the amt of med given during the placement caused his pressure to drop into the 60's. We were able to stabilize him, but intubation was a real possibility for awhile d/t needing to protect that airway.

Speaking of airways, remember that is the A in the ABC's of BLS. Morbidly obese pts often have airways that are difficult to secure. I'm thinking that may be one of pieces of information that you didn't know (and we didn't come right out and say it because it's second nature to many of us)

:paw:

CeilingCat, ASN, RN · Sep 23, 2009

I feel so bad for her! Her OBGYN sent her 2 hours away to a bigger hospital today, and the doctor chose to tell her a story of a pt that DIED from complications. Isn't that heartbreaking? .

Heartbreaking that they're warning her of the dangers of her situation? Or heartbreaking that someone died? (Not sure which you mean)

It's true that one you get to a really big size, anesthesia is a problem. Some morbidly obese who want to get bariatric surgery (to lose weight) have to get their weight down first, because of the issues of anesthesia & their size. I have a friend who is 450# and can't be eligible for bariatric surgery (or any kind of surgery) until he loses quite a bit of weight!

I don't think it's fair to assume that they haven't discussed natural childbirth: we're not there, so we don't know what her doctors said to her. It does seem logical that they considered everything. It's a fact that there are always a % of births that don't go perfectly. If she's not in a hospital set up to do anestesia on a 400 pound person, she could be out of luck, should complications arise. There is also the issue of moving her, so the other hospital should have more access to "bariatric" lifts, stretchers, and other larger equipment.

As a chubby person myself, I have nothing against peoples' weight, big or small. But I also recognize that at 400#, she's stacking the deck against herself. Childbirth itself is not without some risk, plus this is with twins. Morbidy obesity carries its own risks. It's none of my business on why she is pregnant (I will assume this was planned since the last one was), but she should not be feeling descriminated against. It's better she is given full disclosure of her risks and plans to go into a better equipped facility. Instead of feeling bad for her hurt feelings, I'd focus on what is best for the babies and what's best for her health/wellbeing.

**canoehead, BSN, RN** · Sep 23, 2009

This is JMHO, but in general if a woman does well with her first 2 births, probably the same will happen with the third. BUT the reason she's going to a hospital is so they can be ready for that small percentage of women who end up with a problem. It's a trueism that if we are ready for a complication it won't happen, and the minute you let your guard down things go all to hell.

Yes, an obese woman is at higher risk of everything bad, and your friend knows that I'm sure. What is she supposed to DO at this point? Not a thing.

Malick · Mar 21, 2010

300 years Go Women would deliver without it , she has to endure the pain and have her twins , because its better to have the pain , than delivering 2 orphans because she dies due to complications.

Just a point of view,

Malick :redpinkhe

Not_A_Hat_Person, RN · Mar 22, 2010

Since she has had 2 normal, lady partsl births wouldn't going drug free on a natural delivery be your best case scenario? I mean, I know they have to prepare for the worst by fitting her with specific equipment, but she said that nobody has even mentioned a natural birth to her.

Has your friend expressed interest in drug-free childbirth? Since she had 2 uncomplicated epidurals, I think the best-case scenario would be a lady partsl childbirth with an epidural.

Not long ago, I weighed over 300 lbs, and I let myself be talked out of anesthesia for a dental procedure because it was "risky." It was horrifying, and I have been wary of dentists ever since. Childbirth pain may be "different", but when has obesity ever been an acceptable reason to withhold pain relief from a patient? If your friend can't find an anesthesiologist who is willing to give her an epidural, she should keep looking until she finds one.

I think trying to convince a woman with 2 prior uncomplicated epidurals to go drug-free for delivery is a bad idea. A woman's desire to avoid pain should be respected, just like a desire not to breastfeed. Obese people face enough problems accessing medical care without being told they're too fat for pain relief.

cookderosa · Mar 22, 2010

I'm pleasantly surprised that they are so supportive of lady partsl twin delivery. That's not the climate here. Here, she would be considered very high risk and scheduled for a c/s, I have no doubt in my mind.

Anyway, I'm with Malak. The risks of orphaning 4 children are real. I don't think this is a case of being a natural childbirth zealot. Simply, if she and babies all make it to term and are healthy, and they are talking lady partsl birth, then she really should consider not entering anesthesia into the mix. She can and should learn pain coping methods- many of them work very well!

Speaking only as a mom though, making it to term would be my first goal. I say this as an aunt of 3 sets of twins- all early, one set born at 24.5 The medical care fades away and the realities of raising these children set in. Her health now, is SO very important.