Obesity

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Document title:

Obesity

Publication date:

March 2010

Document number:

MN10.14-V3-R15

Replaces document:

MN1003.14-V2-R13

Author:

Queensland Maternity and Neonatal Clinical Guidelines Program

Audience:

Health professionals in Queensland public and private maternity services

Exclusions:

Nil

Review date:

March 2015

Endorsed by:

Statewide Maternity and Neonatal Clinical Network

QH Patient Safety and Quality Executive Committee

Contact:

Queensland Maternity and Neonatal Clinical Guidelines Program

Email: MN-Guidelines@health.qld.gov.au
URL: www.health.qld.gov.au/qcg

Disclaimer
These guidelines have been prepared to promote and facilitate standardisation and consistency of
practice, using a multidisciplinary approach.
Information in this guideline is current at time of publication.
Queensland Health does not accept liability to any person for loss or damage incurred as a result of
reliance upon the material contained in this guideline.
Clinical material offered in this guideline does not replace or remove clinical judgement or the
professional care and duty necessary for each specific patient case.
Clinical care carried out in accordance with this guideline should be provided within the context of
locally available resources and expertise.
This Guideline does not address all elements of standard practice and assumes that individual
clinicians are responsible to:
! Discuss care with consumers in an environment that is culturally appropriate and which
enables respectful confidential discussion. This includes the use of interpreter services
where necessary
! Advise consumers of their choice and ensure informed consent is obtained
! Provide care within scope of practice, meet all legislative requirements and maintain
standards of professional conduct
! Apply standard precautions and additional precautions as necessary, when delivering care
! Document all care in accordance with mandatory and local requirements

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 2.5 Australia licence. To view a copy of this
licence, visit http://creativecommons.org/licenses/by-nc-nd/2.5/au/
State of Queensland (Queensland Health) 2010
In essence you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the authors
and abide by the licence terms. You may not alter or adapt the work in any way.
For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001,
email ip_officer@health.qld.gov.au , phone (07) 3234 1479. For further information contact Queensland Maternity and Neonatal Clinical
Guidelines Program, RBWH Post Office, Herston Qld 4029, email MN-Guidelines@health.qld.gov.au phone (07) 3131 6777.

Refer to online version, destroy printed copies after use

Page 2 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Key Recommendations
No

Recommendation
1.

A multidisciplinary team approach is recommended for the care of obese women

2.

Calculate and document pre-pregnancy BMI for all women early in pregnancy

3.

Use the WHO cut off points for classifying pre-pregnancy BMI

4.

Discuss desirable weight gain and rate of gain with all women early in pregnancy

5.

Advise maternal weight gain within the ranges specified for each BMI classification

6.

Offer counselling on diet and physical activity to all pregnant women

7.

Discuss healthy eating, physical activity and breastfeeding as strategies for returning to
pre-pregnancy weight with all postpartum women

8.

Antenatal anaesthetic consultation is recommended for obese women

9.

Increased clinical surveillance is recommended across the peripartum period for obese
women due to the increased risk of complications

10.

Offer obese women additional support for breastfeeding

11.

Advise obese women of the benefits of weight loss preconception and between
pregnancies

12.

Consider the clinical service capabilities of the facility in determining care provision for
pregnant obese women (including workforce, facility design and equipment
requirements)

Refer to online version, destroy printed copies after use

Page 3 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Abbreviations
BMI

Body mass index

CS

Caesarean section

CTG

Cardiotocograph

CVS

Chorionic villus sampling

IV

Intravenous

NASH

Non alcoholic steatohepatitis

OGTT

Oral Glucose Tolerance Test

SWL

Safe working load

VTE

Venous thromboembolism

WHO

World Health Organisation

Terminology
Local facilities may as required, differentiate the roles and responsibilities assigned in this document
to an Obstetrician according to their specific practitioner group requirements; for example to
General Practitioner Obstetricians, Specialist Obstetricians, Consultants, Senior Registrars and
Obstetric Fellows.

