The American College of

Obstetricians and Gynecologists

WOMEN’S HEALTH CARE PHYSICIANS

A correction was published in December 2016 for this title. Click here to view the correction.

P RACTICE BULLET IN
clinical management guidelines for obstetrician – gynecologists

Number 156, December 2015 (Replaces Committee Opinion Number 549, January 2013)
(Reaffirmed 2018)

Obesity in Pregnancy
Obstetrician–gynecologists are the leading experts in the health care of women, and obesity is the most common health
care problem in women of reproductive age. Obesity in women is such a common problem that the implications rela-
tive to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based treat-
ment options. The management of obesity requires long-term approaches ranging from population-based public health
and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an understanding
of the management of obesity during pregnancy is essential, and management should begin before conception and
continue through the postpartum period. Although the care of the obese woman during pregnancy requires the involve-
ment of the obstetrician or other obstetric care provider, additional health care professionals, such as nutritionists,
can offer specific expertise related to management depending on the comfort level of the obstetric care provider. The
purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in women of repro-
ductive age who are planning a pregnancy.

Background a higher prevalence in non-Hispanic black and Mexican

American women (3). According to recent data from the
Epidemiology Centers for Disease Control and Prevention, this increase

Incidence Table 1. World Health Organization Body Mass Index

Categories ^
Obesity is commonly classified based on body mass
index (BMI), defined as weight in kilograms divided Category BMI*
by height in meters squared (kg/m2). The World Health Underweight Less than 18.5
Organization organizes BMI ranges into six categories Normal weight 18.5–24.9
to define underweight, normal weight, overweight, and
Overweight 25.0–29.9
obesity (Table 1). Based on the 2011–2012 National
Health and Nutrition Examination Survey, the prevalence Obesity class I 30.0–34.9
of obesity in women of reproductive age (20–39 years) in Obesity class II 35.0–39.9
the United States is 31.8% and increases to 58.5% when Obesity class III 40 or greater
the overweight and obese categories are combined (1, 2). Abbreviation: BMI, body mass index.
*Weight in kilograms divided by height in meters squared (kg/m2).
Trends World Health Organization. Obesity: preventing and managing the global
epidemic. Report of a WHO consultation. Geneva: WHO; 2000. Available
From 1999 to 2010, the prevalence of obesity increased at: http://www.who.int/nutrition/publications/obesity/WHO_TRS_894/en.
from 28.4% to 34.0% in women aged 20–39 years, with Retrieved September 2, 2015.

