Checklists and care pathways (synonymous with care maps, critical pathways, and clinical pathways) are document-based tools that link available evidence to health care practice with the intent to optimize clinical outcomes and patient safety.¹ They provide the foundation for translation of evidence into clinical guidelines and protocols. The World Health Organization (WHO) and Institute of Medicine (IOM) have both advocated of the use of checklists as a key concept in reducing medical errors and improving patient safety.^2,3 Checklists and care pathways have clearly shown improvement in many aspects of medical care and patient care.^1,4,5 In a recent study, the use of crisis checklists in critical processes among operating room teams participating in simulated operating room scenarios showed a 75% reduction in failure to adhere to critical management steps in common intraoperative emergencies.⁶ In addition, providers preferred checklists and bundles as memory aids. In the same study, almost all of the study participants (N = 67) stated their desire to have the checklist used if they experienced an intraoperative emergency.

This chapter summarizes the important concepts and provides a framework for the development of checklists and care pathways for obese women spanning preconception to the postpartum period. The checklists are based on the evidence presented in other chapters of this text as well as our own review and summary of the literature.

Checklists and Care Pathways in Pregnancy

One of the earliest reports on obstetric checklists was a 1998 article by Ransom et al.⁷ A 3-week pilot study was conducted with the implementation of a normal vaginal delivery clinical pathway that included standardized order sets. Despite difficulty with pathway development and implementation across sites, the study showed a decrease in length of hospital stay and an approximate $300 reduction in the cost of a vaginal delivery. In a follow-up study, Ransom et al. suggested that clinical pathways for both vaginal and cesarean delivery may reduce litigation costs.⁸ In 2010, the British Columbia Perinatal Health Program disseminated the BC Maternity Care Pathway in an effort to standardize care to pregnant women.⁹ Other examples of obstetric checklists include one for management of suspected placenta accreta, an airway checklist for general anesthesia, and a short, evidence-based checklist to reduce complications of cesarean delivery.^10,11,12

Clark et al. also credit the use of checklist-based protocols in process standardization as a major component in quality and safety improvements in obstetric care in a large health care system.¹³ Furthermore, the implementation of checklists has shown improved communication among obstetric teams.^14,15 In 2011, Fausett et al. published an article in the American Journal of Obstetrics and Gynecology’s Patient Safety Series on developing and implementing an effective checklist.¹⁶ Key concepts in checklist development included careful selection of the clinical process underlying the checklist, multidisciplinary representation, brevity, and ongoing review of the evidence to ensure current standards of care are being met.

The American College of Obstetricians and Gynecologists (ACOG) recently released a statement encouraging the use of protocols and checklists.¹⁷ These checklists have served as the backbone of “bundle” development to standardize obstetric care across health care systems and improve quality of care. Since 2010, ACOG has published nine Patient Safety Checklists, including induction of labor, magnesium sulfate for neuroprotection in the preterm infant, trial of labor after caesarean delivery, and management of postpartum hemorrhage (http://www.acog.org/Resources-And-Publications/Patient-Safety-Checklists, accessed April 2, 2015). The Society for Maternal Fetal Medicine (SMFM) has also published two checklists related to management of monochorionic twin pregnancies (https://www.smfm.org/mfm-practice/checklists-and-safety-bundles, accessed April 2, 2015). While these documents were developed to help in the standardization of health care processes and reduce variation in patient care, both ACOG and SMFM affirmed that these checklists should serve as a foundation rather than as an exclusive management plan. As stated by SMFM, “The regular use of checklists—standardized, validated, evidence- or consensus-based processes—promotes consistency in obstetrical care and helps provide safe, efficient, high-quality patient care” (https://www.smfm.org/mfm-practice/checklists-and-safety-bundles; accessed April 2, 2015).

Checklists and Care Pathways in Obese Pregnant Women

As discussed throughout this book, obesity and morbid obesity are significant contributors to both maternal and neonatal morbidity.^18,19,20 In addition, data suggest that providers comply less with prenatal care recommendations in obese women, further reiterating the importance of checklists to keep compliance with prenatal care recommendations high for all women.²¹ The obstetric literature regarding clinical care pathways in obese women is sparse. Previously, Catalano published a widely use and referenced well-written and thorough expert opinion article on management of the obese pregnant patient.²² In 2013, ACOG updated its committee opinion regarding obesity in pregnancy.¹⁹ Both of these documents provide a rich discussion of pregnancy complications and offer general recommendations surrounding obesity in pregnancy. However, they fall short of establishing a specific framework or checklists for care of the obese pregnant woman. Two recent review articles offer a more structured model in the management of the obese woman throughout pregnancy.^23,24

The Royal College of Obstetricians and Gynecologists in collaboration with the Centre for Maternal and Child Enquiries published a joint guideline in 2010, Management of Women With Obesity in Pregnancy.²⁵ Similar to a traditional care pathway, this guideline was developed by a multidisciplinary and evidence-based effort to standardize care and improve patient outcomes. Fealy et al. implemented and evaluated an alternative (addition to routine prenatal care) clinical care pathway for 79 pregnant women with a body mass index (BMI) of 35 kg/m² or greater. The pathway consisted of written education on obesity, dietician referral, early gestational diabetes mellitus (GDM) screening, evaluation of renal and liver function, anesthesia consultation, routine growth ultrasound, and patient self-weight recordings. The data on outcome, however, were mixed. No women took advantage of self-weighing, and fewer than 20% of women utilized dietetic counseling. Most women took advantage of early GDM screening and serial ultrasounds.²⁶ Despite the lack of direct evidence on outcomes, care maps are effective tools for providers to standardize approach and counseling related to high-risk pregnancy practice.

