Improving Percentage Of Early Referral

And Assessment of the Morbidly Obese

Pregnant Patient to Reduce
Anesthesia-Related Complications

Dept of Anesthesia & Intensive Care

Hospital Port Dickson
Breaking Down Barriers:
Optimizing Anaesthesia Management for Plus-Size Pregnant Women
 OUR TEAM

DR AZLAN DR FATHULLAH DR YASSIN DR ATIKAH

DR HEMA MALINI MR BOON TIANG LAU

DR JULIANA
 PROBLEM IDENTIFICATION AND PRIORITIZATION
"SMART" CRITERIA
No Problems S M A R T TOTAL

Reduce Anesthesia Related Complications In Morbidly

1 Obese Pregnant patients By increasing percentage of early 21 18 20 19 21 99
referral and assessment from 34 weeks of gestation

2 Reducing waiting time for AVF surgery in HPD 19 11 12 13 11 66

3 Improving Decision to Delivery Interval (DDI) in category 1 CS in HPD 18 15 17 14 15 79

Improving percentage of referral to anaesthesia clinic for elective

4 16 15 15 14 11 71
surgery

Reducing rate of cancellation of elective surgical cases after being

5 14 9 15 14 12 64
seen in Anaesthesia Clinic

RATING SCALE: 1=LOW 2= MEDIUM 3= HIGH 7 group members

 Reason for selection

S M A R T
SERIOUSNESS
In 2019, a sentinel event occurred where a ‘near-miss’ incident almost cost the life of an
obese pregnant patient and her baby
Maternal obesity increases the risk of maternal death during pregnancy and labour
25% of maternal cardiac arrests were related to anaesthesia, 75% of this was related
to obesity.
The rate of maternal death increases to 9.8/1000 managed by non-specialists vs
5.2/1000 when managed by anesthesia specialists
In Malaysia, most anesthesia providers are junior medical officers and assistant
medical officers
National Health and Morbidity Survey (NHMS)2011,2015 2019
UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17
Kinsella SM, Winton ALS, Mushambi MC, et al. Failed tracheal intubation during obstetric general anaesthesia: a literature review. International Journal of Obstetric
Anesthesia. 2015s
 Reason for selection

S M A R T
MEASUREABLE

Early referral and assessment by anesthesia team

can be easily monitored through the Hospital
Information System (HIS) and obstetrics anesthesia
assessment form.
 Reason for selection

S M A R T
APPROPRIATENESS
The Royal College of Obstetricians and Gynaecologists recommends that women
with BMI > 40 kg/m2 should have a formal consultation with an anesthetist in
the third trimester of pregnancy
Difficulties with venous access, regional and general anaesthesia should be
assessed.
Anaesthetic management plan for labour and birth should be discussed and
documented.
There is no specific guideline or standard of practice for anesthesia providers in
Malaysian hospitals for early assessment of obese antenatal patients
Care of Women with Obesity in Pregnancy: Green-top Guideline No. 72
2018 Royal College of Obstetricians and Gynaecologists
 Reason for selection

S M A R T
REMEDIABLE

Remedial action could be

implemented to improve the
work process with
multidisciplinary approach
 Reason for selection

S M A R T
TIMELINESS

study can be completed within

short period of time.
PROBLEM STATEMENT
Low referral rates to Anaesthesia team for early assessment of
PROBLEM
morbidly obese pregnant patients

There is no specific guideline or standard of practice for

anesthesia providers in Malaysian hospitals for early assessment
POSSIBLE CAUSE
of obese parturients

Maternal obesity increases the risk of morbidity and mortality

directly or indirectly, such as hemorrhage, high blood pressure,
obstructed labour, and infection.
Many obese parturients require Caesarean section, and are at
EFFECT
high risk for anesthesia
Early referrals enable us to identify risk factors for these mothers,
optimize them before delivery, allows time for further investigations
and plan the safest mode of delivery, analgesia and anesthesia

