The case of M was complex because of her high BMI, advanced maternal age, and gestational diabetes that required insulin to control blood glucose levels. The patient’s BMI of 67 puts her in the category of having super-morbid obesity (BMI > 50). This classification puts her at significant risk for complications, including increased risk of VTE, infections, difficulty with anesthesia, respiratory compromise, hypertension, pre-eclampsia or eclampsia, large for gestational age infant, cesarean delivery, gestational diabetes, and a five-minute Apgar score of less than 7.
Earlier in her pregnancy, first trimester fingersticks were initiated and revealed consistently high fasting blood glucose levels. For this reason, coupled with her super-morbid obesity, she was started on NPH insulin nightly at 16 weeks’ gestation. Although she frequently missed appointments and forgot to bring her insulin logs, she stated that her glucose levels were well-controlled.
Because this patient had numerous risk factors for adverse outcomes, she was presented to the high-risk OB team prenatally so that a comprehensive plan of care could be developed prior to admission. This individualized plan of care involved use of a bariatric care checklist, which includes additional OR equipment, higher dosing for antibiotics and epidural medications, additional personnel in the OR to assist with transferring and retracting, maintenance of proper positioning to maintain adequate airway, and use of screening tools for hemorrhage risk and VTE prevention.
Another important part of this plan of care was a consult with anesthesia prior to admission. Their recommendations included early admission, the use of continuous spinal epidural, ultrasound for landmark identification, long spinal epidural needles and introducers, GlideScope, a trial of supplemental oxygen with room air prior to transfer to postpartum unit, minimal use of narcotics, and early mobilization. They also identified her as having obstructive sleep apnea.
As luck would have it, she arrived unexpectedly during an off-shift. The planning done by the high-risk team, including use of risk-assessment tools, allowed the staff on shift to access a written plan of care for this patient. This patient fell into the high-risk category for VTE because of her multiple risk factors, including high BMI, gestational diabetes, maternal age, pregnancy, and the surgical delivery. Because of this, she was provided sequential compression devices beginning in the OR, and these were continued whenever the patient was in bed during her hospitalization. In addition, early ambulation was encouraged and pharmacological prophylaxis was initiated six hours following surgery. Pharmacy was consulted for appropriate dosing given her elevated BMI.
The patient was discharged on postop day number four with a follow-up appointment scheduled within three to four days for staple removal and glucose monitoring. Her discharge orders included frequent ambulation and chemical prophylaxis for six weeks for VTE prevention in addition to routine C-section postoperative instructions.
Managing and caring for this patient in terms of high-quality delivery, recognition of risk factors, early interventions, and “stellar” hand-off communication was a challenge to the OB nurses. If transfer had been required to a higher level of care, such as ICU, then critical care nurses would require assistance from the obstetric team in managing postpartum assessments.