Throughout this chapter, we endeavor to summarize the best evidence on pregnancy and goals of care for obese women, from preconception to the postpartum period through the use of checklists. The checklists should be routinely evaluated and modified as new evidence becomes available. Our intent is that individual institutions and health care systems will not only tailor these care models to meet the needs of their unique patient populations, as determined by local resources, practice patterns, and service availability, but also expand on them in an effort to standardize care and optimize obstetric management of obese women.

The preconception visit for the obese patient considering pregnancy represents an ideal opportunity for the patient and provider to enter into a discussion regarding the risks of pregnancy and the ways to maximize health for the mother and potential infant prior to entry into pregnancy. This should be viewed not as a visit to bully or scold a patient into radical weight loss behaviors or surgical options, but instead to provide unbiased counseling in an attempt to have patients engage in behaviors that allow them to be the healthiest that they can be at any weight and to motivate patients to begin their weight loss journey as a portion of their preparation for a health pregnancy (Figure 19-1).

The provider should utilize the preconception visit to discuss weight loss methods the patient used in the past, including successes and failures, and discuss the dietary and weight goals for the pregnancy. This should include the IOM weight gain recommendations. It has been shown that a 10% difference in prepregnancy BMI is associated with improved obstetric outcomes.²⁷ There are data to support that obese women who maintain an active and healthy lifestyle will improve their pregnancy outcomes and can decrease excessive weight gain and reduce the risk of GDM.²⁸ Avoiding excess weight gain is associated with improve pregnancy outcome and lower rates of macrosomia.^29,30 Therefore, developing a healthy lifestyle even without weight loss should be emphasized during preconception counseling. Dietary evaluation with avoidance of excessive caloric intake and dietary counseling should be a part of the conversation. A dietician referral should be part of the preconception care pathway. Furthermore, the partner should be involved in these discussions, and dietary and lifestyle interventions should be prescribed not only to the patient, but also to the entire family, with discussion of continuation of good habits after pregnancy to minimize risks of childhood obesity and intergenerational obesity.

Providers should pay special attention to a discussion of weight loss options that may have been particularly metabolically active, such as stimulants, and those regimens involving medications with known cardiac risks, rapid-cycling weight loss, or highly restrictive or liquid supplement–based diets, which could increase the risk of vitamin deficiencies. For those patients planning weight loss surgery prior to pregnancy, a discussion of timing the procedure at least 12–18 months prior to pregnancy is recommended. For patients who have previously undergone weight loss surgery, the time interval to delivery, type of procedure, and the risks and benefits of surgery should be an integral part of the preconception discussion. In a recent study, pregnancies after bariatric surgery were associated with decreased GDM and decreased risk for a macrosomic infant. However, there were increased risks of shorter gestation and infants who were small for gestational age.³¹ Vitamin deficiencies are more common in malabsorptive-type procedures; therefore, screening and supplementation may be needed. For those with symptoms associated with vitamin deficiencies, such as bruising and hair loss, evaluation for more rare deficiencies such as vitamin K and niacin may be warranted.³² Patients with a history of banding procedures, especially adjustable banding, may benefit by revision of the band. Although rare, malabsorptive procedures can be associated with volvulus or obstruction during pregnancy, and clinicians should be aware to take seriously any persistent gastrointestinal complaints. A discussion of sugar/glycemic tolerance may reveal an inability to perform glucose tolerance testing due to gastric dumping, which may therefore necessitate nontraditional testing methods such as candy twists.^33,34

Obese women are known to have a lower intake of recommended amounts of calcium, iron, folate, and vitamin D from diet alone.³⁵ Studies have repeatedly demonstrated poor prenatal vitamin use in this cohort. When prescribing prenatal vitamins, attention should be on folic acid, especially when there is concurrent diabetes. However, excessive folic acid is also associated with later adult complications in animal studies.³⁶ Therefore, counseling on prenatal vitamin supplementation with folic acid should be considered of upmost importance for these women. For all women planning pregnancy, the US Preventative Services Task Force currently recommends 400–800 μg of folic acid daily to reduce the risk of neural tube defects.³⁷ Some groups recommend higher doses of folic acid in obese women.³⁸ In addition, data suggest that only 15%–22% of pregnant and lactating women receive adequate iodine.³⁹ Given the importance of this nutrient to both fetal and maternal thyroid health and fetal brain development, the American Academy of Pediatrics recommends that pregnant and lactating women have adequate iodine intake.^40,41 Given the higher processed food intake, obese women may be iodine deficient despite a high total salt intake as the majority of salt used in processed food in the United States is not iodized. Smoking further blocks iodine transport through thiocyanate exposure; therefore, smoking patients may be an area of focus for supplementation,^41,42 as well as counseling regarding the maternal and neonatal benefits of smoking cessation.

Each patient’s risk going into pregnancy will be slightly different. A thorough medical and genetic history, including complications not related to obesity, should be addressed, as they would be in any preconception consult. The provider and patient should engage in a discussion related to other comorbidities such as hypertension, diabetes, and mobility issues and how these conditions may be affected by weight gain during pregnancy as well as their effect on pregnancy outcomes. Emphasis should be given to optimization of existing comorbidities for at least 3 months prior to conception. Medications should be reviewed for their safety both during pregnancy as well during breastfeeding.