Science & Sensibility

Continuing along in our occasional series on “Welcoming All Families” to our childbirth classes, this two part guest post is written by Pam Vireday,  creator of the Well-Rounded Mama blog.  Today, Pam shares how to promote optimum outcomes at the births of plus sized mothers. Click here to read the first post in the series, where Pam shared how to create childbirth education classes with women of size in mind. – Sharon Muza, S&S Community Manager

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In part one of the series,  we discussed how birth professionals can make women of size feel more welcome by creating a size-friendly space, by addressing special needs, by finding size-positive images and birth stories, and by addressing potential risks in a proactive, non-judgmental way.  Today, in part two, let’s discuss ways to promote optimal outcome in women of size.

Nutrition and Exercise

Many women of size find they feel better and have more stable blood sugar when they combine carbohydrates with protein instead of consuming carbohydrates by themselves. Modestly limiting carbohydrates at meals, eating smaller and more frequent meals, and using whole grains instead of refined carbs may also help promote euglycemia.

An even more powerful tool for optimizing blood sugar is exercise. Intensity of exercise is far less important than regularity of exercise, with daily exercise being optimal. Many women of size find walking, swimming, prenatal yoga, and water aerobics particularly friendly to larger bodies.

Nutrition Diaries

One of the most trying things for some fat women is the pregnancy nutrition diary. If used, these must be done with care.

After years of having every bite nit-picked, pregnancy food diaries can be very triggering for women with long histories of dieting or eating disorders. In addition, many providers don’t believe women of size no matter what they say. As one mom shared, “[My midwife] refused to believe what I recorded. She flat-out accused me of lying, telling me that I ‘must be living on ice cream and donuts.’”  This can be very disillusioning.

If you decide to use food diaries, question your assumptions about what fat women “must” be eating.  Some people eat normally and are still fat, while some thin women have terrible habits and yet are thin. Leave out assumptions, scolding, and lecturing, and find a way to neutrally help women analyze their own intake and gently adjust if needed.

Prenatal Weight Gain

Current weight gain recommendations from the Institute of Medicine are 11-20 lbs. for obese women, and 15-25 lbs. for overweight women.  However, many care providers these days are strongly pressuring obese women to diet to restrict weight gain, or even to deliberately lose weight during pregnancy.

This is a dilemma for women of size, because research suggests that very low gain or gestational weight loss may actually increase the risk of small-for-gestational-age or premature babies. Some research suggests differing weight gain recommendations for differing classes of obesity, but studies on limiting weight gain have many design flaws, so providers must tread carefully to balance potential benefits and risks.

Another alternative is to take a Health At Every Size® approach. Good nutrition and regular exercise is promoted, but without the scale as a goal.  The finger-wagging, shaming approach of most dietary intervention is absent, and although particular weight gain goal ranges can be encouraged, good nutrition is put ahead of rigid goals. Many women with a long history of dieting find a Health At Every Size® approach very freeing because it still emphasizes healthy behaviors, but without the scale as judge and jury.

Weight gain among women of size is extremely variable. A lot depends on the woman’s individual circumstances. Differing amounts can be normal as long as you are eating nutritiously.

As one big mom notes:

Talk about weight gain, but explain that every body is different. Some people gain lots and have healthy babies. Some people gain very little or even lose and have healthy babies. Don’t focus on the scale, but on healthy eating and assure people their bodies will then do what they need to do.

Another mom agrees, saying, “Providers can get across the point that excellent nutrition is key to a healthy pregnancy and birth without making mom stress over it.”

Finding a Size-Friendly Caregiver

Finding a size-friendly caregiver is critical to having a positive birth experience. Unfortunately, bias and mistreatment are not uncommon. Some of it is egregious mistreatment, while other examples show a more subtle bias.  In particular, many well-meaning care providers overutilize interventions in the labors of women of size.

Research shows that obese women are induced at much higher rates, experience a higher rate of interventions, and that caregivers have a lower threshold for surgical intervention in their labors. Although it is commonly believed that obesity predisposes to a cesarean, recent research suggests that cesarean rates can vary dramatically within the same weight class, depending on how the labor is managed.  This suggests that labor management and attitudes may be more of a factor in c-section rates than obesity itself.

High-BMI women need to ask careful questions about special protocols they may be pressured into (like early inductions for suspected macrosomia, early amniotomy, internal monitoring, or early epidurals) and how much wiggle room there is for working around these.