Refer to online version, destroy printed copies after use

Page 4 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Table of Contents
Introduction.....................................................................................................................................6
1.1
Definition ................................................................................................................................ 6
1.1.1 Calculation of BMI..............................................................................................................6
1.1.2 Classification of BMI ..........................................................................................................6
1.1.3 Ethnic variations to the WHO classification .......................................................................6
1.2
Incidence................................................................................................................................ 6
1.3
Health risks of obesity in pregnancy......................................................................................7
1.4
Facility capabilities.................................................................................................................8
1.5
Specialist equipment..............................................................................................................8
1.6
Workforce requirements ........................................................................................................8
1.7
Transfer of care .....................................................................................................................8
1.7.1 Transport capacity .............................................................................................................9
2 Antenatal care ................................................................................................................................ 9
2.1
Weight stigma ........................................................................................................................9
2.2
Documenting BMI ..................................................................................................................9
2.3
Weight gain ..........................................................................................................................10
2.4
Maternal assessment and monitoring..................................................................................10
2.4.1 Maternal investigations ....................................................................................................11
2.5
Fetal assessment and monitoring........................................................................................11
2.5.1 Ultrasound........................................................................................................................11
2.6
Anaesthetic considerations..................................................................................................11
2.7
Counselling ..........................................................................................................................12
2.8
Nutrition................................................................................................................................ 12
2.9
Physical activity ...................................................................................................................12
2.9.1 Medical supervision of exercise programs ......................................................................12
2.9.2 Warning signs to terminate exercise ...............................................................................13
3 Intrapartum care ...........................................................................................................................13
4 Postpartum care ...........................................................................................................................13
4.1
Breast feeding......................................................................................................................14
5 Inter-conception care....................................................................................................................14
6 Pregnancy after bariatric surgery .................................................................................................14
References ..........................................................................................................................................15
Appendix A: Body mass index chart....................................................................................................17
Appendix B: Suggested clinical service capability for referral .............................................................18
Acknowledgements..............................................................................................................................19
1

List of Tables
Table 1. Classification according to BMI ............................................................................................... 6
Table 2. Weight capacity by mode of transport ..................................................................................... 9
Table 3. Target weight gains ............................................................................................................... 10

Refer to online version, destroy printed copies after use

Page 5 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Introduction

Obesity is a significant health issue for women during pregnancy and the puerperium. It is well
recognised that maternal obesity is associated with an increased risk of maternal, antenatal,
peripartum and neonatal complications.1,2 Obesity not only has direct implications for the health of the
pregnancy but also impacts on the weight of the child in infancy and beyond.3,4
There is little high level evidence on best practice management of obesity (Body Mass Index greater
than 30 kg/m2) in pregnancy and the puerperium from randomised trials. This guideline summarises
current information and makes consensus recommendations.

1.1

Definition

Body Mass Index (BMI) provides the most useful albeit crude population level measure of obesity
and can be used to estimate the relative risk of disease in most people.5
Other functional criteria6 may be considered such as maternal:
! weight and girth exceeds or appears to exceed the identified safe working load/capacity of
standard hospital equipment
! mobility is restricted due to size in terms of height or weight
1.1.1 Calculation of BMI
BMI is defined as weight in kilograms divided by the square of the height in metres (kg/m2). Refer to
Appendix A for BMI calculation table.
! Standard procedures for routine measurement of height and weight should be utilised to
improve consistency of serial measurements2
! Pre-pregnancy weight should be used where possible to avoid over estimation of BMI
1.1.2 Classification of BMI
The World Health Organisation (WHO) classifies obesity according to BMI5 as outlined in Table 1.
Table 1. WHO Classification of obesity according to BMI

Classification

BMI (kg/m2)

Risk of co-morbidities

Underweight

Less than 18.5

Low (but risk of other clinical problems increased)

Normal range

18.5- 24.9

Average

Overweight

25-29.9

Increased

Obese I

30-34.9

Moderate

Obese II

35-39.9

Severe

Obese III

Greater than or equal to

40.0

Very severe

1.1.3 Ethnic variations to the WHO classification

Ethnic origin may impact on the health risks associated with various BMI levels2,7
! Asian populations: health risks associated with obesity may occur at lower BMI2,7
! Polynesian populations: health risks associated with obesity may occur at higher BMI8

1.2

Incidence

In 2008 the Queensland Perinatal Data Centre reported that:

! 22% of mothers aged between 15 and 45 were classified as obese at the time of
conception9
! higher proportions of Indigenous mothers were classified as obese compared with nonIndigenous mothers (29.1% compared with 21.8%)9

Refer to online version, destroy printed copies after use

Page 6 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

1.3

Health risks of obesity in pregnancy

Obstetric complications of maternal obesity are generally related to pre-pregnancy obesity although
excessive weight gain during pregnancy is also implicated. The degree of relative risk of
complications is directly related to the level of obesity.
Table 2. Health risks of obesity in pregnancy

Health risk
Preconception
Antenatal

Medical

Peripartum
monitoring

Increasing BMI associated with increased risk of:

!
!
!
!
!
!
!
!
!
!