Committee on Practice Bulletins—Obstetrics. This Practice Bulletin was developed by the Committee on Practice Bulletins–Obstetrics with the assistance
of Patrick M. Catalano, MD and Gayle Olson Koutrouvelis, MD. The information is designed to aid practitioners in making decisions about appropriate
obstetric and gynecologic care. These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice
may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
has leveled off, with no significant change in the preva- Although the absolute risk of stillbirth is low, an
lence of obesity in women of reproductive age between increase of roughly 1 and 1.9 per 1,000 is seen in over-
2003–2004 and 2011–2012 (1). However, of potentially weight and obese women, respectively. This slight upward
greater concern is the increased prevalence of class II trend also is confirmed with increasing classes of obesity:
obesity (17.2%) and class III obesity (7.5%) in women class I (adjusted hazard ratio, 1.3; 95% CI, 1.2–1.4), class
aged 20–39 years in 2009–2010 (4). II (adjusted hazard ratio, 1.4; 95% CI, 1.3–1.6), and class
III (adjusted hazard ratio, 1.9; 95% CI, 1.6–2.1; P<.1)
Effects on Pregnancy (10). Black obese gravidas (adjusted hazard ratio, 1.9;
Pregnancy Loss 95% CI, 1.7–2.1) demonstrated an even greater risk of
stillbirth compared with white obese gravidas (adjusted
There is an increased risk of spontaneous abortion (odds
hazard ratio, 1.4; 95% CI, 1.3–1.5) (10). In a retrospective
ratio [OR], 1.2; 95% confidence interval [CI], 1.01–1.46)
cohort study that included more than 2.8 million women,
and recurrent miscarriage (OR, 3.5; 95% CI, 1.03–12.01)
the association of BMI during pregnancy with still-
in obese women compared with age-matched controls
birth was investigated. Between 30 weeks and 42 weeks
(5). Obese women are at increased risk of pregnancies
of gestation, increasing obesity significantly contributed
affected by neural tube defects; hydrocephaly; and car-
to stillbirth at each increasing gestational age interval
diovascular, orofacial, and limb reduction anomalies (6).
studied. Particularly in the obesity class III group and
In a systematic review and meta-analysis, an increase
in certain congenital anomalies was noted in the off- the group of women who had a BMI of at least 50, the
spring of obese women compared with nonobese women adjusted hazard ratio for stillbirth was 1.40 and 1.69
(Table 2). The risk of gastroschisis in the neonates among at 30–33 weeks of gestation, increasing to 3.20 and
obese gravidas, however, was significantly reduced (OR, 2.95 at 37–39 weeks of gestation and 3.30 to 8.95 at
0.17; 95% CI, 0.10–0.30) (6). 40–42 weeks of gestation, respectively. In addition, an
analysis of increasing gestation by week stratified by BMI
Antepartum Complications class showed that when compared with normal-weight
Compared with normal-weight women, obese women pregnant women, women with a BMI of at least 50 had a
are at increased risk of cardiac dysfunction, proteinuria, 5.7-fold and 13.6-fold greater risk of stillbirth at
sleep apnea, nonalcoholic fatty liver disease (7), gesta- 39 weeks and 41 weeks of gestation, respectively (11).
tional diabetes mellitus (8), and preeclampsia (9). Obese In a systematic review and meta-analysis, the
gravidas are 40% more likely to experience stillbirth relative risk for each 5-unit increase in maternal BMI
compared with nonobese gravidas (adjusted hazard ratio, in overweight and obese pregnant women, compared
1.4; 95% CI, 1.3–1.5) (10). Pregnant women who have with normal-weight pregnant women, was 1.21 for fetal
undergone bariatric surgery should be evaluated for death (95% CI, 1.09–1.35), 1.24 for stillbirth (95% CI,
nutritional deficiencies and the need for vitamin supple- 1.18–1.30), 1.16 for perinatal death (95% CI, 1.00–
mentation when indicated. 1.35), 1.15 for neonatal death (95% CI, 1.07–1.23), and
1.18 for infant death (95% CI, 1.09–1.28). Absolute
Table 2. Increases in Congenital Anomalies in Obese Versus risks are shown in Table 3 (12).
Nonobese Gravidas ^
Congenital Anomaly Increased Risk
Table 3. Absolute Risks Per 10,000 Pregnancies for Body
Neural tube defects OR, 1.87; 95% CI, 1.62–2.15 Mass Index Categories 20, 25, and 30 ^
Spina bifida OR, 2.24; 95% CI, 1.86–2.69
Maternal BMI
Cardiovascular anomalies OR, 1.30; 95% CI, 1.12–1.51
Septal anomalies OR, 1.20; 95% CI, 1.09–1.31 20 25 30
Cleft palate OR, 1.23; 95% CI, 1.03–1.47 Fetal death 76 82 (95% CI, 76–88) 102 (95% CI, 93–112)
Cleft lip and palate OR, 1.20; 95% CI, 1.03–1.40 Stillbirth 40 48 (95% CI, 46–51) 59 (95% CI, 55–63)
Anorectal atresia OR, 1.48; 95% CI, 1.12–1.97 Perinatal death 66 73 (95% CI, 67–81) 86 (95% CI, 76–98)
Hydrocephaly OR, 1.68; 95% CI, 1.19–2.36 Neonatal death 20 21 (95% CI, 19–23) 24 (95% CI, 22–27)
Limb reduction anomalies OR, 1.34; 95% CI, 1.03–1.73 Infant death 33 37 (95% CI, 34–39) 43 (95% CI, 40–47)
Abbreviations: CI, confidence interval; OR, odds ratio. Abbreviations: BMI, body mass index; CI, confidence interval.
Data from Stothard KJ, Tennant PW, Bell R, Rankin J. Maternal overweight and Data from Aune D, Saugstad OD, Henriksen T, Tonstad S. Maternal body mass
obesity and the risk of congenital anomalies: a systematic review and meta- index and the risk of fetal death, stillbirth, and infant death: a systematic review
analysis. JAMA 2009;301:636–50. and meta-analysis. JAMA 2014;311:1536–46.

2 Practice Bulletin No. 156

Intrapartum Complications Facilities and Equipment Considerations
Although obesity is associated with indicated preterm Accommodation of the physical needs of obese preg-
birth, the data conflict as to whether a similar associa- nant women is necessary in inpatient and outpatient
tion exists for spontaneous preterm birth (13–15). Obese settings. For labor and delivery, birthing beds capable
pregnant women are at increased risk of cesarean deliv- of supporting an obese gravida for a vaginal delivery
ery, failed trial of labor, endometritis, wound rupture with appropriate monitoring equipment should be avail-
or dehiscence, and venous thrombosis (16, 17). Obese able. Other common requirements include large chairs,
gravidas undergoing a trial of labor after a previous blood pressure cuffs, and wheelchairs (30). Increase
cesarean delivery have an almost twofold increase in in equipment size necessitates increased storage space
composite maternal morbidity and a fivefold increased and number of staff to safely assist patients. Because
risk of neonatal injury (16). of the increased need for emergency cesarean delivery
in obese pregnant women, doorways and hallways
Postpartum Complications and Long-Term must be spacious enough to accommodate large beds
Outcomes and the additional staff needed to move patients safely.
Operating rooms equipped with motorized lifts will
Obesity-related complications during pregnancy are
make it easier to assist the obese patient onto the oper-
associated with future metabolic dysfunction in these
ating table (31). These rooms should have sufficient
women. Forty-six percent of obese pregnant women
space to allow staff to move safely and efficiently (32).
have gestational weight gain in excess of the Institute of
The operating table should accommodate the size and
Medicine (IOM) pregnancy weight gain guidelines (18).
weight of the patient, or two tables joined together may
Excess gestational weight gain is a significant risk factor
be required. Operating tables typically accommodate
for postpartum weight retention. This further increases
205 kg (450 lb), although some tables can accommo-
the risk of metabolic dysfunction and pregravid obesity
date 455 kg (1,000 lb). The setup should allow the
in future pregnancies. Pregravid obesity is associated
surgeon adequate maneuverability during the surgical
with early termination of breastfeeding, postpartum ane-
procedure, provide protection on patient pressure areas
mia, and depression (19–21).
to avoid neural injuries and pressure sores, and ensure
availability of secure belts and gel pads to prevent move-
Fetal Complications and Childhood ment of the patient on the table (33). Although there is
Morbidities no consensus on the optimal positioning of the obese
Fetuses of obese gravidas are at increased risk of mac- gravida at the time of cesarean delivery (34), the operat-
rosomia and impaired growth (22, 23). Likewise, infants ing tables should be able to accommodate various posi-
of obese women tend to have more body fat than tions to the satisfaction of anesthesia and obstetric staff,
infants of normal-weight women. Long-term risks for as well as patient safety. Long instruments may be nec-
the offspring of obese women include an increased risk essary to facilitate the surgeon’s access to proper tissue
of metabolic syndrome (24) and childhood obesity (25). planes.
The risk of childhood obesity in the offspring of obese
women persists even after adjustment for complica-
tions, such as gestational diabetes mellitus (26). In a Clinical Considerations and
large Scandinavian study, higher maternal BMI was
associated with an increased risk of childhood asthma
Recommendations
(27). Maternal obesity also has been linked to altered
Are there interventions for the management
behavior in the offspring, including an increased risk
of obesity before and during pregnancy?
of autism spectrum disorders, childhood developmental
delay, and attention-deficit/hyperactivity disorder (28). Optimal control of obesity begins before conception.
As compelling as these data may seem, it is impossible Weight loss before pregnancy, achieved by surgical or
to separate different prenatal and postnatal influences nonsurgical methods, has been shown to be the most
on outcomes in the offspring of obese women. Family effective intervention to improve medical comorbidities
socioeconomic issues, behavior, activity, and diet often (35, 36). Obese women who have even small weight
are considered as confounding factors in the analysis of reductions before pregnancy may have improved preg-
metabolic outcomes in the offspring of obese women nancy outcomes. Motivational interviewing techniques
and limit the interpretation and generalizability of these involve an individualized, patient-centered approach
results (29). toward exploring and resolving ambivalence. The goal

