SMFM Papers

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Impact of morbid obesity on epidural

anesthesia complications in labor
Laura K. Vricella, MD; Judette M. Louis, MD, MPH; Brian M. Mercer, MD; Norman Bolden, MD
OBJECTIVE: We sought to determine whether morbid obesity is associ-

ated with increased maternal hypotension or fetal heart rate (FHR) abnormalities after epidural anesthesia placement during labor.
STUDY DESIGN: This was a retrospective cohort study of women undergoing epidural anesthesia during labor at term from April 2008
through July 2010.
RESULTS: A total of 125 morbidly obese patients were matched for age

and race with 125 normal-weight patients. Morbidly obese patients had
more frequent persistent systolic (16% vs 4%, P .003) and diastolic
(49% vs 29%, P .002) hypotension and more prolonged (16% vs 5%,

P .006) and late (26% vs 14%, P .03) FHR decelerations. Increasing body mass index was associated with persistent systolic (odds ratio,
1.06; 95% confidence interval, 1.021.10) and diastolic (odds ratio,
1.04; 95% confidence interval, 1.011.06) hypotension after controlling for epidural bolus dose and hypertensive disorders.
CONCLUSION: Morbidly obese women have more hypotension and pro-

longed FHR decelerations following epidural anesthesia during labor at

term.
Key words: complications, epidural, hypotension, morbid obesity,
obstetric anesthesia

Cite this article as: Vricella LK, Louis JM, Mercer BM, et al. Impact of morbid obesity on epidural anesthesia complications in labor. Am J Obstet Gynecol
2011;205:370.e1-6.

aternal hypotension is not uncommon with labor epidural anesthesia placement, complicating 5-17%
of cases.1,2 Pregnancy increases maternal
dependence on sympathetic vascular
tone to maintain venous return and
uteroplacental perfusion.3,4 Regional
anesthesia-associated sympathectomy
with resultant maternal hypotension decreases uteroplacental perfusion and is
an important potential cause of intrapartum fetal heart rate (FHR) abnormalities
and emergent cesarean delivery. UncorFrom the Division of Maternal-Fetal
Medicine, Department of Obstetrics and
Gynecology (Drs Vricella, Louis, and Mercer),
and the Department of Anesthesiology (Dr
Bolden), MetroHealth Medical Center, Case
Western Reserve University School of
Medicine, Cleveland, OH.
Received March 9, 2011; revised May 2, 2011;
accepted June 22, 2011.
The authors report no conflict of interest.
Presented as a poster at the 31st Annual
Meeting of the Society for Maternal-Fetal
Medicine, San Francisco, CA, Feb. 7-12, 2011.
Reprints not available from the authors.
0002-9378/free
2011 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2011.06.085

For Editors Commentary,

see Table of Contents

370.e1

rected maternal hypotension during regional anesthesia can cause decreased

uteroplacental perfusion resulting in fetal and neonatal hypoxia and/or acidosis.5 Published data have demonstrated
that pregnancy and obesity both decrease local anesthetic requirements
during epidural anesthesia and may result in increased cephalad spread of epidural block.6-8 However, the association
between maternal obesity and epiduralassociated hypotension is unknown. Our
objective is to determine whether morbid obesity is associated with increased
maternal hypotension or FHR abnormalities after epidural anesthesia placement during labor.

M ATERIALS AND M ETHODS

In this retrospective cohort study,
women who had undergone epidural anesthesia placement during labor from
April 2008 through July 2010 at an academic tertiary care center were identified
utilizing our computerized perinatal database. Women admitted for labor or induction who consented to epidural catheter placement and delivered at least 1
hour after epidural dosing were included. Women with multifetal deliveries, preterm deliveries, nonvertex presentations, major fetal anomalies, and

American Journal of Obstetrics & Gynecology OCTOBER 2011

those delivering within 1 hour of epidural dosing were all excluded.