Neonatal

!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!

Childhood

Anaesthetic

Intrapartum

Postpartum

Infertility10
Antepartum stillbirth11
Maternal mortality12
Diabetes (Gestational and Type 2)11
Preeclampsia11
Obstructive sleep apnoea-may be related to adverse fetal outcomes11
Thromboembolic disease11
Cholecystitis11
Depression2
Difficulties obtaining adequate auscultation of fetal heart and
cardiotocograph (CTG)13
Suboptimal ultrasonography3
Increased failure of epidural analgesia during labour11
Difficult intubations11
Increased risk of regurgitation and aspiration of stomach contents14
Failed attempts at vaginal birth after caesarean section11
Induction of labour11
Failed induction of labour11
Caesarean section (CS)11
Operative and complicated vaginal birth11
Difficult surgical access15
Shoulder dystocia11
Obstructed labour13
Haemorrhage11
Endometritis13
Surgical site infections13
Chest, genital tract, and urinary infections11
Reduced breastfeeding11
Preterm birth11
Admission to neonatal intensive care units11
Macrosomia11
Congenital malformations16
o neural tube defects
o congenital heart disease
o omphalocele
Increased risk of obesity11

Refer to online version, destroy printed copies after use

Page 7 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

1.4

Facility capabilities
!

!
!

1.5

Specialist equipment
!
!
!
!

1.6

Large patient equipment that has sufficient SWL and appropriate size/width to
accommodate patient girth is required (for example hoists, beds, shower chairs, lateral
transfer devices, wheelchairs, bed-side chairs)
Each facility should maintain an inventory of large patient equipment including equipment
location, accessibility and contact person
Clear labelling of large patient equipment with SWL is required
Each facility should have standard operating procedures for the safe use, movement and
storage of all large patient equipment

Workforce requirements
!
!
!
!

1.7

Each facility should consider its physical and service delivery capabilities in determining
appropriate care, referral or transfer of obese women, including (but not limited to):
o facility design (for example width of access doors and pathways, turning circles for
large patient equipment, availability of suitable accommodation)
o availability of large patient equipment with appropriate safe working loads (SWL)
and widths
o workforce capabilities (for example access to a range and number of appropriately
skilled health care professionals)
o capability to manage the potential risks and complications of obesity
A facility/district-wide management plan that outlines the facilitys response to the planned
or unplanned admission of an obese woman is recommended6,17
Facilities have a responsibility to inform the community of limitations within the service
regarding the care of obese women

Additional workforce may be required to care for obese women13

Access to a range of allied health staff is recommended7
Task specific training, including safe handling procedures and the use of large patient
equipment should be provided to all staff involved in the care of obese women
Consider work allocation and rotation of staff caring for obese women to minimise
physical strain on the workforce

Transfer of care

Transfer or referral to higher level facilities may be appropriate at various BMI thresholds [see
Appendix B for suggested service capabilities].
! All service levels should:
o have documented processes for referral and transfer to higher level services
o ensure safe patient transport in vehicles with sufficient load capacity
! In the event a woman does not choose to follow the advice offered regarding transfer of
care:
o clear and detailed records of all conversations should be made in the health record
o facilities are advised to conduct an individual risk assessment and formulate a risk
management plan in consultation with the woman

Refer to online version, destroy printed copies after use

Page 8 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

1.7.1 Transport capacity

Transport weight restrictions for Retrieval Services Queensland are outlined in Table 3
Table 3. Weight capacity by mode of transport

Mode of transport
Road ambulance stretcher
Fixed wing aircraft

Maximum
weight (kg)
160
160

Rotary Helo A139

Rotary Helo Bell 412
Large patient ambulance

180
250
300

Comment

Width of patient (hip to hip) not greater than 80 cm

to allow entrance through aircraft door
No width restrictions through aircraft door
No width restrictions through aircraft door
Only two (2) in QLD both in Brisbane

Antenatal care

The management of obesity requires a multidisciplinary approach7 which may include access to:
Midwives, Obstetricians, Physicians, Ultrasonographers, Maternal Fetal Medicine Specialists,
Anaesthetists, Dietitians, Physiotherapists, Occupational Therapists, Psychologists, Social Workers
and other Allied Health Care Professionals. Management options will depend on the resources and
services available at each facility.