Practice Bul­le­tin No. 156 3

of motivational interviewing is to help patients move What are the recommendations for weight
through the stages of dealing with unhealthy behavior. gain in pregnancy for overweight and obese
Motivational interviewing has been used successfully women?
within the clinical setting to promote weight loss,
dietary modification, and exercise (37, 38). In a review Gestational weight gain recommendations aim to opti-
of randomized trials using motivational interviewing mize outcomes for the pregnant woman and her infant.
for obese nonpregnant patients, a significant decrease At the initial prenatal visit, prepregnancy weight and
in weight and a nonsignificant decrease in BMI was height should be recorded for all women to allow calcu-
achieved (39). Although achieving a normal BMI is the lation of BMI. If the prepregnancy weight is unknown,
ideal, a weight loss of 5–7% over time can significantly the initial prenatal visit weight is recorded. Body mass
improve metabolic health (38). The U.S. Preventive index calculated at the first prenatal visit should be used
Services Task Force recommends that all adults aged to provide diet and exercise counseling guided by IOM
18 years and older with a BMI of 30 or greater be recommendations for gestational weight gain during
offered or referred to intensive multicomponent behav- pregnancy.
ior interventions (40). The IOM guidelines recommend a total weight
Medications for weight management are not recom- gain of 6.8–11.3 kg (15–25 lb) for overweight pregnant
mended during the time of conception or during preg- women (BMI of 25–29.9) (18, 51). Given the limited
nancy because of safety concerns and adverse effects data on pregnancy weight gain by obesity class, the
(41, 42). These types of drugs include typical anorectics, IOM recommendation for weight gain is 5.0–9.1 kg
which alter the release and reuptake of neurotransmit- (11–20 lb) for all obese women (Table 4).
ters that suppress appetite, and other drugs that decrease Citing a lack of sufficient data regarding short-
intestinal fat absorption by inhibiting pancreatic lipase. term and long-term maternal and newborn outcomes,
Metformin, which is used to treat type 2 diabetes, the IOM report did not recommend lower targets for
decreases hepatic glucose production and has been asso- pregnant women with more severe degrees of obe-
ciated with decreased gestational weight gain in some sity (18, 51). Gestational weight gain below the IOM
studies when used to treat mild gestational diabetes (43). recommendations among overweight pregnant women
The primary weight management strategies during has been noted to have varying effects on fetal growth
pregnancy are dietary control, exercise, and behavior and neonatal outcomes (52). Among extremely obese
modification. These strategies have been used either women with weight loss or restricted weight gain dur-
alone (44, 45) or in combination (46, 47) to avoid exces- ing pregnancy, the risk of a small-for-gestational-age
sive gestational weight gain. In at least one study, gen- (SGA) infant contrasts with perceived benefits, such as
eral dietary strategies appeared to be more useful than a decrease in the rate of cesarean delivery, decreased
exercise in avoiding excessive gestational weight gain in risk of a large-for-gestational-age infant, and postpar-
pregnancy (48). Some studies on diet have examined the tum weight retention. One study using data from the
role of foods with a low glycemic index (44), whereas Centers for Disease Control and Prevention Pregnancy
others have employed probiotic interventions (49). A Nutrition Surveillance System assessed the association
recent meta-analysis that included 49 randomized trials of gestational weight gain and prevalence of SGA at
and 11,444 women analyzed interventions to prevent birth with class of obesity. Prepregnancy BMI was used
excessive gestational weight gain. The interventions in for selection of obesity class as follows: class I, BMI
this review included diet only, low-glycemic or low- 30.0–34.9; class II, BMI 35.0–39.9; and class III,
caloric diets, diet plus exercise, and exercise only. The BMI of at least 40.0. For women with class I obe-
exercise varied and was supervised in some cases and sity, no weight gain or weight loss up to 4.9 kg
unsupervised in others. Interventions reduced the risk (11 lb) was associated with an increased risk of
of excessive gestational weight gain by 20% compared SGA (adjusted OR, 1.2; 95% CI, 1.24–2.12) (53). A
with control groups (50). There was no clear difference later study of inadequate weight gain (no more than
between intervention versus no intervention for cesarean 5 kg [11 lb] versus more than 5 kg [11 lb]) in over-
delivery overall (relative risk, 0.95; 95% CI, 0.88–1.03), weight and obese women showed similar findings.
although the effect estimate showed a 5% difference The neonates of women who gained no more than 5 kg
in favor of the interventions. There was no difference (11 lb), compared with women who gained more than
between the groups for preterm delivery or macrosomia, 5 kg (11 lb), were more likely to be SGA (9.6% versus
however, in a subgroup analysis of overweight and 4.9% [adjusted OR, 2.6; 95% CI, 1.4–4.7; P=.003]),
obese women, the interventions decreased the risk of have lower birth weight, smaller length, lower lean and
macrosomia by 15% (50). fat mass, and smaller head circumference (54). Finally, a

