Care of Women with Obesity in Pregnancy
Green-top Guideline No. 72
November 2018
Please cite this paper as: Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, Diamond A, on behalf of the
Royal College of Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy.
Green-top Guideline No. 72. BJOG 2018; https://doi.org/10.1111/1471-0528.15386.000:1–45.
, DOI: 10.1111/1471-0528.15386 RCOG Green-top Guidelines
Care of Women with Obesity in Pregnancy
FC Denison, NR Aedla, O Keag, K Hor, RM Reynolds, A Milne, A Diamond, on behalf of the Royal
College of Obstetricians and Gynaecologists
Correspondence: Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG.
Email:
This is the second edition of this guideline. The first edition was published in 2010 as a joint guideline with the
Centre of Maternal and Child Enquiries under the title ‘Management of Women with Obesity in Pregnancy’.
Executive summary
Prepregnancy care
What care should be provided in the primary care setting to women of childbearing age with obesity who wish to
become pregnant?
Primary care services should ensure that all women of childbearing age have the opportunity to
P
optimise their weight before pregnancy. Advice on weight and lifestyle should be given during
preconception counselling or contraceptive consultations. Weight and BMI should be measured
to encourage women to optimise their weight before pregnancy.
Women of childbearing age with a BMI 30 kg/m2 or greater should receive information and
advice about the risks of obesity during pregnancy and childbirth, and be supported to lose
D
weight before conception and between pregnancies in line with National Institute for Health
and Care Excellence (NICE) Clinical guideline (CG) 189.
Women should be informed that weight loss between pregnancies reduces the risk of stillbirth,
hypertensive complications and fetal macrosomia. Weight loss increases the chances of
B
successful vaginal birth after caesarean (VBAC) section.
What nutritional supplements should be recommended to women with obesity who wish to become pregnant?
Women with a BMI 30 kg/m2 or greater wishing to become pregnant should be advised to take
5 mg folic acid supplementation daily, starting at least 1 month before conception and
D
continuing during the first trimester of pregnancy.
Obese women are at high risk of vitamin D deficiency. However, although vitamin D
supplementation may ensure that women are vitamin D replete, the evidence on whether
B
routine vitamin D should be given to improve maternal and offspring outcomes remains
uncertain.
RCOG Green-top Guideline No. 72 2 of 45 ª 2018 Royal College of Obstetricians and Gynaecologists
,Provision of antenatal care
How and where should antenatal care be provided?
Care of women with obesity in pregnancy can be integrated into all antenatal clinics, with clear
local policies and guidelines for care available.
D
What are the facilities, equipment, and personnel required?
All maternity units should have a documented environmental risk assessment regarding the
P
availability of facilities to care for pregnant women with a booking BMI 30 kg/m2 or greater.
This risk assessment should address the following issues:
circulation space
accessibility, including doorway widths and thresholds
safe working loads of equipment and floors
appropriate theatre gowns
equipment storage
transportation
staffing levels
availability of, and procurement process for, specific equipment, including large blood pressure
cuffs, appropriately sized compression stockings and pneumatic compression devices, sit-on
weighing scale, large chairs without arms, large wheelchairs, ultrasound scan couches, ward and
delivery beds, mattresses, theatre trolleys, operating theatre tables and lifting and lateral transfer
equipment.
Maternity units should have a central list of all facilities and equipment required to provide
P
safe care to pregnant women with a booking BMI 30 kg/m2 or greater. The list should include
details of safe working loads, product dimensions, as well as where specific equipment is
located and how to access it.
Women with a booking BMI 40 kg/m2 for whom moving and handling are likely to prove
unusually difficult should have a moving and handling risk assessment carried out in the third
D
trimester of pregnancy to determine any requirements for labour and birth. Clear
communication of manual handling requirements should occur between the labour and theatre
suites when women are in early labour.
Some women with a booking BMI less than 40 kg/m2 or greater may also benefit from assessment of
P
moving and handling requirements in the third trimester. This should be decided on an individual basis.