A total of 125 morbidly obese women
with body mass index (BMI) 40 kg/m2
at delivery were matched for age and race
to 125 normal-weight women with BMI
25 of kg/m2 (World Health Organization criteria). Individual patient charts,
anesthesia records, and electronic fetal
monitor (EFM) tracings were reviewed
by a single investigator (L.K.V.). Tracing
interpretation was performed in a
masked fashion. Baseline maternal characteristics, epidural catheter placement
information, hemodynamic parameters,
and delivery outcomes were compared
between groups.
The primary outcome measure was
the occurrence of maternal hypotension
within 1 hour of epidural placement. The
secondary outcome measure was the
new onset of fetal heart tracing abnormalities within 1 hour of epidural
placement.
During this time period, women routinely received a 500-mL bolus of intravenous crystalloid for volume expansion
prior to the procedure. Following epidural catheter placement and administration of a test dose, a bolus dose of 2-8 mL
of a bupivacaine 0.125%, fentanyl 7.5
g/mL, and epinephrine 5 g/mL solution was administered. If the initial dose
did not achieve satisfactory analgesia

SMFM Papers

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TABLE 1

Baseline characteristics by body mass index category

Characteristics

Normal weight
n 125

Morbidly obese
n 125

Age, y

24 [2131]

25 [2132]

.6

Gestational age, wk

39 [3840]

39 [3840]

.6

Nulliparity, %

35

44

.2

P value

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Prior vaginal deliveries

1 [02]

1 [02]

.4

..............................................................................................................................................................................................................................................

Race, %

.....................................................................................................................................................................................................................................

Black

50

58

Hispanic

10

10

White

40

32

.3

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Insurance, %

.....................................................................................................................................................................................................................................

Public

84

84

.1

Private

16

16

.1

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
2

BMI, kg/m

.....................................................................................................................................................................................................................................

Pregravid

20 [1821]

41 [3946]

.0001

Delivery

24 [2325]

45 [4249]

.0001

2 [22]

2 [22]

.4

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

ASA score, U

..............................................................................................................................................................................................................................................

Medical comorbidities, %

.....................................................................................................................................................................................................................................

18

.0001

Preeclampsia spectrum

10

20

.05

Diabetes, pregestational

.03

10

.006

10

15

.3

Chronic hypertension

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

Diabetes, gestational

.....................................................................................................................................................................................................................................

Asthma

..............................................................................................................................................................................................................................................

ASA, American Society of Anesthesiologists; BMI, body mass index.

Data presented as percent or median [interquartile range].
Vricella. Morbid obesity and epidural anesthetic complication for labor. Am J Obstet Gynecol 2011.

then additional anesthetic boluses were

administered. The amount of epidural
anesthetic bolus administered and the
decision to administer any additional
boluses were determined by the attending anesthesiologist, as was the decision
to administer intravenous pressor support. Phenylephrine was the only pressor
agent used.
Baseline blood pressure was defined as
the value recorded immediately prior to
epidural catheter placement. Blood pressures were assessed in the supine position with a tilt. The lowest systolic and
diastolic blood pressures recorded in 10minute intervals for the first 30 minutes
and at 15-minute intervals for the next
30 minutes were compared with baseline
values. An optimal standard definition
for obstetric anesthesia-related hypotension has not been established.9 We de-

fined systolic and diastolic hypotension

as a 20% decrease in systolic and a 20%
decrease in diastolic blood pressure, respectively.10 Although hypotension has
been commonly defined by the systolic
value in published studies, hypotension
based on diastolic values is uncommonly
evaluated. Because diastolic blood pressure maintains uteroplacental perfusion,
diastolic hypotension could potentially
have more clinical significance in this
obstetric context and was therefore evaluated separately. Persistent hypotension
was defined as at least a 20% decrease
from baseline in 3 intervals during the
first 60 minutes after epidural anesthetic
bolus. We defined sustained hypotension as that occurring in all 5 measured
intervals in the hour following epidural
dosing. In an effort to be comprehensive
we evaluated systolic and diastolic hypo-

