Are you sure there’s a baby there? A tale of the morbidly obese parturient

The case A 32-year-old gravida 1 para 0 (G1P0) presents to labor and delivery for induction of labor for a large-for-gestational-age fetus. The patient is at 39 weeks' gestation. Past medical history is significant for morbid obesity. She is 5 foot 6 inches but weighs 400 pounds. She presents to the floor for induction in the early evening, a similar practice for most inductions as patients should then be in active labor during the daytime hours. Anesthesia staff is present 24 hours, however, with less help available during the evening hours. During your evening huddle – a meeting between obstetrics (OB), nursing, and anesthesia services – this patient's case is discussed. The patient is also a socalled difficult patient, demanding of the nursing staff, and lacks insight into the severity of her situation. She is unhappy that she is being treated differently than the other expectant mothers on the floor. Discussion between OB and anesthesia determines that appropriate management will be as follows: (1) placement of an epidural (prior to induction) available for use for emergency cesarean section for maternal or fetal distress, (2) induction of labor, and (3) vaginal delivery – a reasonable plan. The reality: Nursing staff is unable to obtain intravenous (IV) access. Anesthesia requires IV access prior to epidural placement in case of emergency. Central venous access is placed secondary to inadequate peripheral access. Epidural is placed after multiple attempts, with success after a second anesthesia team attempts epidural placement.