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Trial of Labor Compared With Cesarean Delivery in Superobese Women

Grasch, Jennifer L. MD; Thompson, Jennifer L. MD; Newton, J. Michael MD, PhD; Zhai, Amy W. MD; Osmundson, Sarah S. MD, MS

doi: 10.1097/AOG.0000000000002257
Contents: Obesity: Original Research

OBJECTIVE: To examine whether labor compared with planned cesarean delivery is associated with increased maternal and neonatal morbidity.

METHODS: We conducted a retrospective cohort study of all women with body mass indexes (BMIs) at delivery of 50 or greater delivering a live fetus at 34 weeks of gestation of greater between January 1, 2008, and December 31, 2015. Pregnancies with multiple gestations and major fetal anomalies were excluded. The primary outcome was a composite of maternal and neonatal morbidity and was estimated to be 50% in superobese women based on institutional data. A sample size of 338 women determined the study period and was selected to show a 30% difference in the incidence of the primary outcome between the two groups. Multivariate logistic regression adjusted for potential confounders.

RESULTS: There were 344 women with BMIs of 50 or greater who met eligibility criteria, of whom 201 (58%) labored and 143 (42%) underwent planned cesarean delivery. Women who labored were younger, more likely to be nulliparous, and less likely to have pre-existing diabetes. Among women who labored, 45% underwent a cesarean delivery, most commonly for labor arrest (61%) or nonreassuring fetal status (28%). Composite maternal and neonatal morbidity was reduced among women who labored even after adjusting for age, parity, pre-existing diabetes, and prior cesarean delivery (adjusted odds ratio 0.42, 95% CI 0.24–0.75). In the subgroup of women (n=234) who underwent a cesarean delivery, whether planned (n=143) or after labor (n=91), there were no differences in maternal and neonatal morbidity except that severe maternal morbidity was increased in women (n=12) who labored (8.8% compared with 2.1%, relative risk 4.2, 95% CI 1.14–15.4).

CONCLUSION: Despite high rates of cesarean delivery in women with superobesity, labor is associated with lower composite maternal and neonatal morbidity. Severe maternal morbidity may be higher in women who require a cesarean delivery after labor.

Trial of labor is associated with reduced maternal and neonatal morbidity compared with scheduled cesarean delivery in superobese women.

Vanderbilt University Medical Center, Nashville, Tennessee.

Corresponding author: Jennifer L. Grasch, MD, 1161 21st Avenue South, B-1118 MCN, Nashville, TN 37232; email:

Financial Disclosure The authors did not report any potential conflicts of interest.

Presented at the Society for Maternal-Fetal Medicine Annual Meeting, January 22–28, 2017, Las Vegas, Nevada.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.