Screen for gestational diabetes with:

• a HbA₁C at booking (normal is less than 6.0%=42 mmol/mol)
• and, an OGTT at 24-28 weeks

Consultant led booking and care for those with a BMI over 40.

Potential points to discuss are increased chance of pre-eclampsia, gestational diabetes, venous thrombo-embolism, induction, cesarean, anaesthetic complications, IUGR

• Refer to anaesthetics via Badger at booking
• Growth scans at 28 and 34 weeks

• IV access in labour
• TEDs should be worn in 1st stage if an epidural is in progress, prior to caesarean section or postnatally
• Raniditine 150mg PO should be given 6 hourly
• Alert anaesthetist on bleep 3933 - see section on anaesthetic guidelines
• Alert theatre if weight more than 120kg (bleep 1977) - additional theatre table side sections may be required 9 (max weight is 247kg)
• Active Mx 3^rd stage

Assess for post-natal thromboprophylaxis using usual risk assessment sheet. 

• The anaesthetist should ideally be ST6 or above - the anaesthetic trainee is to alert the consultant anaesthetist on call if a patient with a BMI more than 40 is admitted to labour ward
• Early epidural is recommended due to increased risk of obstetric intervention
• Consider conflict of regional anaesthesia and thromboprophylaxis if on thromboprophylaxis antenatally
• Venous access should be established early in labour - ensure Group and Screen is sent
• If a general anaesthetic is required consider use of the bariatric ramp and pre-oxygenate in the reverse Trendelenberg position (25 degrees head up) - a consultant anaesthetist should ideally be present
• Use dose of non-depolarising muscle relaxant based on actual body weight
• Direct arterial pressure measurement may be useful in the morbidly obese patient where sphygmomanometry may be inaccurate