To increase early referral and assessment percentage of morbidly

AIM OF STUDY
obese pregnant patients at 34 weeks of gestation and onwards
 REASONS FOR SELECTION
No standardized workflow
Weakness of system and work for referral and assessment
process with lacking of of obese parturients
awareness, knowledge and involving doctors of
Since 2011 till obsteric and anesthesia
inappropriate practice among now
staff. team

WHAT WHY WHERE WHEN WHO HOW

Early assessment for Obstetric ward Doctors, nurses,

obese parturients by and clinic patients
anesthesia team is not
done in obstetric
combined clinics
 Introduction
Malaysia has the highest prevalence of obesity in South East Asia, at about 30.6%
among adults. The rate is higher for women, 33.6%
Maternal obesity increases the risk of morbidity and mortality directly or indirectly,

such as hemorrhage, high blood pressure, obstructed labour and infection.

Due to this, many obese parturients require Caesarean section, and invariably
present to the anesthesia team
Obesity is a risk factor for many anesthetic-related complications and has been

identified as a significant risk factor for anesthesia-related maternal mortality.

National Health and Morbidity Survey (NHMS)2011,2015 2019

UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17
Kinsella SM, Winton ALS, Mushambi MC, et al. Failed tracheal intubation during obstetric general anaesthesia: a literature review. International Journal of Obstetric
Anesthesia. 2015s
 Introduction/ Literature review
25% of maternal cardiac arrests were related to anesthesia, 75% of this was related to

obesity.
Anesthesia-related deaths resulted from airway complications such as difficult or failed
tracheal intubation, esophageal intubation, bronchospasm, aspiration, higher risk of
desaturation when difficulty is encountered and post-operative atelectasis
Epidural resite rate in the women with class III obesity (greater than 136 kg in weight)
was 17% vs 3% in the control group (less than 113 kg in weight)

The increased difficulties associated with the provision of general and regional
anesthesia in the obese can lead to an increased decision-to-delivery time (DDI) in
women who require a category 1 or 2 caesarean section

Care of Women with Obesity in Pregnancy: Green-top Guideline No. 72

2018 Royal College of Obstetricians and Gynaecologists
 Introduction/ Literature review
In many major and minor specialist hospitals in Malaysia, anesthesia is provided by

medical officers and Assistant Medical

The rate of maternal death increases to 9.8 per 1000 managed by non-specialist and

5.2 per 1000 when managed by an anesthesia specialist.

Early referrals enable anesthesia providers to identify risk factors for these mothers,

optimize them before delivery, to allow time for further investigations and plan the

safest mode of delivery, analgesia and anesthesia.

Difficulties with venous access, regional and general anaesthesia can be assessed

Multidisciplinary discussion and planning should occur where significant

potentialdifficulties are identified.

 TERMS AND DEFINITION
BMI Classifications
Classification BMI Cut-Off Points (kg/m²)

Healthy Weight 18.5-24.99

Overweight (including obesity) ≥25.00

Obesity ≥30.00

Severe Obesity ≥40.00

WHO/NUT/NCD, 2000
BMI Classification (Asian)
Classification BMI (kg/m2)

Underweight < 18.5

Normal range 18.5-22.9

Overweight 23-24.9

Obesity Class I 25-29.9

Obesity Class II 30-34.9

Obesity Class III (morbidly obese) >35

WHO/NUT/NCD, 2000
 lack of spaces in the
clinic
PROBLEM ANALYSIS CHART
No continous
obstetric reminder
colleagues not Referral is not Lack of experience in
able to cope with properly managing obese
the workload documented
Lack of awareness patients
among anesthesia &
obstetric provider
no proper anaesthesia
assessment form
No lack attending
standardised courses
Low percentage of
anesthesia
clinical referal for early
assessment
examination vary assessment of
morbid obese no standard
no national pregnant patients lack of protocol
guidelines communication
between
Lack of health department
education
patient did not
lack of awareness to clinic for TCA
among patients No standard
No instruction from
medical officers workflow
patient forgets
logistic issues
 PROBLEM ANALYSIS CHART
No continous
obstetric reminder
colleagues not Referral is not Lack of experience in
able to cope with properly managing obese
the workload documented
Lack of awareness patients
among anesthesia &
obstetric provider
no proper anaesthesia
assessment form
No lack attending
standardised courses
Low percentage of
anesthesia
clinical referal for early
assessment
examination vary assessment of
morbid obese no standard
no national pregnant patients lack of protocol
guidelines communication
between
department