RCOG Green-top Guideline No. 72 3 of 45 ª 2018 Royal College of Obstetricians and Gynaecologists
, Measuring weight, height and BMI
When and how often should maternal weight, height and BMI be measured?
All pregnant women should have their weight and height measured using appropriate
equipment, and their BMI calculated at the antenatal booking visit. Measurements should be
D
recorded in the handheld notes and electronic patient information system.
For women with obesity in pregnancy, consideration should be given to reweighing women
P
during the third trimester to allow appropriate plans to be made for equipment and personnel
required during labour and birth.
What is the acceptable gestational weight gain in obese women?
There is a lack of consensus on optimal gestational weight gain. Until further evidence is available,
P
a focus on a healthy diet may be more applicable than prescribed weight gain targets.
Information giving during pregnancy
What are the clinical risks of maternal obesity to maternal and fetal health in pregnancy?
All pregnant women with a booking BMI 30 kg/m2 or greater should be provided with accurate
and accessible information about the risks associated with obesity in pregnancy and how they
D
may be minimised. Women should be given the opportunity to discuss this information.
What dietetic and exercise advice should be offered in pregnancy?
Dietetic advice by an appropriately trained professional should be provided early in the
P
pregnancy where possible in line with NICE Public Health Guideline 27.
What is the role of anti-obesity drugs in pregnancy?
Anti-obesity or weight loss drugs are not recommended for use in pregnancy.
C
Risk assessment during pregnancy in women with obesity
What specific risk assessments are required for anaesthetics?
Pregnant women with a booking BMI 40 kg/m2 or greater should be referred to an obstetric
anaesthetist for consideration of antenatal assessment.
D
Difficulties with venous access and regional and general anaesthesia should be assessed. In
addition, an anaesthetic management plan for labour and birth should be discussed and
D
documented. Multidisciplinary discussion and planning should occur where significant potential
difficulties are identified.
RCOG Green-top Guideline No. 72 4 of 45 ª 2018 Royal College of Obstetricians and Gynaecologists
Green-top Guideline No. 72
November 2018
Please cite this paper as: Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, Diamond A, on behalf of the
Royal College of Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy.
Green-top Guideline No. 72. BJOG 2018; https://doi.org/10.1111/1471-0528.15386.000:1–45.
, DOI: 10.1111/1471-0528.15386 RCOG Green-top Guidelines
Care of Women with Obesity in Pregnancy
FC Denison, NR Aedla, O Keag, K Hor, RM Reynolds, A Milne, A Diamond, on behalf of the Royal
College of Obstetricians and Gynaecologists
Correspondence: Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent’s Park, London NW1 4RG.
Email:
This is the second edition of this guideline. The first edition was published in 2010 as a joint guideline with the
Centre of Maternal and Child Enquiries under the title ‘Management of Women with Obesity in Pregnancy’.
Executive summary
Prepregnancy care
What care should be provided in the primary care setting to women of childbearing age with obesity who wish to
become pregnant?
Primary care services should ensure that all women of childbearing age have the opportunity to
P
optimise their weight before pregnancy. Advice on weight and lifestyle should be given during
preconception counselling or contraceptive consultations. Weight and BMI should be measured
to encourage women to optimise their weight before pregnancy.
Women of childbearing age with a BMI 30 kg/m2 or greater should receive information and
advice about the risks of obesity during pregnancy and childbirth, and be supported to lose
D
weight before conception and between pregnancies in line with National Institute for Health
and Care Excellence (NICE) Clinical guideline (CG) 189.
Women should be informed that weight loss between pregnancies reduces the risk of stillbirth,
hypertensive complications and fetal macrosomia. Weight loss increases the chances of
B
successful vaginal birth after caesarean (VBAC) section.
What nutritional supplements should be recommended to women with obesity who wish to become pregnant?
Women with a BMI 30 kg/m2 or greater wishing to become pregnant should be advised to take
5 mg folic acid supplementation daily, starting at least 1 month before conception and
D
continuing during the first trimester of pregnancy.
