Obesity in western populations

Increasing rates of obesity in western populations present management difficulties for clinicians caring for obese pregnant
women. Various governing bodies have published clinical guidelines for the care of obese parturient. These guidelines refer
to two components of anesthetic care: anesthetic consultation in the antenatal period for women with a body mass index
(BMI) ≥ 40 kg/m2
and the provision of early epidural analgesia in labor. These recommendations are based on the increased
incidence of obstetric complications and the predicted risks and difficulties in providing anesthetic care. The concept behind
early epidural analgesia is logical—site the epidural early, use it for surgical anesthesia and avoid general anesthesia if
surgery is required. Experts support this recommendation, but there is weak supporting evidence. It is known that the
management of labor epidurals in obese women is complicated and that women with extreme obesity require higher rates
of general anesthesia. Anecdotally, anesthetists view and apply the early epidural recommendation inconsistently and
the acceptability of early epidural analgesia to pregnant women is variable. In this topic review, we critically appraise these
two practice recommendations. The elements required for effective implementation in multidisciplinary maternity care are
considered. We identify gaps in the current literature and suggest areas for future research. While prospective cohort studies
addressing epidural extension (‘top-up‘) in obese parturients would help inform practice, audit of local practice may better
answer the question “is early epidural analgesia beneficial to obese women in my practice?”.