No standard
Factors that we can improve on workflow
 STUDY
OBJECTIVES
GENERAL OBJECTIVES
To increase early referral and
assessment percentage of
morbidly obese pregnant
patients from 34 weeks of
gestation onwards
SPECIFIC OBJECTIVE
To verify the percentage of obese pregnant
ladies being referred for early anesthetic
assessment in clinic or bedside
To identify the contributing factors to the low
percentage of referral of obese patients to
the anesthesia clinic
To formulate and implement proper remedial
action
To evaluate the effectiveness of remedial
action
 PROCESS OF CARE
ANTENATAL PATIENTS WITH BMI>35 IS IDENTIFIED BY OBSTETRICS
TEAM

OBSTETRICS TEAM REFER TO ANESTHESIA CLINIC MO OR ANESTHESIA

MO ON-CALL

NO
Give appointment to
(POG) MORE THAN 34 WEEKS?
Anaesthesia Clinic for
YES assessment
DETAILED ANESTHETIC ASSESSMENT GUIDED BY
OBSTETRIC MORBIDLY OBESE ASSESSENT FORM
YES

Spine Assessment (Is it difficult) ultrasound guided spinal marking

on admission
NO
NO
Early epidural placement for labor analgesia

other modes of anesthesia YES

Delivery POG:period of gestation

 Model Of Good Care
STEPS CRITICAL STEPS CRITERIA STANDARD

Weight and Height measurement of the

Identification of 100%
patient to calculate BMI
1 morbidly obese
antenatal patients
POG of patients >34 weeks 100%

Referral by obstetris team in HIS system 100%

Echocardiography should be done prior to

100%
anesthesia assessment
Early referral to
2
anesthesia team
100%

POG of patients >34 100%

 INDICATOR AND STANDARD

Percentage of early referral and assessment by anesthesia

01 INDICATOR
team

Number of Antenatal Total number of Antenatal

patients with BMI>35 patients with BMI>35 per
02 FORMULA
referred per month month

03 STANDARD 75% as agreed between obstetrics and anaesthetic team

PROCESS OF GATHERING INFORMATION
RE-EVALUATION 2
OCTOBER - DECEMBER 2022

RE-EVALUATION 1
JULY TO SEPTEMBER 2022

CYCLE 2

CYCLE 1 APRIL - JUNE 2022

VERIFICATION STUDY JAN -MARCH 2022

JUNE - DECEMBER 2021
METHODOLOGY

PHASE STUDY PERIOD

Verification JUNE - DECEMBER 2021

Cycle 1 JAN -MARCH 2022

Cycle 2 APRIL -JUNE 2022

RE-EVALUATION 1 JULY - SEPTEMBER 2022

RE-EVALUATION 2 OCTOBER T0 DECEMBER 2022

METHODOLOGY
Study Design Cross sectional study

Sampling
Universal sampling
technique

Data collection
Designated assessment form
technique

Study setting Antenatal clinics, Patient Assessment Center (PAC), Antenatal Wards

Inclusion
All received bedside referrals and Obstetric clinic referrals
criteria

Exclusion
Patients who were planned for elective Cesarean sections
criteria
 PLAN OF DATA COLLECTION
Variable Source of data Data collector Data collection Time Method of Collection
(WHAT) (WHERE) (WHO) (WHEN) (HOW)

Antenatal clinics,
Number of HIS , log book antenatal,
Patient Assessment anaesthesia 3 montly data
referal for BMI > GOT log book
Center (PAC), Antenatal team colection
35 clinic log book
and Labour Wards

