Anaesthetic Referral

What is it?

The RCOG recommends that all pregnant women with a BMI of 40 and above “should have an antenatal consultation with an obstetric anaesthetist, so that potential difficulties with venous access, regional or general anaesthesia can be identified.”

This is regardless of whether you’ve expressed any interest in receiving an epidural or not!

When?

Generally takes place in the third trimester of pregnancy.

How?

The anaesthetist will generally want to examine your lower back (in case they need to site an epidural), and will prod around a little to see how much fat you have there and whether they can feel the Hospital Oxygen Equipmentvertebrae easily.

They will look at your face and neck, ask you to jut your lower jaw out etc. to see if there might be any problems with intubation if you needed a general anaesthetic.

They will likely examine your hands to see if there is easy access to a vein, if needed.

If there are any concerns they will note this and a plan should be made to address any issues.

It is likely that you will be advised that if you are considering an epidural, you should ask for it earlier in labour rather than hold on until you are desperate for it, as it may take a little longer to provide due to your physique.

Why?

Obese pregnant women are at higher risk of anaesthesia-related complications than ‘normal’ sized women, with epidurals taking longer to site, and more likely to fail.

However, the study used by the RCOG to illustrate this only shows that it was the midwives who expressed dissatisfaction about the epidurals in larger women, the women themselves showed no difference in satisfaction scores, although it was shown that the epidurals were more likely to need re-siting on obese women.

The RCOG recommends that all women with a BMI of 40 or greater should have ‘venous access established’ early in labour to avoid the potential for delay in an emergency situation. In practice, this means a cannula (large needle with a plastic socket on the end) in the back of your hand. Be aware that consenting to this usually means you cannot get it wet, so no bath, birth pool etc.

One benefit of having the consultation with an anaethetist is that they can look at your hands to quickly determine the likelihood of any problems and note if they feel that this recommendation is neccessary. The RCOG’s guidance on this point is baced on level ‘D’ grade of evidence – that is to say based on no studies, merely expert opinion.

Why not?

You may feel like you have no intention of using an epidural or other anaesthesia while in labour, and that therefore such a consultation is unneccessary, but other than being a likely waste of time, there is no real reason to refuse an appointment with an anaesthetist.

The consultation is relatively quick, is non-invasive, and could prove valuable in the event of complications or if you change your mind. After all, you never really know how you’re going to feel when in labour until you’re actually there.

It is worth remembering the downsides of epidural anaesthesia however, before you jump for the ‘pain free’ option; lack of mobility, catheterisation because you are no longer able to sense when you need to urinate, longer labours, ‘disconnection’ with your labour as you may be unable to feel contractions or when to push, greater likelihood of instrumental (forceps or ventouse) delivery, increased risk of caesarean section, possibility of nausea or itching, and the rare but risky potentially serious complication of puncture of the spinal cord or infection, amongst others.

As always; be informed and make the decision that’s right for you.

There have been some studies to show that how our labours are managed may in some part be responsible for impacting on how those labours turn out:

The Impact of Negativity on Labour and Birth

So if you feel that you’re being talked or herded into having an epidural, or even into having an epidural sited ‘just in case you want one later’ when you really don’t think you want to, don’t be afraid to stand your ground and say no. Remember, professionals are there to advice and recommend options to you – it’s your right and responsibility to consider the options and make your own decision!

References

Management of Women with Obesity in Pregnancy (1.0 MiB)

Maternal obesity in the UK: findings from a national project (4.5 MiB)

Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London (216.5 KiB)

Audit of the influence of body mass index on the performance of epidural analgesia in labour and the subsequent mode of delivery (12.8 KiB)

Anaesthesia for the Obese Patient (431.7 KiB)

Leave a reply here to get involved!