tension separately to determine which

was more profoundly affected by epidural catheter dosing and which had a
greater association with fetal heart tracing abnormalities.
FHR tracings (EFM) for 60 minutes
before and after epidural anesthetic
bolus were classified according to the
2008 National Institute of Child Health
and Human Development (NICHD)
EFM guidelines.11 The preepidural and
postepidural tracings were categorized as
category I (normal), category II (indeterminate), or category III (abnormal) according to the published NICHD guidelines. Findings that were not present
prior to epidural placement were considered new changes. New occurrence of
decreased variability (minimal or absent), recurrent variable decelerations,
recurrent late decelerations, and prolonged decelerations (2 minutes) constituted nonreassuring tracings that
would require an obstetric intervention.
A nonreassuring tracing was defined as
one that would require an obstetric intervention to either return to a category I
tracing or necessitate delivery. Because
prolonged and late decelerations are the
anticipated tracing abnormalities with
uteroplacental insufficiency after epidural-associated hypotension, these 2 findings were evaluated together as a composite variable.12,13 The occurrence of
tachysystole in association with late
or prolonged decelerations was also
recorded.

Statistical analysis
We note that a 5% incidence of hypotension has been found in the general
population during epidural catheter
placement for labor when intravenous
preloading is performed.1,14 A priori
analysis demonstrated that to detect a 15%
incidence of hypotension in morbidly
obese women, at an alpha of 0.05 and a
beta of 0.2, 100 women would be needed
in each group. Statistical analyses were
performed using commercially available
software (SPSS, version 18.0; SPSS Inc,
Chicago, IL). We evaluated differences
between the groups using the Student t
test for continuous variables, and the
Mann-Whitney U test and Fishers exact
tests for categorical variables. We then

OCTOBER 2011 American Journal of Obstetrics & Gynecology

370.e2

SMFM Papers
performed multinomial logistic regressions for factors predictive of persistent
systolic hypotension, persistent diastolic
hypotension, and FHR abnormalities.
Factors included in the models for persistent systolic and persistent diastolic
hypotension were BMI, preeclampsia
spectrum conditions, chronic hypertension, and epidural anesthetic bolus.
Factors included in the model for FHR
abnormalities were BMI, preeclampsia
spectrum conditions, chronic hypertension, epidural anesthetic bolus, persistent systolic hypotension, and persistent
diastolic hypotension. P .05 was significant. This retrospective chart review
was approved by the institutional review
board at MetroHealth Medical Center,
Cleveland, OH.

www.AJOG.org

TABLE 2

Delivery and anesthesia outcomes by body

mass index category outcome
Outcome
Induction, %

Normal weight
n 125

Morbidly obese
n 125

P value

21

47

.0001

10

.3

.1

.....................................................................................................................................................................................................................................

Oligohydramnios

.....................................................................................................................................................................................................................................

Intrauterine growth restriction

..............................................................................................................................................................................................................................................

Delivery, %

.....................................................................................................................................................................................................................................

Spontaneous vaginal

93

72

.0001

Operative vaginal

.03

Cesarean

20

.001

Emergent (operative vaginal or cesarean)

10

.01

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Apgar score

.....................................................................................................................................................................................................................................

1 min

9 [99]

9 [99]

.9

5 min

9 [99]

9 [99]

.9

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Infant weight, g

3132 417

3380 465

.0001

..............................................................................................................................................................................................................................................

R ESULTS
A total of 125 morbidly obese women
met inclusion criteria and were matched
by age and race with 125 normal-weight
women. Both groups were similar in age,
gestational age at delivery, race, insurance
status, parity, and frequency of asthma
(Table 1). Morbidly obese women had
more frequent chronic hypertension, preeclampsia spectrum disorders (gestational
hypertension, mild and severe preeclampsia, eclampsia), and diabetes (gestational
and pregestational).
Regarding delivery and anesthesia
outcomes, morbidly obese women had
more frequent labor induction, cesarean
delivery, operative vaginal delivery, and
emergent delivery for FHR abnormalities (Table 2). Rates of antepartum diagnosis of oligohydramnios and intrauterine growth restriction were similar in
both groups. Apgar scores at 1 and 5
minutes were similar between groups.
Infants born to morbidly obese women
were heavier than those of normalweight women (3380 465 g vs 3132
417 g, P .0001).
Morbidly obese women had similar
rates of initial successful epidural catheter placement and the groups were similar in initial and total epidural anesthetic
bolus dose administered over the first
hour. Morbidly obese women received
more frequent and higher doses of intra370.e3

Epidural catheter placement

.....................................................................................................................................................................................................................................