4 Practice Bulletin No. 156

 Table 4. Recommendations for Total and Rate of Weight Gain During Pregnancy by
Pregnancy Body Mass Index ^

Recommended Rates
of Weight Gain† in the
Prepregnancy Recommended Second and Third
Weight Body Mass Range of Total Trimesters (lb)
Category Index* Weight Gain (lb) (Mean Range [lb/wk])
Underweight Less than 18.5 28–40 1 (1–1.3)
Normal weight 18.5–24.9 25–35 1 (0.8–1)
Overweight 25–29.9 15–25 0.6 (0.5–0.7)
Obese (includes 30 and greater 11–20 0.5 (0.4–0.6)
all classes)
*Body mass index is calculated as weight in kilograms divided by height in meters squared or as weight in pounds
multiplied by 703 divided by height in inches.
†
Calculations assume a 1.1–4.4 lb weight gain in the first trimester.
Modified from Institute of Medicine (US). Weight gain during pregnancy: reexamining the guidelines. Washington, DC.
National Academies Press; 2009. Copyright 2009 National Academy of Sciences.

systematic review focused on outcomes in obese women One retrospective cohort study examined ultra-
with gestational weight loss identified increased risk of sound images for pregnant women at 18–24 weeks of
SGA below the 10th percentile (adjusted OR, 1.76; 95% gestation who underwent either standard or targeted
CI, 1.45–2.14) and 3rd percentile (adjusted OR, 1.62; ultrasonography (56). Detection of anomalous fetuses
95% CI, 1.19–2.20) (55). Collectively, these reports decreased with increasing maternal BMI by at least 20%
indicate that inadequate weight gain and gestational in obese women compared with normal-weight women.
weight loss should not be encouraged for obese pregnant Potential means to optimize ultrasonographic image
women. quality in obese pregnant women include a vaginal
approach (57) in the first trimester or using the mater-
How should antepartum care be altered for nal umbilicus as an acoustic window, as well as tissue
the obese patient? harmonic imaging (58, 59). Fetal magnetic resonance
imaging obviates many of these technical problems, but
Antenatal Diagnosis of Congenital because its use is limited by cost and availability, mag-
Anomalies netic resonance imaging is not recommended for routine
Obese women have an increased risk of fetal structural screening (60).
congenital anomalies (6). Detection of congenital anom- A secondary analysis of the First- and Second-
alies by ultrasonography is significantly reduced with Trimester Evaluation of Risk for aneuploidy trial evalu-
increasing maternal BMI (P<.001, test for trend) (Table 5). ated the effect of BMI on the ultrasonographic detection
Obese women should be counseled about the limitations of fetal structural anomalies and soft markers for aneu-
of ultrasound in identifying structural anomalies. ploidy (61). Only the detection of increased nuchal fold,
echogenic bowel, and echogenic cardiac focus as markers
for aneuploidy were not altered by BMI. When two or
Table 5. Detection of Fetal Anomalies ^ more markers were evaluated, a lower sensitivity with
Body Mass Standard Targeted
an elevated false-negative rate and missed-diagnosis rate
Index Ultrasonography Ultrasonography were observed in obese women compared with normal-
weight women (22% sensitivity and 78% false-negative
Normal (less than 25) 66% 97%
rate versus 32% sensitivity and 68% false-negative rate,
Overweight (25–29.9) 49% 91% respectively). The detection rate for cardiac anomalies
Class I obesity (30–34.9) 48% 75% among women with a BMI less than 25 was higher
Class II obesity (35–39.9) 45% 88% (21.6%), with a significantly lower false-positive rate
Class III obesity (40 or more) 22% 75% (78.4% [95% CI, 77.3–79.5%]) in comparison with obese
Data from Dashe JS, McIntire DD, Twickler DM. Effect of maternal obesity on the
women (8.3%) with a higher false-positive rate (91.7%
ultrasound detection of anomalous fetuses. Obstet Gynecol 2009;113:1001–7. [95% CI, 90.1–92.2%]). In an additional analysis using a