2.1

Weight stigma

Overweight and obese women may experience discrimination and prejudice due to their body weight
and appearance. Health professionals can minimise weight stigma by ensuring:
! a non-judgmental approach to care
! womens comfort, modesty and privacy with appropriately sized equipment and gowns
! private measurement and discussion of body weight and weight gain

2.2

Documenting BMI
!
!
!
!
!

Height and pre-pregnancy weight should be recorded in the health record for all women at
the initial antenatal visit7,13 (including by primary care providers)
Height and pre-pregnancy weight should be recorded for all women on the Perinatal Data
Collection Form (MR63d) to facilitate the collection of state-wide data on BMI in
pregnancy1
Pre-pregnancy BMI should be calculated for all women13 [Refer to Appendix A for BMI
calculations]
Referral letters and health records across reproductive health should include information
on measured and documented body weight and BMI7
Inter-pregnancy weight gain should be documented7

Refer to online version, destroy printed copies after use

Page 9 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

2.3

Weight gain
!
!
!

!
!

Recommendations for weight gain during pregnancy are outlined in Table 42,3,13
Recommended weight gain ranges for teenagers, short women and racial and ethnic
groups are the same as those for the whole population2
Recommendations for total weight gain for women pregnant with twins per BMI
classification are:2
o normal: 16-24 kg
o overweight: 14-22 kg
o obese: 11-19 kg
The range of desirable total weight gain and rate of gain should be discussed with the
woman early in pregnancy and a plan documented2,14
Women should be weighed at each antenatal consultation
o the pattern of gain at each antenatal visit relative to the desirable weight gain and
rate of gain should be reviewed7
o plotting of weight against gestation may assist identification of trends2
Clinical experience suggests that weight loss during pregnancy can occur with adoption of
a healthy lifestyle. This may be acceptable - although there is no clear evidence

Table 4. Target weight gains

Pre-pregnancy BMI (kg/m2)

Rate of gain 2nd and 3rd

trimester (kg/week)*

Recommended total gain

range (kg)

Less than 18.5

0.45

12.5 to 18

18.5 to 24.9

0.45

11.5 to 16

25.0 to 29.9

0.28

7 to 11.5

Greater than or equal to 30.0

0.22

5 to 9

* Calculations assume a 0.5-2 kg weight gain in the first trimester

2.4

Maternal assessment and monitoring

Increased clinical surveillance is recommended due to the increased risk of complications.

! Perform a thorough antenatal assessment including:
o medical, surgical and obstetric history
o physical assessment
o assessment of current physical activity and diet
o accurate estimation of blood pressure using an appropriate sized cuff is essential
! Consider an early booking visit to plan pregnancy care7 (ideally as soon as pregnancy
confirmed)
! Consider an increased frequency of antenatal visits in the second and/or third trimester
! Where maternal BMI is greater than 35 kg/m2 in the first trimester, consultation with an
obstetrician is recommended18
! Consider antenatal thromboprophylaxis in the presence of additional clinical risk factors
for venous thromboembolic disease (VTE).7 [Refer to Venous thromboembolic
prophylaxis in pregnancy and the puerperium guideline]
! Obese pregnant women should be advised to cease taking prescription and over the
counter weight loss medications and preparations
! In the third trimester, consider an individual mobility assessment to identify equipment,
workforce and procedural requirements for safe delivery of care

Refer to online version, destroy printed copies after use

Page 10 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

2.4.1

Maternal investigations
!

!
!

2.5

Oral Glucose Tolerance Test (OGTT) to assess for overt diabetes at the initial antenatal
visit or in the first trimester13,15
o repeat at 26-28 weeks if initial OGTT negative13
Establish baseline renal and liver function to assist in distinguishing chronic renal
dysfunction secondary to maternal chronic hypertension and /or diabetes from pregnancy
associated hypertensive disorders15
o repeat renal and liver function tests for clinical indications (for example hypertensive
features)
Consider cardiac evaluation for women with pre-existing medical conditions13 especially
smokers and those with Type II diabetes
Investigations should include:
o transaminases (for non-alcoholic steatohepatitis (NASH))
o urine protein creatinine ratio

Fetal assessment and monitoring

!

A detailed anomaly scan and serum screening for congenital abnormality should be
recommended7 including:
o first trimester Combined Test performed between 11.0 and 13.6 weeks or
o Triple Test performed between 15-20 weeks if Combined Test not done
o morphology scan performed between 18 and 20 weeks
Consider serial ultrasound monitoring of fetal growth where clinical assessment is limited
by obesity

2.5.1 Ultrasound
Maternal obesity can limit the accuracy and effectiveness of antenatal ultrasound examinations of
the fetus and therefore increases the likelihood of an undetected fetal structural abnormality.14
! Ultrasonography should be performed by operators experienced in the scanning of obese
women
! Transvaginal ultrasound assessment may improve visualisation of fetal structures
! Prenatal diagnostic procedures such as chorionic villus sampling (CVS) or amniocentesis
may be more difficult in obese women

2.6

Anaesthetic considerations
!
!