No. of attempts

1 [11]

1 [11]

.1

Initial anesthetic bolus, mL

4.7 0.9

4.8 1.0

.5

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

Total anesthetic bolus, 1 h, mL

5.5 1.9

5.3 1.6

.3

.....................................................................................................................................................................................................................................

Anesthesia level

T9 [T7T10]

T8 [T6T9]

.1

..............................................................................................................................................................................................................................................

Phenylephrine

.....................................................................................................................................................................................................................................

Any dose, %

14

.3

.....................................................................................................................................................................................................................................

Total dose, g

345 280

702 1058

.2

..............................................................................................................................................................................................................................................

Baseline blood pressure, mm Hg

.....................................................................................................................................................................................................................................

Systolic

125 14

130 16

Diastolic

76 12

76 12

.1

.....................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................

Data presented as mean SD, percent, or median [interquartile range].

Vricella. Morbid obesity and epidural anesthetic complication for labor. Am J Obstet Gynecol 2011.

venous pressor support with phenylephrine than normal-weight women; however the differences were not significant.
Although morbidly obese women had
more frequent chronic hypertension and
preeclampsia spectrum disorders, baseline blood pressures taken immediately
before epidural dosing were similar between groups.
A single episode of postepidural hypotension occurred frequently in both
morbidly obese and normal-weight
groups (systolic hypotension: 44% vs
30%, P .04; diastolic hypotension:
75% vs 66%, P .2) (Figure). Persistent
diastolic hypotension was more common than persistent systolic hypotension across both groups and persistent

American Journal of Obstetrics & Gynecology OCTOBER 2011

hypotension overall was more common

in the morbidly obese group (systolic:
16% vs 4%, P .003; diastolic: 49% vs
29%, P .002). There was a 6-fold
higher incidence of sustained diastolic hypotension among morbidly obese
women; however the occurrence of sustained systolic hypotension was low
across both groups and the difference
among them was not significant (systolic: 2% vs 0%, P .4; diastolic: 13% vs
2%, P .003). Overall, diastolic hypotension occurred more frequently
than systolic hypotension, and both systolic and diastolic hypotension were
more prevalent among morbidly obese
women compared with normal-weight
controls.

SMFM Papers

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FIGURE

Systolic and diastolic

hypotension by BMI
(kg/m2) category

Hypotension was more common among morbidly

obese patients than normal-weight patients. Diastolic hypotension was more common than systolic hypotension across groups.
BMI, body mass index.
Vricella. Morbid obesity and epidural anesthetic
complication for labor. Am J Obstet Gynecol 2011.

New findings of decreased long-term

variability and mild, moderate, and severe variable decelerations were similar
among BMI groups (Table 3). Morbidly
obese women demonstrated new-onset
late decelerations twice as frequently
(26% vs 14%, P .03) and new-onset
prolonged decelerations 3 times more
frequently (16% vs 5%, P .006) than
normal-weight women. Tachysystoleassociated late or prolonged decelera-

tions were more common among morbidly obese women (6% vs 1%, P .04).
Morbidly obese women were twice as
likely to have a change from a category I
tracing preepidural dosing to a category
II tracing after epidural dosing (P .02)
and also more frequently developed a
nonreassuring tracing than normalweight women (36% vs 20%, P .007).
Logistic regression analysis was performed to determine factors predictive
of maternal hypotension and FHR abnormalities (Table 4). Each unit increase
in BMI was associated with an increased
risk of both persistent systolic and persistent diastolic hypotension after controlling for epidural bolus dose and
hypertensive disorders. Epidural bolus
dose was associated with persistent diastolic hypotension, but not persistent
systolic hypotension. Increasing BMI,
persistent systolic hypotension, and persistent diastolic hypotension were each
associated with new onset of late or prolonged variable decelerations after controlling for hypertensive disorders and
epidural anesthetic bolus dose.