Contributing Antenatal clinics,

factors to the Patient Assessment
anaesthesia 3 montly data
quality Center (PAC), Antenatal via google form
team colection
improvement and Labour Wards
issue ICU

Antenatal clinics,
Patient Assessment anaesthesia daily data taking
Critical steps referal form and HIS
Center (PAC), Antenatal team during office hours
and Labour Wards
 GOOGLE FORM DATA

obstetrician feedback
Analysis & Interpretation
(Verification Period)

23
 VERIFICATION STUDY
FROM JUNE - DECEMBER 2021
BMI > 35 10%

Percentage of Early Referral to Anesthesia

 Model Of Good Care
STEPS CRITICAL STEPS CRITERIA STANDARD VERIFICATION

Weight and Height of

the patient to 100% 100%
Identification of obese
1 calculate BMI
parturients

POG of patients >34 100% 100%

referral form in HIS

100% 10%
system

Echocardiography
should be done prior to 100% 15%
Early referral to anesthesia assessment
2
anesthesia team

BMI > 35 100% 10%

POG of patients >34 100% 10%

Main Contributing Factors
65.8% 25.5% 8.7%

Lack of
Lack of awareness
standardized Unsure
among the
assessment regarding
obstetric and
process for referral
anesthesia
anesthesia workflow
doctors
doctors
STRATEGY OF
CHANGE
Lack of awareness
amongst

STRATEGY OF
obstetrician

CME was conducted

CHANGE No standardised
clinical
examination and
1st Cycle risk stratification

A review protocol was

created
E-A-S-E

Lack of skills in Unclear workflow

spinal ultrasound of referral for
and management obese parturient
of obese pregnant
women A new workflow was
created for referral
Workshop on spinal of morbidly obese
ultrasound and CME among mothers
Anesthesia medical officer
Review Protocol For Morbidly Obese Pregnant Women
In view of the challenges posed to the anesthesia providers, we created the E-A-S-E
review bundle for morbidly obese parturients in this hospital.
This includes:
a. Early referral for consultation by the anesthesia provider for risk factors
b. Airway assessment and examination
c. Spine assessment.
If the spine is not palpable by physical examination, planned ultrasound guided
marking of desirable spinal or epidural insertion point upon admission to labor wards.
d. Epidural in Early Labour
Training and education of the anesthesia
providers

Our anesthesia provider colleagues were instructed to

review every parturient with BMI > 35 that was
referred for early anesthesia consultation and
assessment.
Multiple CME were carried out to educate providers on
anesthesia risks and complications in obesity and
pregnancy and the importance of early epidural
placement.
Hands-on spine ultrasound workshops were conducted
to precisely mark the point of entry for spinal or
epidural needles.
 Training and education of the obstetric providers

The obstetricians in our center were instructed to refer

patients with BMI > 35 to the Anaesthesia Clinic at 34
weeks of gestation.
Continuous medical education (CME) was organized to
educate and emphasize the importance of early
anesthetic assessment, morbidity, and mortality
related to obese parturients
The importance of early epidural placement was also
emphasized.
Establishing a feasible
workflow

Every antenatal patient with BMI > 35 kg/m2

was referred to Anesthesia Clinic or in
Patient Assessment Centre for early
anesthesia consultation and assessment.
 STRATEGY OF
Improve
awareness
amongst
obstetrician
CHANGE
more CME was
conducted
Pamphlets distributed
2nd Cycle
No standardised
clinical
examination and
risk stratification
No clear flow of
referral for obese Obstetric Morbidly
parturient Obese Assessment
Form
Workflow charts
were created and
distributed
Information Pamphlets

Pamphlets were distributed amongst

obstetric providers and patients to
educate on risks of anesthesia related
complications in obese parturients.
Thus emphasizing on early referral and
assessment by anesthetists for every
obese parturient
Obstetric Anesthesia
Assessment Form is created to
guide Anesthesia medical
officers in a standardized
clinical assessment and risk
stratification
 Workflow charts were
distributed in Ward, PAC and
the antenatal clinic to
facilitate referrals and serve
as reminders.
Effect of
Change
HOSPITAL PORT DICKSON
 TOTAL NUMBER OF
ANTENATAL CASES
Percentage of BMI > 35 in 2022
24
0