 One plus-sized postpartum nurse states bluntly:

As far as labor, the best advice I could give another [plus-sized] mom is to STAY MOBILE!!!!! Staying in bed, getting an epidural too soon, not being able to change positions frequently [equals] dysfunctional labor and c-section.

Other tips for lowering an obese woman’s chances for a cesarean can be found here and here.

Like other women, women of size need information on patient rights, how to advocate for themselves, their right to decline procedures, and information on filing a complaint if needed.  Knowing that they have the right to stand up for themselves and say “no” is a new concept to far too many plus-sized women.

Pay Attention to Fetal Position

There is some research and anecdotal evidence that suggests that women of size have a higher rate of malpositioned babies, and that this may play a role in their increased cesarean rate. Talk with women about fetal position, discuss ways to promote optimal fetal positions, and mention the possibility of chiropractic adjustments for those who are interested.

Since some very heavy women have pendulous bellies which may make it harder for the baby to engage in the pelvis, include some information about the “abdominal lift and tuck” exercise, as well as other positions that can help babies to engage during labor.

Birthing Positions for Women of Size

Encourage women of size to experiment with finding useful laboring and birthing positions that work with their bodies. Remember that like all women, women of size will vary in how athletic and flexible they are. Explore each position without judgment.

Many women of size find the all-fours position or a forward-leaning kneeling position useful. If the woman has an epidural, side-lying can be extremely helpful. Although “soft tissue dystocia” is an unproven concept, if there is any question of pelvic capacity frequent position changes and asymmetric positions like lunging may be helpful.  A birth ball (appropriate for height and weight) can also help relax the perineum, open the pelvis, and allow easier rotation among positions.

Many women of size report loving laboring in water. The buoyancy of the water allows position changes with greater ease, and eases pressure on the knees. The pain-relieving effect of water is another bonus, since epidurals can be harder to place in larger women.

Further information (and pictures) on birthing positions for women of size can be found here and here. Some care providers actively discourage mobility in women of size, so having a supportive caregiver is key. Practice multiple positions beforehand, emphasize the importance of frequent position changes, and promote having a labor support person who can help women utilize position changes more easily.

Summary

Although women of size are more at risk for certain complications, remember that women of all sizes can experience complications. All women benefit from the same basic advice for excellent nutrition, regular exercise, reasonable weight gain, choosing good providers, attention to fetal position, and use of flexible birthing positions. Emphasize proactive health behavior across the board.

What has been your experience in helping prepare women of size for birth?  How have the women you might have had in your classes or practice found the experience of pregnancy and birth as a large sized woman?  Do you have suggestions to add about your observations and favorite resources? Please share with our community.- SM

Plus-Sized Resources

Finding Size-Friendly Care

• http://www.cat-and-dragon.com/stef/Fat/ffp.html – size-friendly providers of all types
• http://plussizebirth.com/plussizedoulaconnections – size-friendly doulas
• http://plussizebirth.com/midwife-ob-gyn-connections – size-friendly midwives and OBs
• http://www.aafp.org/afp/2002/0101/p81.html – guidelines from the American Academy of Family Practitioners for improving care for obese patients
• www.amplestuff.com – catalogue with products sized for larger people, such as larger blood pressure cuffs, scales that go to higher weights, larger exam gowns, etc.

General Size Acceptance and Health At Every Size® Resources

• http://www.jonrobison.net/Health_Every_Size.pdf – pamphlet on Health At Every Size®
• http://healthateverysizeblog.org/ – blog about Health At Every Size® issues
• www.sizediversityandhealth.org – Association for Size Diversity and Health
• www.cswd.org – Council on Size and Weight Discrimination
• http://www.lindabacon.org/HAESbook/excerpts.html – info on Health At Every Size®
• http://danceswithfat.wordpress.com/blog/ – size acceptance and Health At Every Size®
• http://www.healthyweight.net/cntrovsy.htm – Healthy Weight Network
• www.naafa.org – National Association to Advance Fat Acceptance
• http://www.cat-and-dragon.com/stef/Fat/ffp2.html – tips on obtaining good health care
• http://www.fwhc.org/health/fatfem.htm – Large Women’s Healthcare Experiences

Books on Health At Every Size®

• Bacon, Linda. Health at Every Size: The Surprising Truth About Your Weight. BenBella Books, 2010.
• Campos, Paul. The Obesity Myth: Why America’s Obsession With Weight is Hazardous To Your Health, Gotham Books, 2004.