Practice Bul­le­tin No. 156 5

logistic regression model, maternal obesity significantly Stillbirth and Antenatal Fetal
decreased the likelihood of ultrasonographic detection of Surveillance
common anomalies (adjusted OR, 0.7; 95% CI, 0.6–0.9;
Obesity in pregnancy is associated with an increased
P=.001) (61). Maternal obesity also affects measures of
risk of early fetal loss and stillbirth (7). However, even
serum analytes because of the increased plasma volume
though stillbirth rates are higher in obese gravidas,
in obese pregnant women. Although weight adjustment
there is no evidence showing a clear improvement
for analytes improves detection of neural tube defects and
in pregnancy outcomes with antepartum surveillance,
trisomy 18, this adjustment does not improve detection of
and a recommendation cannot be made for or against
Down syndrome (60).
routine antenatal fetal surveillance in obese pregnant
women.
Metabolic Disorders of Pregnancy
Obese women are at increased risk of metabolic syn- How might intrapartum care be altered for
drome. Increased insulin resistance during pregnancy the obese patient?
may cause preexisting but subclinical cardiometabolic Numerous studies report an increased risk of cesarean
dysfunction to emerge as preeclampsia, gestational dia- delivery among overweight and obese women compared
betes, and obstructive sleep apnea (OSA) (62). These with normal-weight women. One meta-analysis showed
complications are associated with adverse pregnancy that the unadjusted odds ratios for cesarean delivery
outcomes (63–65). Obese pregnant women should be are 1.46 (95% CI, 1.34–1.60), 2.05 (95% CI, 1.86–2.27),
screened for glucose intolerance and OSA at the first and 2.89 (95% CI, 2.28–3.79) among overweight,
antenatal visit with history, physical examination, and obese, and severely obese women, respectively, com-
laboratory and clinical studies, as needed. pared with normal-weight women (17). Maternal obe-
Women with suspected OSA (snoring, excessive sity alone is not an indication for induction of labor
daytime sleepiness, witnessed apneas, or unexplained (70); however, obese women are at increased risk of a
hypoxia) should be referred to a sleep medicine special- prolonged pregnancy and have an increased rate of labor
ist for evaluation and possible treatment (66). If OSA induction (71).
is confirmed, or for pregnant women with known OSA, Increasing maternal BMI, particularly for the nul-
evaluation by a sleep medicine expert is recommended liparous woman, has been associated with longer labor
for management based on the severity of symptoms and (72). In a study that adjusted for maternal height, labor
level of impairment. induction, membrane rupture, oxytocin use, epidural
Compared with women without OSA, women with anesthesia use, net maternal weight gain, and fetal size,
OSA are more likely to experience preeclampsia the median duration of labor from 4 cm to 10 cm of cer-
(adjusted OR, 2.5; 95% CI, 2.2–2.9), eclampsia (adjusted vical dilation was significantly longer in overweight and
OR, 5.4; 95% CI, 3.3–8.9), cardiomyopathy (adjusted OR, obese women (73). Another study found that increasing
9.0; 95% CI, 7.5–10.9), pulmonary embolism (adjusted maternal BMI was not associated with longer second
OR, 4.5; 95% CI, 2.3–8.9), and in-hospital mortality stage of labor (74). Allowing a longer first stage of labor
(adjusted OR, 5.28; 95% CI, 2.45–11.53) (67). Studies before performing cesarean delivery for labor arrest
evaluating the effects of OSA on fetal growth, early should be considered in obese women. An inverse rela-
delivery, or stillbirth are inconclusive because of small tionship exists between prepregnancy BMI and success
sample size, observation designs, and incomplete ascer- rates for vaginal birth after cesarean delivery (Table 6).
tainment of maternal comorbid conditions (66–68). Pregnant women with class III obesity undergoing a
All pregnant patients should be screened for ges- trial of labor after previous cesarean delivery had greater
tational diabetes mellitus based upon medical history, rates of composite morbidity (prolonged hospital stay,
clinical risk factors, or laboratory screening test results to endometritis, rupture or dehiscence) and neonatal injury
determine blood glucose levels. Routine screening gen- (fractures, brachial plexus injuries, and lacerations) com-
erally is performed at 24 –28 weeks of gestation. Early pared with women with class III obesity who had elec-
pregnancy screening for glucose intolerance (gestational tive repeat cesarean delivery, but the absolute frequency
diabetes or overt diabetes) should be based on risk fac- of morbidities was low (16). Compared with normal-
tors, including maternal BMI of 30 or greater, known weight pregnant women, pregnant women with class III
impaired glucose metabolism, or previous gestational obesity have a significantly increased risk of postpar-
diabetes (69). If the initial early diabetes screening result tum atonic hemorrhage (bleeding greater than 1,000 mL)
is negative, a repeat diabetes screening generally is per- after a vaginal delivery (5.2%) but not after cesarean
formed at 24 –28 weeks of gestation. delivery (75).

6 Practice Bulletin No. 156

Table 6. The Inverse Relationship Between Prepregnancy sive disorders, compared with normal-weight pregnant
Body Mass Index and Success Rates for Vaginal Birth After women (78). The combination of spinal anesthesia and
Cesarean Delivery* ^ obesity significantly impairs respiratory function for up
to 2 hours after the procedure (79). General anesthesia