17%

1425

HOSPITAL PORT DICKSON

BMI > 35 in antenatal patients
Rates of BMI > 35 in 3 monthly data in 2022

72 61 49 58

17% 21% 14% 16%

430 295 339 361

January till April till June July till October till

March September December
1st CYCLE : BMI > 35 REFERRED
JANUARY TO MARCH
2022

67%

Only 48 out of 72 patients

were referred
 ANTENATAL BMI > 35
REFERRED

1st Cycle RE-EVALUATION 1

JANUARY TO MARCH 2022 JULY TO SEPTEMBER 2022

48/72 67% 46/51 75%

2nd cycle RE-EVALUATION 2

APRIL TO JUNE 2022 OCTOBER TO DECEMBER 2022

42/58 72% 37/49 76%

 80%

BMI> 35 60%

REFERRED
40%
there is a steady rise in the
number of referral from the
second phase following the
20%
remedial actions

0%
JAN-MAR APR-JUN JUL-SEPT OCT-DEC
ACHIEVABLE BENEFIT NOT ACHIEVED
(ABNA)
100% ABNA
100% ABNA ABNA
ABNA 3% 0% -1%
75% 76%
75% 8% 72%
75%
67%

50%

ABNA
65%
25%
10%

0%
IDEAL STANDARD VERIFICATION CYCLE 1 CYCLE 2 RE-EVUALATION 1 RE-EVUALATION 2
 Model Of Good Care
CYCLE RE-EVELUATION RE-
STEPS CRITICAL STEPS CRITERIA STANDARD VERIFICATION CYCLE 1 EVULATION 2
2 1

Weight and Height

of the patient to 100% 100% 100% 100% 100% 100%
Identification of calculate BMI
1
obese parturients

POG of patients >34 100% 100% 100% 100% 100% 100%

referral form in HIS

100% 10% 67% 72% 75% 76%
system

Echocardiography
should be done
100% 15% 60% 70% 70% 76%
Early referral to prior to anesthesia
2
anesthesia team assessment

BMI > 35 100% 10% 67% 72% 75% 76%

POG of patients >34 100% 10% 67% 72% 75% 76%

 IMPACT OF THE PROJECT
6
The number of patients
receiving early epidural
placement in 2022 was 47. 4

Out of that number, only 1

patient with BMI of more
2

than 35 had to be converted

to general anesthesia
0
2020 2021 2022
 IMPACT OF THE PROJECT

Apgar scores of babies whose mothers received epidural

analgesia intrapartum were more than 7
only 2 cases had Apgar Scores < 7
(1 was delivered via instrumentation and 1 had high
fatality antenatal syndrome)

Apgar is a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score determines how well
the baby tolerated the birthing process. The 5-minute score tells the health care provider how well the baby is
doing outside the mother's womb.
 IMPACT OF THE PROJECT

Of the total of 173 morbidly obese mothers

referred for Early Assessment, we had ZERO
complications related to anesthesia causes in
both mother and baby.
 Lessons Learnt
Fast turnover of new obstetric and anesthesia medical officers, therefore requires
continuous reminder and education regarding early referral

EASE protocol helps to improve delivery outcomes in obese patients

workflow chart should be displayed in ward counters, PAC, and obstetric clinic for
easier reference
Every referral should be documented in HIS and obstetric anesthesia assessment

form for future referral and data purposes

 The Next Plan
To share the ideas and experiences with all major and minor specialist hospitals and

hospitals without specialists which provide obstetric and anesthesia services

Regular CME and reminders among medical officers for early referral of obstetric
patients to improve referral rates
We hope to create awareness among the patients regarding obesity related

morbidities, and to advise obese patients regarding the importance of weight

reduction in planning for their next pregnancy

To expand the study to the state and national level

THANK YOU