High BMI Patients Pregnancy Pathway

  • BMI (kg/ht m2 ) should be based on pre pregnancy or early pregnancy weight.
  • All women with a BMI ≥35  after booking in must be seen in the Obstetric Clinic for early antenatal assessment (medium risk)
  • Recommended folate supplementation dose is 5mg
  • All women with high BMI should be offered referral to a dietician (see Antenatal Nutrition and Physiotherapy Combined Group Information )
  • Information on expected weight gain should be provided to women- expected weight gain chart
  • Medical issues related to obesity should be discussed
  • Blood pressure should be checked using an appropriate sized cuff
  • Antenatal thromboprophylaxis is recommended in obese women who require bed rest for any reason

Frequency of Antenatal Visits

Antenatal visits are usually at least fortnightly from 28 weeks and weekly from 36 weeks due to increased risk of pregnancy complications.


Hospital Visits

ALL WOMEN should visit Hospital at;

  • Booking In Clinic (around 12 weeks). Appointments can be made by calling 9784 2600 – GP Referral required Referral Form- Antenatal Clinic
  • Early Obstetric Clinic Appointment for obstetric review for antenatal assessment and to determine degree of risk and set visit schedule.
  • Either 34 OR 36 weeks. The 34/36 week hospital appointment is made during the Booking In clinic visit. The patient can also book ph 9784 2600.
  • Advanced Pregnancy Clinic. All uncomplicated post-date pregnancies are booked for induction of labour between 41 weeks 3 days and 42 weeks. Appointments for the Advanced Pregnancy Clinic (weekly) can be made by calling 9784 2600.


TESTS AND RESULTS (GENERAL & HIGH BMI SPECIFIC)

  • Early glucose tolerance test (OGTT) at 12-14 weeks recommended as well as at 26-28 weeks
  • Ultrasound frequency and timing

Mid trimester fetal morphological assessment should be performed at 20-21 weeks (rather than 18-20) to enable more accurate fetal assessment and maternal obesity should be highlighted on the request form *

A repeat ultrasound for fetal weight, liquor volume and umbilical artery doppler studies in the 3rd trimester (28-34wks) may be helpful to assess fetal growth if palpation is difficult**

GP SMCAs (Shared Maternity Care Affiliates) are responsible for following up results of tests ordered in general practice.

SMCAs should record test results in the VMR AND SEND COPIES to Frankston Hospital Antenatal Clinic- Outpatient Area 1- Building D

Significantly ABNORMAL results should be discussed with Obstetric Registrar or Consultant via switchboard PH 9784 7777

 

First Trimester

Visit 1 - Confirmation of pregnancy

Supplements

Supplements 2014

  • Folic acid 5mg daily (high risk dose)  from1 month preconception and for 1st Trimester
  • Iodine- 150mcg daily

Dietary Advice

Dietary Advice 2014 includes list of foods to avoid

Lifestyle Advice

Lifestyle Advice 2014

Refer to Booking In Clinic

Referral Form- Antenatal Clinic

Discuss Screening


Visit 2 - Around 10 weeks

General History & Examination

Medical, reproductive, obstetric, family/genetic, medications, alcohol and drug, nutritional, psychosocial and demographic

Physical Exam (Medical Clearance): BP, CVS ( Heart murmurs), BMI (BMI ≥35-40 follow High BMI pathway , BMI ≤18 or ≥40 high risk not for Shared Care)

Establish Estimated Due Date (EDD)

Supplements

Supplements 2014

Dietary advice

Dietary Advice 2014 includes list of foods to avoid

Discuss Screening

Early Oral Glucose Tolerance Test (OGTT) for high risk GDM (high BMI or PH GDM)

Standard First Trimester Antenatal Investigations

  • Blood group, Rhesus status Antibody Screen
  • Serum ferritin
  • FBE
  • Hepatitis B surface antigen
  • Hepatitis C Antibodies
  • Rubella Antibodies
  • RPR
  • HIV
  • Serum Vitamin D • MSU- microscopy and culture
  • Pap smear- if required (*cytobrush not to be used)
  • Discuss and/or organise Maternal Serum Screening Test (MSST)
  • Consider ; OGTT
  • Chlamydia, TSH, Varicella Screening

Note: All results to Antenatal Clinic – 13 Hastings Road

Visit 3 - Around 16 weeks

Obstetric Assessment

Confirm Estimated Due Date (EDD)

RH Negative

Ensure Maternal Serum Screening Test (MSST) has been discussed and result checked (see MSST Increased Risk Pathway 2014)

20-21 weeks Fetal Morphology Scan discussed/organised

 