C OMMENT
We found that morbidly obese women
given similar bolus doses of epidural anesthetic had more frequent postepidural

TABLE 3

Postepidural anesthetic bolus fetal heart tracing

changes by body mass index category
Tracing change

Normal weight
n 125

Morbidly obese
n 125

P value

Prolonged decelerations

16

Decreased variability

.006

Late decelerations

14

26

.03

Nonreassuring tracing

20

36

.007

..............................................................................................................................................................................................................................................

1.0

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Variable decelerations

.....................................................................................................................................................................................................................................

Mild

1.0

Moderate

11

.1

Severe

1.0

Late or prolonged decelerations

14

35

.0001

Tachysystole-associated

.04

16

30

.02

.....................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
.....................................................................................................................................................................................................................................

..............................................................................................................................................................................................................................................

Category I-II

..............................................................................................................................................................................................................................................

Data presented as percent.

Vricella. Morbid obesity and epidural anesthetic complication for labor. Am J Obstet Gynecol 2011.

hypotension and related late or prolonged FHR decelerations than normalweight controls. We also found that
diastolic hypotension occurred more
frequently among both BMI groups than
systolic hypotension. Increasing BMI is
associated with increased risk of persistent postepidural hypotension and subsequent late or prolonged variable decelerations. The incidence of persistent
diastolic hypotension was positively related to the increasing epidural anesthetic dose.
Our finding of a high overall incidence
of epidural-related hypotension is not
surprising as it is a well-documented
consequence of regional anesthesia in
pregnancy.3,4 In a term patient progressively dependent on the sympathetic
nervous system for hemodynamic stability, pharmacologic sympathectomy can
compromise venous return and uteroplacental perfusion.3,4 Our findings that
diastolic blood pressures decreased more
than systolic blood pressures is in keeping with prior studies documenting decreasing systemic vascular resistance
during pregnancy that affects diastolic
blood pressures to a greater extent.15
However, we found that both persistent
systolic and diastolic hypotension were
associated with the occurrence of late or
prolonged variable decelerations. This
finding suggests that although diastolic
hypotension occurred more frequently
than systolic, both contribute to maintaining uteroplacental perfusion to some
extent.
The cause of increased hypotension in
morbidly obese women compared to
normal-weight women is likely multifactorial; however we propose 2 possible
mechanisms: anatomic distortion of the
epidural space and inadequate volume
preloading. The epidural space is smaller
and epidural space pressures are higher
in obese women at term due to increased
density and engorgement of the epidural
venous plexus exacerbated by increased
vena cava compression from higher intraabdominal pressure.8,16-18 Magnetic
resonance imaging studies have shown
that obese women have decreased cerebrospinal fluid volume but have not
shown a clear relationship between
epidural space fat distribution and