Consider antenatal anaesthetic consultation 7,13 for women with BMI greater than
35 kg/m2
Assess co-morbidities particularly those that increase anaesthetic risk including difficulty
of:
o intubation
o regional anaesthesia
o obtaining venous access
! avoid damaging hand and forearm veins during blood sampling in the antenatal
period
! ultrasound may be required to assist with venous access
An anaesthetic management plan should be developed and documented in consultation
with the treating obstetric team

Refer to online version, destroy printed copies after use

Page 11 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

2.7

Counselling

Pregnancy is a crucial life event when interventions to address obesity may be most effective.4
! Access and referral to healthcare professionals able to support the adoption of a healthy
lifestyle is recommended7
! Specific information concerning the maternal and fetal risks and complications of obesity
in pregnancy should be provided13
! Consider the requirement for psychological support and counselling
! Consider the requirement for interpreters or Indigenous Liaison Officers for Aboriginal and
Torres Strait Islander women and for women from other culturally and linguistically
diverse groups

2.8

Nutrition

Obese pregnant women should be:

! advised to eat a healthy diet as per the Australian Guide to Healthy Eating19
! offered nutritional consultation2,13 ideally with a dietitian
! advised not to restrict dietary intake below the recommended food group requirements for
pregnancy2,19
! encouraged to adhere to target weight gains14 as outlined at section 2.2

2.9

Physical activity
!
!
!
!
!
!

Obese pregnant women should be encouraged to be active as part of a healthy lifestyle

A womans overall health, including obstetric and medical risks should be evaluated
before prescribing an exercise program20
In the absence of obstetric or medical complications 30 minutes of moderate exercise on
most days of the week is recommended20
Health care professionals should use their professional judgement as to the type,
intensity, duration and frequency of exercise that is advised for individual women21
Consider physiotherapy consultation to assist with assessment and individual exercise
prescription
Pregnant women should be advised:
o to choose activities that will minimise the risk of maternal and fetal injury20-22
o that moderate exercise during lactation does not affect the quantity or composition
of breast milk

2.9.1 Medical supervision of exercise programs

Medical supervision of exercise programs is required if there are associated conditions including:20,21
! cardiac disease
! restrictive lung disease
! preeclampsia /poorly controlled hypertension
! intrauterine growth restriction
! placenta praevia after 26 weeks
! preterm prelabour rupture of membranes
! heavy smoker
! orthopaedic limitations
! extremely sedentary lifestyle
! multiple gestation
! BMI greater than 40 kg/m2
! poorly controlled diabetes mellitus
! poorly controlled seizures

Refer to online version, destroy printed copies after use

Page 12 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

2.9.2 Warning signs to terminate exercise

Pregnant women should be advised to stop exercising and seek medical attention if they
experience20,22:
! excessive shortness of breath
! chest pain
! dizziness
! painful uterine contractions
! leakage of amniotic fluid
! vaginal bleeding
! excessive fatigue
! abdominal pain
! reduced fetal movement
! calf pain or swelling
! headache

Intrapartum care
!
!
!
!
!

A team approach that includes frequent communication between care providers is

required
Anaesthetic and theatre staff should be notified of an obese woman presenting to birth
suite in labour or for induction
Consider the requirement for and potential difficulty of IV access
o USS may be required to visualise veins
Ensure large patient equipment is accessible in the intrapartum and postnatal period (for
example bed, hoists, limb lifters, transfer equipment)
There is no specific requirement for continuous fetal monitoring in an otherwise
uncomplicated pregnancy
o internal fetal monitoring may be considered if a satisfactory recording cannot be
obtained by external fetal monitoring
Consider the possible requirement for additional blood products13
o consider blood Group and Hold

Postpartum care
!
!
!

!
!
!