Obese women are at high risk of vitamin D deficiency. However, although vitamin D
supplementation may ensure that women are vitamin D replete, the evidence on whether
B
routine vitamin D should be given to improve maternal and offspring outcomes remains
uncertain.
RCOG Green-top Guideline No. 72 2 of 45 ª 2018 Royal College of Obstetricians and Gynaecologists
,Provision of antenatal care
How and where should antenatal care be provided?
Care of women with obesity in pregnancy can be integrated into all antenatal clinics, with clear
local policies and guidelines for care available.
D
What are the facilities, equipment, and personnel required?
All maternity units should have a documented environmental risk assessment regarding the
P
availability of facilities to care for pregnant women with a booking BMI 30 kg/m2 or greater.
This risk assessment should address the following issues:
circulation space
accessibility, including doorway widths and thresholds
safe working loads of equipment and floors
appropriate theatre gowns
equipment storage
transportation
staffing levels
availability of, and procurement process for, specific equipment, including large blood pressure
cuffs, appropriately sized compression stockings and pneumatic compression devices, sit-on
weighing scale, large chairs without arms, large wheelchairs, ultrasound scan couches, ward and
delivery beds, mattresses, theatre trolleys, operating theatre tables and lifting and lateral transfer
equipment.
Maternity units should have a central list of all facilities and equipment required to provide
P
safe care to pregnant women with a booking BMI 30 kg/m2 or greater. The list should include
details of safe working loads, product dimensions, as well as where specific equipment is
located and how to access it.
Women with a booking BMI 40 kg/m2 for whom moving and handling are likely to prove
unusually difficult should have a moving and handling risk assessment carried out in the third
D
trimester of pregnancy to determine any requirements for labour and birth. Clear
communication of manual handling requirements should occur between the labour and theatre
suites when women are in early labour.
Some women with a booking BMI less than 40 kg/m2 or greater may also benefit from assessment of
P
moving and handling requirements in the third trimester. This should be decided on an individual basis.
RCOG Green-top Guideline No. 72 3 of 45 ª 2018 Royal College of Obstetricians and Gynaecologists
, Measuring weight, height and BMI
When and how often should maternal weight, height and BMI be measured?
All pregnant women should have their weight and height measured using appropriate
equipment, and their BMI calculated at the antenatal booking visit. Measurements should be
D
recorded in the handheld notes and electronic patient information system.
For women with obesity in pregnancy, consideration should be given to reweighing women
P
during the third trimester to allow appropriate plans to be made for equipment and personnel
required during labour and birth.
What is the acceptable gestational weight gain in obese women?
There is a lack of consensus on optimal gestational weight gain. Until further evidence is available,
P
a focus on a healthy diet may be more applicable than prescribed weight gain targets.
Information giving during pregnancy
What are the clinical risks of maternal obesity to maternal and fetal health in pregnancy?
All pregnant women with a booking BMI 30 kg/m2 or greater should be provided with accurate
and accessible information about the risks associated with obesity in pregnancy and how they
D
may be minimised. Women should be given the opportunity to discuss this information.
What dietetic and exercise advice should be offered in pregnancy?
Dietetic advice by an appropriately trained professional should be provided early in the
P
pregnancy where possible in line with NICE Public Health Guideline 27.
What is the role of anti-obesity drugs in pregnancy?
Anti-obesity or weight loss drugs are not recommended for use in pregnancy.
C
Risk assessment during pregnancy in women with obesity
What specific risk assessments are required for anaesthetics?
Pregnant women with a booking BMI 40 kg/m2 or greater should be referred to an obstetric
anaesthetist for consideration of antenatal assessment.
D
Difficulties with venous access and regional and general anaesthesia should be assessed. In
addition, an anaesthetic management plan for labour and birth should be discussed and
D
documented. Multidisciplinary discussion and planning should occur where significant potential
difficulties are identified.
RCOG Green-top Guideline No. 72 4 of 45 ª 2018 Royal College of Obstetricians and Gynaecologists