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SMFM Papers
BMI.19,20 The idea that maternal obesity
distorts the epidural space is supported
by 2 studies by Hodgkinson and Hussain6,7 that show that increasing BMI
and weight increase the cephalad spread
of epidural anesthesia, however Milligan
et al21 found no relationship between
obesity and cephalad spread. Obese
women have been found to require lower
epidural bupivacaine doses to achieve
similar quality of analgesia to normalweight women; supporting the idea that
decreased epidural space volumes and
increased epidural space pressures in
obese women lead to higher concentration and greater cephalad spread of a
given anesthetic dose.8 We propose that
our finding of more frequent hypotension among morbidly obese women can
be explained by similar mechanisms of
reduced volume and increased pressure
of the epidural space.
Another plausible explanation for the
increased incidence of hypotension in
morbidly obese women is inadequate
volume preloading related to greater circulating blood volumes. Morbidly obese
women have a higher circulating blood
volume and cardiac output of normalweight women.22 Volume preloading
with 500-1000 mL of intravenous solutions has been shown to decrease the incidence of maternal hypotension following regional anesthesia placement and
has become standard practice.14 In our
study, women in both groups received a
standard 500-mL crystalloid intravenous
fluid bolus immediately before epidural
dosing; this may have been inadequate
for morbidly obese women with twice
the circulating blood volumes compared
to normal-weight women. It is likely that
morbidly obese women require greater
volumes of intravenous fluid to achieve
adequate volume preloading prior to regional anesthesia placement.
The findings of our study suggest that
standard obstetric anesthesia practices
with established safety profiles in normal-weight women could be inappropriate for morbidly obese women. Simple alterations to anesthesia protocols,
including decreased anesthetic bolus
doses and increased volume preloading,
may achieve adequate pain control in
morbidly obese women while decreasing
370.e5

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TABLE 4

Logistic regression: factors associated with persistent

hypotension and fetal heart tracing abnormalities
Finding
Systolic hypotension

Variable

Coefficient

Adjusted OR

95% CI

BMI, kg/m

0.006

1.06

1.021.10

..............................................................................................................................................................................................................................................
2

Diastolic hypotension

BMI, kg/m

0.002

1.04

1.011.06

Volume anesthetic

0.048

1.33

1.001.77

BMI, kg/m

0.007

1.04

1.011.07

Systolic hypotension

0.003

4.21

1.6310.85

Diastolic hypotension

0.002

2.80

1.465.34

.........................................................................................................................................................................

..............................................................................................................................................................................................................................................
2

New-onset late or
prolonged decelerations

.........................................................................................................................................................................
.........................................................................................................................................................................

..............................................................................................................................................................................................................................................

Controlled for chronic hypertension, preeclampsia spectrum disorders, and epidural anesthetic volume.
BMI, body mass index; CI, confidence interval; OR, odds ratio.
Vricella. Morbid obesity and epidural anesthetic complication for labor. Am J Obstet Gynecol 2011.

the risk of maternal hypotension and resultant FHR abnormalities. In the morbidly obese obstetric population already
known to be at increased risk for emergent cesarean delivery during which they
are at greater risk for general anesthesia,
failed intubation, and death, epiduralrelated hypotension has potentially severe consequences.23,24
This study is limited by its retrospective nature. It is plausible that the actual
volume of intravenous fluid preload administered could have differed from
what was recorded. Variations in technique for measuring blood pressure have
been shown to falsely elevate readings.
However, techniques in epidural dosing
and vital sign measurement after epidural are standardized, providing an intervention and measures that are objective
and reproducible. The strengths of this
study include the adequate sample size to
measure the primary outcome and the
effective matching maintaining similarity among groups.
We failed to demonstrate significant
differences in need for intravenous pressor support. However, the power to detect the demonstrated 30% increase in
these outcomes was just 17% based on
our sample size. Similarly, although
morbidly obese women had more frequent emergent deliveries (operative
vaginal and cesarean delivery), the study
was not powered to detect a relationship
between incidence of epidural-related
maternal hypotension and emergent delivery. A larger study focusing on the
incidence of profound maternal hypo-

American Journal of Obstetrics & Gynecology OCTOBER 2011

tension requiring intravenous pressor

support would be needed to evaluate the
incidence of emergent cesarean due to
maternal hypotension with refractory fetal bradycardia.
In summary, we found that morbidly
obese women undergoing epidural anesthesia placement for labor had more hypotension and related FHR abnormalities than normal-weight women, and
that diastolic blood pressure was more
common than systolic hypotension. The
optimal definition of epidural-related
hypotension has not yet been determined. Further studies are needed to
identify the most clinically significant
definition of epidural-related hypotension in the obstetric population.
Prospective studies are needed to determine if lower epidural anesthetic
doses or greater volume preloading
will achieve adequate analgesia in morbidly obese women with decreased risk
of hypotension.
f
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