More frequent clinical observations may be required due to the risk of airway compromise
and obstructive sleep apnoea and subsequent increased risk of aspiration - particularly
following administration of narcotic and sedative medications
Consider the requirement for postpartum thromboprophylaxis
Encourage mobilisation:
o review and update mobility assessment as required
o consider regular physiotherapy to encourage mobilisation, particularly of women
who have had a caesarean birth
o consider pressure area care requirements during periods of immobility
Due to the increased risk of infection (chest, urinary, wound or breast) increased clinical
surveillance for signs of infection is required including:
o regular wound care (abdominal and perineal)
o thorough assessment of elevated maternal temperature
Continuation of nutritional counselling and exercise programs postpartum should be
encouraged13
If hormonal methods of contraception are considered (particularly estrogenic compounds)
risk assessment of VTE should occur
Women with gestational diabetes should be offered a glucose tolerance test at 6 weeks
postpartum

Refer to online version, destroy printed copies after use

Page 13 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

4.1

Breast feeding
!
!

Inter-conception care
!
!
!
!
!
!
!

Breastfeeding should be encouraged and supported

Obese pregnant women are at an increased risk of lactation failure and delay in
establishing lactation for a variety of reasons23. Consider24:
o referral to a lactation consultant (antenatal and/or postpartum)
o early postpartum feeding support
o the timing of discharge so as to allow for establishment of breastfeeding prior to
discharge
o referral to or continued access to breastfeeding support services post discharge

Obesity is a modifiable risk factor which ideally should be addressed preconception4,15

and between pregnancies
Preconception counselling about the potential pregnancy complications of obesity is
recommended13
Obese women should be encouraged to lose weight before beginning infertility
treatment7,13
Screen for diabetes prior to the next pregnancy
Modest amounts of weight loss between pregnancies can reduce the risk of gestational
diabetes in subsequent pregnancies11
Bariatric surgery is the only therapy with evidence of durable weight loss for Class II and
Class III obesity, although it has well recognised complications25
Bariatric surgery prior to pregnancy may improve pregnancy outcomes4,13

Pregnancy after bariatric surgery

Pregnant women who have previously undergone bariatric surgery (diversionary or malabsorptive
procedures) should be managed by a multidisciplinary team that includes an Obstetrician, Midwife,
Obstetric Physician, Bariatric Surgeon, Dietitian, Anaesthetist, Maternal Fetal Medicine Specialist,
Physiotherapist, Social Worker and Occupational Therapist.
! The type of bariatric surgery should be ascertained and documented in the clinical notes
! Encourage continuation of prescribed nutritional supplements
! Nutritional deficiencies are common after bariatric surgery.27 Evaluation of nutritional
deficiencies and correction by appropriate supplements should be considered13,15
! Intestinal obstruction as a complication of gastric bypass surgery may present as
abdominal complaints, morning sickness, reflux or uterine contractions. Increased clinical
surveillance and a high index of suspicion is required26
! Early pregnancy nausea and vomiting may require partial or complete deflation of
laparoscopicadjustable gastric banding4,11,27
! Bariatric surgery is not a contraindication to breast feeding. Maternal nutritional
supplementation may be required27

