High BMI Patients Pregnancy Pathway

  • BMI (kg/ht m2 )should be based on pre pregnancy or early pregnancy weight
  • Women with a BMI ≥35 must be referred after booking in to the Obstetric Clinic for early antenatal assessment (medium risk)
  • Women with a BMI of >40 are considered high risk and is considered not suitable to GP or midwife shared care
  • Women with a BMI of 50 or over must be referred for tertiary level antenatal care at Monash Health or equivalent service
  • Recommended folate supplementation dose is 5mg
  • All women with high BMI should be offered referral to a dietician
  • 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

GP Antenatal Visits

  • Antenatal visits are usually at least fortnightly from 28weeks and weekly from 36 weeks due to increased risk of pregnancy complications. Fitting in with the hospital schedule above would mean GP visits at 30 weeks, 34 weeks, 37 weeks and 39 weeks.
  • Suggested visit schedule is outlined below.


Hospital Visits

Hospital Visits: ALL WOMEN in this model of care should visit Hospital at

  • Booking In Clinic (around 12 weeks)- referral can be faxed to 9788 1879 (GP referral is essential)
  • Obstetric Clinic (around 14 weeks) -for obstetric review, antenatal assessment and to determine visit schedule.
  • 28 weeks -to review the patient and results of the 28 weeks scan results.
  • 32 weeks –to review serial growth scans
  • 36 weeks– to review serial growth scans and collate results
  • 38 weeks- for general obstetric review and GBS swab results
  • 40 weeks– for general obstetric review and booking for induction


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
    • Serial Growth Scans, Umbilical Artery Dopplers 4 weekly at 28/40, 32/40 and 36/40
    • Fortnightly visits from 28 weeks is recommended
      • It is expected that the GP will organise the scan to be done prior to the 28 weeks Obstetric Clinic visit.  
      • The  woman will be seen at 28 weeks at Obstetric Clinic for results
      • Obstetric Clinic would then organise scans at 32 and 36 weeks and follow up of those results
    • It is recommended that scans in the third trimester be requested at Peninsula Health Radiology at Frankston Hospital on 9784 7501.
    • GP SMCAs (Shared Maternity Care Affiliates) are responsible for following up results of tests ordered in general practice.
    • SMCAs must record test results in the VMR AND SEND COPIES to- Women’s Services Antenatal Clinic Outpatient Area 1 Building D- Frankston Hospital
    • Significantly ABNORMAL results should be discussed with Obstetric Registrar or Consultant via switchboard PH 9784 7777

 First Trimester

Visit 1 - Confirmation of pregnancy

Supplements

Folic acid

  • High risk dose 5mg daily
  • 1 month preconception and for 1st Trimester

Iodine- 150mcg daily

  • Dietary Advice and referral to dietician offered
  • Lifestyle -alcohol, smoking, dental health
  • Immunisations
  • Refer to Booking In Clinic- Referral Form- Antenatal Clinic
  • Discuss Screening
  • Tests
    • 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)
    • Consider – Chlamydia, TSH, Varicella 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)
    • Establish EDD
    • Supplements
    • Dietary advice
    • Discuss Screening

    First Trimester Antenatal Investigations

    • Early OGTT at 12-14 weeks for high risk GDM (high BMI or PH GDM)
      • If abnormal refer to GDM Clinic
      • if normal repeat 26-28 weeks

Visit 3 - Around 16 weeks

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Confirm EDD
  • IF RH Negative, discuss management
  • Ensure MSST has been discussed and result checked (see MSST ‘Increased Risk’ Pathway)
  • Discuss Fetal Movements
  • 20-21 weeks Fetal Morphology Scan discussed/organised

Second Trimester

Visit 4- Around 20-21 weeks

Obstetric Assessment

  • Fundal height in cm
  • Smoking
  • Blood pressure
  • Fetal Movements
  • Inspection of legs for oedema or thromboembolic disease
  • Fetal Morphology Scan results discussed
  • Discuss/Organise OGTT 26-28 weeks


Visit 5- Around 24 weeks

Obstetric Assessment

  • Fundal height in cm
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Inspection of legs for oedema or thromboembolic disease
  • Fetal Morphology Scan results discussed

Organise Standard Antenatal Investigations at 26-28 weeks

  • HB
  • Serum Ferritin
  • Rhesus antibodies
  • OGTT for ALL women at 26 – 28 weeks
  • Referral for growth scan at 28 weeks (result to be reviewed in antenatal clinic)

Visit 6- Around 28 weeks- Hospital Visit

Obstetric Assessment AND Discuss results of Standard Antenatal  Investigations at 26-28 weeks

      • HB
      • Serum Ferritin
      • Rhesus antibodies and
      • OGTT for ALL women at 26-28 weeks
      • Review 28 week Growth Scan
      • Refer for Serial Growth Scans at 32 and 36 weeks

Rhesus antibodies and RH immunoglobulin given if RH Neg (  Anti-D Prophylaxis Pathway in the community-Feb 2014)

Third Trimester

Visit 7- Around 30 weeks

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Inspection of legs for oedema or thromboembolic disease


Visit 8- Around 32 weeks

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Inspection of legs for oedema or thromboembolic disease

Review  32 week Serial Growth Scan

 

Visit 9- Around 34 weeks

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Check for unstable/abnormal lie-Refer
  • Inspection of legs for oedema or thromboembolic disease
  • RH immunoglobulin given (if Rh Negative) see RhD pathway
  • Preparation for labour discussion including timing of birth and VBAC (if appropriate)
  • Breast Feeding Information

Visit 10- Around 36 weeks- Hospital Visit

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Check for unstable/abnormal lie -Refer
  • Inspection of legs for oedema or thromboembolic disease

Review  36 week Serial Growth Scan


Visit 11- Around 37 weeks

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Check for unstable/abnormal lie -Refer
  • Inspection of legs for oedema or thromboembolic disease

 

Standard Antenatal Investigations at 36-37 weeks

  • Hb
  • GBS swab- low vaginal (37 weeks)
  • Routine weight


Visit 12- Around 38 weeks - Hospital Visit

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Check for unstable/abnormal lie -Refer
  • Inspection of legs for oedema or thromboembolic disease

Review 

  • GBS swab result


Visit 13- Around 39 weeks

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Check for unstable/abnormal lie -Refer
  • Inspection of legs for oedema or thromboembolic disease


Visit 14- Around 40 weeks- Hospital Visit

Obstetric Assessment

  • Fundal height
  • Smoking
  • Blood pressure
  • Fetal Auscultation
  • Fetal Movements
  • Fetal Presentation
  • Check for unstable/abnormal lie -Refer
  • Inspection of legs for oedema or thromboembolic disease

Booking for induction

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.