Vaginal Birth After Cesarean also poses a risk for obese pregnant women because of
BMI† Success Rate (%)
potential difficulties with endotracheal intubation due
<19.8 83.1 to excessive tissue and edema (80). General anesthesia
19.8−26 79.9 is not contraindicated in obese pregnant women, but
26.1–29 69.3 consideration should be given to preoxygenation, proper
>29 68.2 patient positioning, and having fiberoptic equipment
available for intubation (81).
Abbreviation: BMI, body mass index.
*P<.001
†
Antibiotics
Weight in kilograms divided by height in meters squared (kg/m2).
Reprinted from Juhasz G, Gyamfi C, Gyamfi P, Tocce K, Stone JL. Effect of body
Broad-spectrum antimicrobial prophylaxis is recom-
mass index and excessive weight gain on success of vaginal birth after cesarean mended for all cesarean deliveries unless the patient
delivery. Obstet Gynecol 2005;106:741–6. is already receiving antibiotics for conditions such as
chorioamnionitis. For obese women undergoing cesar-
ean delivery, consideration may be given to using a
What are the operative and perioperative higher preoperative antibiotic dose for surgical pro-
considerations in labor and delivery for the phylaxis. Some recommendations based on general
obese patient? surgical procedures would suggest a 2-g prophylactic
Maternal obesity presents challenges associated with cefazolin dose for women who weigh more than 80 kg
management of anesthesia as well as increased risk of (175 lb), with an increase to 3 g for those who weigh
complicated and emergent cesarean deliveries. For these more than 120 kg (265 lb) (33, 82). Few studies
reasons, an anesthesia consultation for the obese gravida have specifically addressed the question of weight-
should be obtained before labor or in early labor to based dosage for antibiotic prophylaxis at the time of
allow adequate time to develop an anesthetic plan that cesarean delivery. In a study of normal-weight, over-
addresses the availability of proper equipment for blood weight, and obese women who received 2g of cefazolin
pressure monitoring, venous access, and the influence 30–60 minutes before skin incision, drug concentra-
of comorbid conditions such as sleep apnea (32, 76). tions in adipose tissue were inversely proportional to
Consultation with anesthesia service should be consid- BMI. In obese and extremely obese patients, adipose
ered for obese pregnant women with OSA because they tissue concentrations of cefazolin were obtained. At
are at an increased risk of hypoxemia, hypercapnia, and the time of skin incision, concentrations were less than
sudden death. Development of a preoperative and post- 4 micrograms/g of tissue, the minimally inhibitory con-
operative protocol for management of these patients may centration for gram-negative rods, in 20% and 33% of
be of benefit (66). Factors to consider in this planning obese and severely obese patients, respectively; at skin
include use of epidural or spinal anesthesia, antibiotics, closure, concentrations reached these levels in 20% and
and choice of incision. 44% of patients, respectively (83). A double-blind ran-
domized controlled trial of women with BMI of 30
Epidural or Spinal Anesthesia or greater randomized antibiotic dosage to 2 g or 3 g
The use of epidural or spinal anesthesia for intrapartum cefazolin; adipose tissue concentrations did not signifi-
pain relief is recommended but may be technically dif- cantly differ between the two dosage strategies, and thus,
ficult because of body habitus and loss of landmarks. this trial did not support the use of the 3-g dose (84).
The risk of epidural analgesic failure is greater in obese Conclusive recommendations for weight-based dosage
women compared with normal-weight and overweight are difficult to establish because of a lack of evidence
women (77); therefore, early labor epidural catheter demonstrating different adipose tissue concentrations
placement should be considered after discussing risks or decreased surgical site infections with higher dosage
and benefits with the patient. Epidural catheters placed strategies in an obese cohort.
for labor may reduce the decision-to-incision interval
for an emergency cesarean delivery. At term, pregnant Incision
women with class III obesity have significantly greater The optimal skin incision for primary cesarean delivery
hypotension and prolonged fetal heart rate decelerations, in class II and III obese patients has not been determined.
after controlling for epidural bolus dose and hyperten- One study, using data from a perinatal database, reported