Refer to online version, destroy printed copies after use

Page 14 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

References
1. Callaway L, Prins J, Chang A, McIntyre D. The prevalence and impact of overweight and obesity
in an Australian obstetric population. MJA. 2006; 184(2):56-9.
2. IOM (Institute of Medicine) (US). Weight gain during pregnancy; reexamining the guidelines.
Washington DC: The National Academy Press; 2009.
3. Catalano PM, Ehrenberg HM. The short- and long-term implications of maternal obesity on the
mother and her offspring. BJOG: An International Journal of Obstetrics & Gynaecology. 2006;
113(10):1126-33.
4. Birdsall KM, Vyas S, Khazaezadeh N, Oteng-Ntim E. Maternal obesity: a review of interventions.
Int J Clin Pract. 2009; 63(3):494-507.
5. World Health Organization. Obesity: preventing and managing a global epidemic. WHO Tech Rep
Ser. 2000; 894:1-4.
6. New South Wales Government. Guidelines for the management of occupational health and safety
(OHS) issues associated with the management of bariatric (severely obese) patients. [online]. 2005,
[cited 13 October 2009]. Available from:
http://www.health.nsw.gov.au/policies/gl/2005/pdf/GL2005_070.pdf.
7. Baker P, Balen A, Poston L, Sattar N. Obesity and reproductive health - study group statement:
consensus views arising from the 53rd study group: obesity and reproductive health. 2007 [cited
2009 August 17]. Available from: http://www.rcog.org.uk/womens-health/clinical-guidance/obesityand-reproductive-health-study-group-statement
8. World Health Organization. The Asia-Pacific perspective: redefining obesity and its treatment.
Health Communications Australia Pty Ltd; 2000.
9. Watson M, Howell S. Characteristics of overweight and obese mothers in Queensland 2008.
Queensland Health StatBite # 21 [online]. 2009 [cited 23 October 2009]. Available from:
http://qheps.health.qld.gov.au/hic/pdf/statbite/statbite21.pdf.
10. Grodstein F, Goldman MB, Cramer DW. Body mass index and ovulatory infertility. Epidemiology.
1994; 5(2):247-50.
11. Rowlands I, Graves N, de Jersey S, McIntyre HD, Callaway L. Obesity in pregnancy: outcomes
and economics. Semin Fetal Neonatal Med. 2009.
12. Lewis G, editor. The confidential enquiry into maternal and child health (CEMACH). Savings
mothers' lives: reviewing maternal deaths to make motherhood safer -2003-2005. The seventh report
on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH; 2007.
13. American College of Obstetricians and Gynecologists. ACOG committee opinion. Number 315,
September 2005. Obesity in pregnancy. Obstetrics & Gynecology. 2005; 106(3):671-5.
14. Ramachenderan J, Bradford J, McLean M. Maternal obesity and pregnancy complications; a
review. Aust N Z J Obstet Gynaecol. 2008; 48:228-235.
15. Catalano PM. Management of obesity in pregnancy. Obstetrics & Gynecology. 2007; 109(2):Part
1, 419-433.
16. Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and obesity and the risk of
congenital anomalies: a systematic review and meta-analysis. JAMA. 2009; 301(6):636-50.
17. Queensland Health Corporate Workplace Health & Safety Reform Unit. Large patient
management plan and equipment database. [online]. 2007 [cited 27/01/2010]. Available from:
http://qheps.health.qld.gov.au/safety/ergo/documents/ohws1583_bariatric07.pdf.
18. Australian College of Midwives. National midwifery guidelines for consultation and referral. 2nd
ed; 2002.
Refer to online version, destroy printed copies after use

Page 15 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

19. Children's Health Development Foundation SA. Australian Guide to Healthy Eating.
Commonwealth of Australia 1998.
20. American College of Obstetricians and Gynecologists. ACOG committee opinion. Number 267,
January 2002. Exercise during pregnancy and the postpartum period. Int J Gynaecol Obstet. 2002;
77(3):79-81.
21. Royal College of Obstetricians and Gynaecologists. Exercise in pregnancy. Statement No. 4.
2006.
22. Davies GAL, Wolfe LA, Mottola MF, MacKinnon C, Society of Obstetricians and gynecologists of
Canada SCPOC. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the
postpartum period. Can J Appl Physiol. 2003; 28(3):330-41.
23. Amir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention,
initiation and duration. BMC Pregnancy and Childbirth. [Systematic Review]. 2007; 7(9).
24. Rasmussen KM, Kjolhede C. Prepregnant overweight and obesity diminish the prolactin
response to suckling in the first week postpartum. Pediatrics. 2004; 113(5):e465-71.
25. Sjostrom L, Narbro K, Sjostrom CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric
surgery on mortality in Swedish obese subjects. N Engl J Med. 2007; 357(8):741-52.
26. Maggard M, Li Z, Yermilov I, Maglone M, Suttorp M, Carter J, et al. Bariatric surgery in women of
reproductive age: special concerns for pregnancy. Evidence Report/Technology Assessment No 169.
Rockville, MD: Agency for Healthcare Research and Quality; 2008.
27. Guelinckx I, Devlieger R, Vansant G. Reproductive outcome after bariatric surgery: a critical
review. Hum Reprod Update. 2009; 15(2):189-201.
28. Queensland Health. Proposed clinical services capability framework: maternity module 2009 (not
yet endorsed).

Refer to online version, destroy printed copies after use

Page 16 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Appendix A: Body mass index chart

Source: http://www.health.qld.gov.au/patientsafety/pupp/documents/bodymassindex.pdf

Refer to online version, destroy printed copies after use

Page 17 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Appendix B: Suggested clinical service capability for referral

The 6 clinical service levels outlined below are those proposed in the Clinical Services Capability Framework (2009).28 Refer to the complete document for detailed
service level capabilities.
Service
level
Level 1

Level 2

Level 3

Level 4

Level 5

Level 6

Overview of proposed QLD maternity

service levels28

Capability to care for obese

obstetric women

Suggested responsibilities for referral Consider individual clinical

circumstances when determining the requirement for referral

! Community antenatal and/or postnatal

care
! No inpatient maternity services
! No planned births
! Antenatal and postnatal care to women
without risk factors
! May provide low risk birthing services

