Morbid obesity: Optimizing neuraxial analgesia and cesarean delivery outcomes

The issue of obesity continues to reach new levels globally, affecting individuals across the age continuum. Obesity in pregnancy is associated with myriad comorbidities which may negatively impact the fetus, particularly dysfunctional labor and failure to progress ending in unplanned cesarean delivery. Neuraxial anesthesia represents the gold standard for cesarean delivery anesthesia and is increasingly beneficial for obese patients due to the risk of difficult airway. Obese parturients demonstrate higher rates of venous thromboembolism and wound infections and appropriate prophylaxis strategies to prevent these complications is imperative. While neuraxial anesthesia is the preferred technique for peripartum analgesia and cesarean delivery anesthesia, procedures can be technically challenging in patients with obesity, and may require more time, longer needles, increased experience, or ultrasound guidance. There is some concern for respiratory depression with the administration of neuraxial opioids in patients with obesity which has culminated in the development of post-operative monitoring guidelines.