Practice Bul­le­tin No. 156 7

that a vertical skin incision was associated with a higher zation after cesarean delivery for women without addi-
rate of wound complications compared with a transverse tional risks (96).
incision (85). The relationship between skin incision and For prevention of venous thromboembolism in
the development of wound complications in women with very-high-risk groups, pharmacologic thromboprophy-
class III obesity was evaluated in a secondary analysis laxis should be considered in addition to pneumatic
of the Maternal–Fetal Medicine Units Network cesar- compression devices (93, 96). Increasing obesity, immo-
ean registry. A univariate analysis using a composite bility, preeclampsia, fetal growth restriction, infection,
of wound complications (infection, seroma, hematoma, and emergency cesarean delivery are among the condi-
wound evisceration, and facial dehiscence) showed that tions noted to increase the risk of venous thromboem-
patients with a vertical skin incision had a significantly bolism (96). The American College of Chest Physicians
higher rate of wound complications; after adjustment currently recommends low-molecular-weight (LMW)
for confounding factors, vertical incision was associ- heparin for the prevention and treatment of venous
ated with a significantly lower risk of wound complica- thromboembolism instead of unfractionated heparin (96).
tions (86). The discrepancy was most likely because of The optimal prophylactic dose of LMW heparin has not
selection bias and the observational nature of the study. been determined, but enoxaparin 40 mg daily is com-
Other reports on obese women with a large panniculus monly used (96). A prospective sequential cohort study
have reported favorable outcomes with a supraumbilical compared venous thromboembolism prophylaxis using
incision (87). Closure of the subcutaneous tissue with weight-based with BMI-stratified dosage regimens.
a depth greater than 2 cm can significantly decrease Venous thromboembolism prophylaxis was started
the incidence of wound disruption (88). However, the 12 hours after cesarean delivery using weight-based
use of a subcutaneous drain with bulb suction in obese (0.5 mg/kg enoxaparin every 12 hours) dosage or
women with at least 4 cm of subcutaneous fat was not BMI-stratified (BMI of 40–59.9 received enoxaparin
effective in preventing wound complications and may 40 mg every 12 hours and BMI of 60 or greater received
have potentiated postcesarean wound complications enoxaparin 60 mg every 12 hours) dosage. The primary
(89). Subcutaneous drains increase the risk of postpar- outcome was anti-Xa concentrations in the adequate
tum cesarean wound complications and should not be thromboprophylaxis range (0.2–0.6 international units/
used routinely. Types of skin preparation, skin closure mL). Anti-Xa concentrations were significantly higher
techniques, and supplemental oxygen have not proved in the weight-based group, suggesting weight-based
useful in decreasing the rate of postcesarean infectious dosage for venous thromboembolism thromboprophy-
morbidity (90–92). laxis may be more effective than BMI-stratified dos-
age strategies in class III obese women after cesarean
How should postpartum care be altered for delivery (97).
the obese patient? In a retrospective study of 2,492 cesarean deliveries,
the risk of surgical site infection after cesarean delivery
Obesity is a risk factor for venous thromboembolism was 18.4%. The risk of surgical site infection after cesar-
in the general medical population (93). In a nested ean delivery was highest among obese women, with an
case–control study in Denmark of more than 71,000 odds ratio of 1.43 (95% CI, 1.09–1.88) after adjustment
women, obesity in early pregnancy was associated with for diabetes and emergent or elective cesarean delivery
an increased risk of venous thromboembolism (adjusted (98). Compared with normal-weight women, there
OR, 5.3; 95% CI, 2.1–13.5). The odds ratio was adjusted is an increased risk of surgical site infections after a
for age, parity, clomiphene citrate stimulation, and cesarean delivery in women who are overweight (OR,
diabetes (94). Because of the increased risk of venous 1.6; 95% CI, 1.2–2.2), obesity class I (OR, 2.4; 95%
thromboembolism in obese women, it is recommended CI, 1.7–3.4), and obesity class II and III (OR, 3.7; 95%
that pneumatic compression devices be placed before CI, 2.6–5.2) (99). Management of surgical site infec-
a cesarean delivery and continued postpartum for all tion after cesarean delivery may include antibiotics,
women not already receiving thromboprophylaxis (95). exploration, and debridement (100). If the surgical site
However, cesarean delivery in the emergency setting infection appears superficial and without purulent drain-
should not be delayed by the time it takes to implement age, conservative therapy with antibiotics alone may be
thromboprophylaxis (95). Mechanical thromboprophy- considered; however, deep surgical site infection may
laxis is recommended before cesarean delivery, if pos- require wound exploration and debridement (100). The
sible, as well as after cesarean delivery. In addition to resulting open wound can be managed by secondary
the use of pneumatic compression devices, the American closure, secondary intention with dressings, and second-
College of Chest Physicians recommends early mobili- ary intention using negative pressure wound therapy.

8 Practice Bulletin No. 156

Strategies in nonpregnant patients with surgical site intervention involving diet and physical activity (108).
infection after laparotomy, including secondary closure In a small study, the use of an Internet-based program
or the addition of negative pressure wound therapy to that computes energy needs to achieve a defined weight
the wound, were associated with improved healing times loss based on demographic, anthropometric, and lactation
compared with allowing closure by secondary intention status (U.S. Department of Agriculture’s MyPyramid
alone (100, 101). Menu Planner for Moms) resulted in significantly more
weight loss in overweight and obese lactating women
What are effective postpartum care and inter- compared with a control group (109). A larger study of
conceptual strategies for weight loss before breastfeeding women compared a Mediterranean-style
the next pregnancy? diet with the U.S. Department of Agriculture’s My-
Pyramid Menu Planner for Pregnancy and Breastfeed-
Weight loss between pregnancies in obese women
ing. Both groups achieved moderate weight loss over
has been shown to decrease the risk of a large-for-
4 months (−2.3 ± 3.4 kg and −3.1 ± 3.4 kg for the
gestational-age infant (adjusted OR, 0.61; 95% CI,
Mediterranean-style and comparison diets, respectively),
0.52–0.73), whereas interpregnancy weight gain has
but there was no significant difference between groups
been associated with an increased risk of having a large-
(110). In a randomized clinical trial, family-based behav-
for-gestational-age infant (adjusted OR, 1.37; 95% CI,
ioral intervention did not result in a significant increase
1.21–1.54) (102). Interpregnancy weight loss in obese
in postpartum weight loss compared with a control
women may decrease the risk of a large-for-gestational-
group. After adjusting for covariables in a multivari-
age neonate in a subsequent pregnancy.
ate analysis, only baseline energy intake, work status,
There was no increased risk of a small-for-
and breastfeeding were significant predictors of weight
gestational-age infant unless there was maternal weight
change (111). Nutrition counseling is recommended for
loss of more than 8 BMI units (102). The interpregnancy
all overweight and obese women, and they should be
interval in women who lost weight in this study was lon-
encouraged to follow an exercise regimen. Although evi-
ger than for those who gained weight between pregnan-
dence from a Cochrane review suggests that diet alone or
cies. Thus, contraceptive counseling is important with
diet plus exercise but not exercise alone helped women
this patient population (103).
lose weight postpartum, there may be other beneficial
Excessive gestational weight gain is associated with
effects from including exercise in lifestyle habits (112).
short-term and long-term postpartum weight retention
Behavioral interventions employing diet and exercise
(104). In a meta-analysis of the influence of gestational
can improve postpartum weight reduction in contrast
weight gain on postpartum weight retention in studies
to exercise alone. Nutrition and exercise counseling
that included more than 65,000 women, those with a
should continue postpartum and before attempting another
gestational weight gain above the IOM recommenda-
pregnancy. For women who were breastfeeding, more
tions retained 3.06 kg (6.75 lb) (95% CI; 1.50, 4.63 kg)
evidence is required to confirm whether diet, exercise,
after 3 years and 4.72 kg (10.41 lb) (95% CI; 2.94,
or both provides the most benefit for postpartum weight
6.50 kg) after 15 years or more compared with those
reduction (112).
who gained weight within the recommendations (104).
Gestational weight gain below the guidelines was asso-
ciated with 3 kg (6.6 lb) less weight retention within Summary of
6 months postpartum. In another study, in pregnant
women who gained in excess of 20 kg (45 lb), the risk of Recommendations and
postpartum weight retention was sixfold greater than in Conclusions
women who gained 10–15 kg (22–33 lb) (105). Similar
findings were reported in Asian populations (106). The following recommendations are based on
In the Fit for Delivery study, although behavioral good or consistent scientific evidence (Level A):
intervention did not significantly decrease excessive
Body mass index calculated at the first prenatal visit
gestational weight gain in overweight and obese women,
should be used to provide diet and exercise counsel-
intervention did increase the percentages of normal-
ing guided by IOM recommendations for gestational
weight, overweight, and obese women who reached
weight gain during pregnancy.
their preconception weights or below at 6 months post-
partum (30.7% of the intervention group versus 18.7% Subcutaneous drains increase the risk of postpartum
of the standard-care group) (107). Traditional means to cesarean wound complications and should not be
decrease postpartum weight have employed behavioral used routinely.