! No capacity to manage obese

maternity care (BMI greater than 30
kg/m2)

! All obese women are referred to a higher level service

! Perinatal care including birth, for

women with no complications or comorbidities and with BMI less than
2
35 kg/m

! Community and inpatient antenatal and

postnatal care
! Planned birthing for healthy women not
expected to have labour or birth
complications
! Maternity care for low and moderate
risk women

! Perinatal care including birth, for

women with no complications or comorbidities and with BMI less than
35 kg/m2

! Maternity care for low to high risk

women
! Able to manage all unexpected
pregnancy and neonatal emergency
presentations

! Perinatal care including birth for

women with complications and comorbidities and BMI less than 60
kg/m2 or less than 180 kg
(whichever is lower)

! All levels of maternity care

! Able to manage the perinatal care

for all obese obstetric women
regardless of BMI or body weight

! Women with BMI greater than 35 kg/m2 at booking: Consider if referral to a level
3,4,5 or 6 facility is required for:
o assessment by an obstetrician
o anaesthetic consultation
o birthing
2
! Women with BMI greater than 35 kg/m or weight 125 kg at booking or during
pregnancy: Consider if referral to a level 4,5, or 6 facility is required for:
o assessment by an obstetrician
o anaesthetic consultation
o birthing
2
! Women with BMI greater than 40 kg/m at booking or during pregnancy: Consider
if referral to a level 5 or 6 facility is required for:
o assessment by an obstetrician
o anaesthetic consultation
o birthing
2
! Women with BMI greater than 60 kg/m or weight greater than 180 kg (whichever
is lower) at booking or during pregnancy: Consider if a referral to a level 6 facility
is required for:
o assessment by an obstetrician
o anaesthetic consultation
o birthing
! Are prepared to accept the perinatal care responsibility of an obese obstetric
woman from across Queensland with BMI greater than 60 kg/m2 or weight greater
than 180 kg

Refer to online version, destroy printed copies after use

! Perinatal care including birth, for

women with minor complications
and co-morbidities that remain
stable and BMI less than 40 kg/mg2

Page 18 of 19

Queensland Maternity and Neonatal Clinical Guideline: Obesity

Acknowledgements
The Queensland Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge the
contribution of Queensland clinicians and other stakeholders who participated throughout the
guideline development process particularly:
Working Party Clinical Lead
Associate Professor Leonie Callaway, Obstetric Physician, Royal Brisbane and Womens Hospital
Working Party Members
Ms Annette Baldry, Midwife, Bundaberg Hospital
Associate Professor Bruce Chater, Rural and Remote Medicine
Ms Rebecca Christensen, Occupational Therapist, Mater Health Services, Brisbane
Ms Christine Colavitti, Physiotherapist, The Prince Charles Hospital
Ms Susan de Jersey, Dietitian-Nutritionist, Royal Brisbane and Womens Hospital
Dr Timothy Donovan, Neonatal Paediatrician, Royal Brisbane and Womens Hospital
Ms Kerri Green, Midwife, Hervey Bay Hospital
Ms Lorelle Hawes, Physiotherapist, Royal Brisbane and Womens Hospital
Associate Professor Rebecca Kimble, Obstetrician, Royal Brisbane and Womens Hospital
Ms Jenny McCormick, Occupational Health and Safety Consultant, Statewide Health Ergonomics
Professor David McIntyre, Obstetric Physician, Mater Health Services, Brisbane
Ms Sara Nest, Consumer Representative, Maternity Coalition
Dr Renuka Sekar, Maternal Fetal Medicine Specialist, Royal Brisbane and Womens Hospital
Dr Liana Tanda, Obstetrician, Caboolture Hospital
Dr Morne Terblanche, Anaesthetist, Bundaberg Hospital
Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Womens Hospital
Dr Shelley Wilkinson, Dietitian-Nutritionist, Mater Health Services, Brisbane
Program Team
Associate Professor Rebecca Kimble, Director, Queensland Maternity and Neonatal Clinical
Guidelines Program
Ms Joan Kennedy, Principal Program Officer, Queensland Maternity and Neonatal Clinical Guidelines
Program
Ms Jacinta Lee, Program Officer, Queensland Maternity and Neonatal Clinical Guidelines Program
Ms Catherine van den Berg, Program Officer, Queensland Maternity and Neonatal Clinical
Guidelines Program
Steering Committee, Queensland Maternity and Neonatal Clinical Guidelines Program

Refer to online version, destroy printed copies after use

Page 19 of 19