Second Trimester

Visit 4- Around 20-21 weeks

Obstetric Assessment

Fetal Morphology Scan results discussed

Discuss/Organise OGTT 24-28 weeks


Visit 5- Around 24 weeks

Obstetric Assessment

Fetal Morphology Scan results discussed

Organise Standard Antenatal Investigations at 26-28 weeks

Visit 6- Around 28 weeks

Obstetric Assessment

Standard Antenatal Investigations at 26-28 weeks

  • HB
  • Serum Ferritin
  • Rhesus antibodies  (see below)
  • OGTT for ALL women at 24-28 weeks- if abnormal refer to GDM clinic- GDM Clinic referral form 2015

RH Negative

 

 

Third Trimester

Consider repeat ultrasound for fetal weight, liquor volume and umbilical artery doppler studies in the 3rd trimester (28-34wks). This may be helpful to assess fetal growth if palpation is difficult** 

Visit 7- Around 30 weeks

Obstetric Assessment


Visit 8- Around 32 weeks

Obstetric Assessment

All women must visit Hospital at either 34 OR 36 weeks to allow time for consultant review, discussion of previous results, a routine antenatal check and for an opportunity to discuss issues and ask questions on preparation for labour and birth, unless a alternate schedule of visits has been determined at obstetric review. This appointment is usually made during the Booking In clinic visit or the patient can phone 9784 2600. 

Visit 9- Around 34 weeks

Obstetric Assessment

RH Negative

RH immunoglobulin given – refer to Anti-D Prophylaxis Pathway in the community-Feb 2014

Anti-D Consent, Order and Administration Form

Discussion Points

  • Preparation for labour discussion including timing of birth and VBAC (if appropriate)
  • Breast Feeding Information


Visit 10- Around 36 weeks

Obstetric Assessment

Standard Antenatal Investigations at 36-37 weeks

  • Hb
  • GBS swab- low vaginal (37 weeks)
  • Routine weight- over 120kg- refer to Obstetric clinic

Discussion Points

  • Preparation for labour discussion including VBAC (if appropriate)
  • Breast feeding Information


Visit 11- Around 37 weeks

Obstetric Assessment


Visit 12- Around 38 weeks

Obstetric Assessment

GBS swab result

Book Advanced Pregnancy Clinic Appointment – Ph 9783 8324


Visit 13- Around 39 weeks

Obstetric Assessment

 Book Advanced Pregnancy Clinic Appointment – Phone 9783 8324


Visit 14- Around 40 weeks

Obstetric Assessment

Confirm 41 weeks appointment for Advanced Pregnancy Clinic booked

 

Post Partum

Visit 15 Around- 4-6 weeks Postpartum

Obese women should be encouraged to breastfeed to enhance maternal weight loss. Advise on benefits of weight loss before any further pregnancy, if planned. BMI (kg/ht m2 )should be based on pre pregnancy or early pregnancy weight.

Maternal Check

  • Debrief of labour
  • Follow up of any pregnancy complications eg hypertension, gestational diabetes
  • Signs of anaemia
  • Blood pressure
  • Breast and nipple examination
  • Breastfeeding
  • Perineum – check symptoms eg urinary and faecal continence, dyspareunia and signs eg wound/episiotomy check
  • LUCS wound check
  • Uterine fundus, vaginal loss
  • Contraception
  • Post-natal depression
  • Parenting support and services
  • Settling and sleep

Consider:

  • FBE
  • Iron Studies
  • Coagulation Studies
  • TSH
  • Vitamin D
  • MSU
  • Glucose Tolerance Test if gestational diabetes
  • Pap Test (6-8 weeks postpartum only)
  • Appropriate vaccinations: MMR, Varicella, Pertussis (“Boostrix”for parents, consider immunization of grandparents)

       Immunisations 2014

 Baby Check

  • Enquire about parental concerns (including vision and hearing)
  • Follow up tests and complications (including Vitamin D supplementation if mother was vitamin D deficient )
  • Feeding, breast feeding issues
  • SIDS
  • Immunisation
  • Passive smoking
  • Height, weight, head circumference, growth charts
  • Developmental assessment including smiling at 6 weeks
  • General Physical examination including
  • Jaundice
  • Tone
  • CDH/ clicky hips
  • Fontanelles
  • CVS/murmurs
  • Hernias
  • Testes
  • Squint/ red reflex
  • Primitive reflexes

Disclaimer

These guidelines have been developed by the Peninsula Health GP Liaison Unit and the Peninsula Health Women's Services as a general guide to the management of women participating in the Peninsula Health Shared Maternity Care Program. They may not be applicable in every clinical case. They should not replace thorough clinical assessment and judgement.

Care should be taken when printing any information or Clinical Guidelines. Updates to these guidelines will take place as necessary. It is therefore advised that regular visits to this Website will be needed to access the most current information.