Practice Bul­le­tin No. 156 9

 2. National Center for Health Statistics. NCHS obesity data.
Behavioral interventions employing diet and exer- Hyattsville (MD): NCHS; 2014. Available at: http://
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contrast to exercise alone. Retrieved September 2, 2015. (Level II-3) ^
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The following recommendations are based on lim- Prevalence and trends in obesity among US adults, 1999-
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Allowing a longer first stage of labor before per-
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14 Practice Bulletin No. 156

112. Amorim Adegboye AR, Linne YM. Diet or exercise,
or both, for weight reduction in women after childbirth. The MEDLINE database, the Cochrane Library, and the
Cochrane Database of Systematic Reviews 2013, Issue 7. American College of Obstetricians and Gynecologists’
Art. No.: CD005627. DOI: 10.1002/14651858.CD005627. own internal resources and documents were used to con­
pub3. (Meta-analysis) [PubMed] [Full Text] ^ duct a lit­er­a­ture search to lo­cate rel­e­vant ar­ti­cles pub­lished
be­tween January 1990–February 2013. The search was
re­strict­ed to ar­ ti­
cles pub­ lished in the English lan­ guage.
Pri­or­i­ty was given to articles re­port­ing results of orig­i­nal
re­search, although re­view ar­ti­cles and com­men­tar­ies also
CORRECTION were consulted. Ab­stracts of re­search pre­sent­ed at sym­po­
In “Practice Bulletin No. 156: Obesity in Pregnancy” sia and sci­en­tif­ic con­fer­enc­es were not con­sid­ered adequate
from the American College of Obstetricians and for in­clu­sion in this doc­u­ment. Guide­lines pub­lished by
Gynecologists, there is an error on page 2 in the first or­ga­ni­za­tions or in­sti­tu­tions such as the Na­tion­al In­sti­tutes
of Health and the Amer­i­can Col­lege of Ob­ste­tri­cians and
paragraph in the right-hand column. The second sen- Gy­ne­col­o­gists were re­viewed, and ad­di­tion­al studies were
tence should indicate “P<.01” instead of “P<.1.” The located by re­view­ing bib­liographies of identified articles.
correct sentence is as follows: “This slight upward When re­li­able research was not available, expert opinions
trend also is confirmed with increasing classes of from ob­ste­tri­cian–gynecologists were used.
obesity: class I (adjusted hazard ratio, 1.3; 95% CI, Studies were reviewed and evaluated for qual­i­ty ac­cord­ing
1.2–1.4), class II (adjusted hazard ratio, 1.4; 95% to the method outlined by the U.S. Pre­ven­tive Services
CI, 1.3–1.6), and class III (adjusted hazard ratio, 1.9; Task Force:
95% CI, 1.6–2.1; P<.01) (10).” I Evidence obtained from at least one prop­ er­
ly
de­signed randomized controlled trial.
II-1 Evidence obtained from well-designed con­ trolled
tri­als without randomization.
II-2 Evidence obtained from well-designed co­ hort or
case–control analytic studies, pref­er­ab­ ly from more
than one center or research group.
II-3 Evidence obtained from multiple time series with or
with­out the intervention. Dra­mat­ic re­sults in un­con­
trolled ex­per­i­ments also could be regarded as this
type of ev­i­dence.
III Opinions of respected authorities, based on clin­i­cal
ex­pe­ri­ence, descriptive stud­ies, or re­ports of ex­pert
committees.
Based on the highest level of evidence found in the data,
recommendations are provided and grad­ed ac­cord­ing to the
following categories:
Level A—Recommendations are based on good and con­
sis­tent sci­en­tif­ic evidence.
Level B—Recommendations are based on limited or in­con­
sis­tent scientific evidence.
Level C—Recommendations are based primarily on con­
sen­sus and expert opinion.

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Obesity in pregnancy. Practice Bulletin No. 156. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e112–26.

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