 About Pamela Vireday

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

Sharon Muza Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, informed Consent, Maternal Obesity, Series: Welcoming All Families, Uncategorized Childbirth Education, guest posts, maternal obesity, obesity in pregnancy, Pamela Vireday, risks of maternal obesity, welcoming all families

In the last issue of the American Journal of Obstetrics & Gynecology, a large Norwegian study was published by Camilla Haavaldsen MD, et al, which looked at the association of fetal death in relation to maternal age and length of gestation.  It is, after all, no secret that in many cultures around the world (not just the U.S.!) women are extending their childbearing years, considerably.  According to the March of Dimes, 1 in 5 American women have their first baby at age 35 or beyond.  Research then, which assesses pregnancy outcomes in terms of maternal age are important as this trend continues.

The statistics in the Haavaldsen study, not unlike others of similarity (referenced in the publication) are strikingly concerning.  The study’s conclusion states,

Women 40 years old or older had the highest risk of fetal death throughout pregnancy, particularly in term and post-term pregnancies.

For the tens of thousands of women who are delaying their childbearing years, the raw data and even relative risk numbers are staggering.

In many ways, this study seems to be well thought out:  potentially confounding variables were controlled for, including:  parity, plurality, year of delivery, paternal age and existence of pre-eclampsia (defined as maternal blood pressure > 140/90).  Following a complex system of data analysis, the blanket results were as follows:  of the 2,182,756 pregnancies studied between 1976-2006,  22,754 resulted in fetal deaths—1.049%.  Of note, the data came from the Medical Birth Registry of Norway—a compulsory method of tracking perinatal mortality rates which, of course, we here in the U.S. have no federally mandated system of any similarity.  Also of note, the results of over 28,000 pregnancies which lasted longer than 43 weeks were excluded due to coding problems—a reasonable enough number that could have had an influence on the overall results, had they been included.

The Details
The researchers aimed to relate maternal age ranges (five year increments between 20 and 45) to various weeks of gestation (16-22, 23-29, 30-36, ≥45) and, thus, determine “the association of fetal death with maternal age by length of gestation.”  In general, the results suggested that increased maternal age + increased weeks of gestation (>40yrs. old, >36 completed weeks of gestation) resulted in a significantly increased risk of stillbirth.   The resultant jump in risk of fetal death at term from >40-year-olds to >45-year-olds is almost two-fold.  Despite this, and other studies showing similar results, “Advanced Maternal Age” tends to include women aged 35 and above, rather than starting the definition at age 40.  (Recommendations on how to manage “higher risk” pregnancies in women >35 y.o. are also linked to well-documented increased risk of chromosomal birth defects as maternal age advances beyond 35.)

Admittedly, the data this large study provides is worthy of great attention.   However, before implementing practice guidelines based on these findings, such as “All women aged 40 or older should be disallowed to carry a pregnancy beyond 37 completed gestational weeks,” I believe several other factors need to be analyzed.

A Closer Look
We know that multiple underlying conditions, beyond those controlled for in the Haavaldsen study, are associated with increased rates of preterm birth and/or stillbirth, some of which include:  pre-pregnancy diabetes (and gestational diabetes), pre-existent thyroid disease, obesity and smoking.  Race, unfortunately, also plays a statistical role.  And yet, none of these potentially underlying factors are addressed in the study.  In fact, we have no idea how many of the study participants may have had one or more of these potentially confounding variables.  (This very issue is, interestingly enough, brought to light in the ACOG Guidelines for Stillbirth Management.)

Likewise, other factors that have not garnered much attention in the literature but, in my estimation, certainly influence a woman’s general state of health and well-being (and thus potentially, the health of her pregnancy) are factors such as: diet, exercise routine and overall stress level.   Designing a future study which could control for these additional variables would undoubtedly alter the data tremendously, prompting questions such as, “to what exponential degree does any one underlying condition increase the relative risk of fetal death?”  Likewise, assuming that the Norwegian study participants may have had some of the additional variables I suggest here, in some cases relative risk of stillbirth could even be decreased in any given maternal age group, when that/those underlying conditions were controlled for.   Following such a study, would it be feasible then, to develop an Adjusted Relative  Risk (ARR) Coding System for pregnant women which would go on to advise certain levels of perinatal and intrapartum care, based on the identified code?

Let’s take a look at a few hypothetical pregnant women to prove my point, but through a more intuitively analytical lens:

Sample Pt.

Age

Gest. Wks.

BMI

Smoker

Diabetes

Thyroid Ds.

Woman A:	23	37.4	21	N	N	N
Woman B:	24	39.2	31	N	Y	N
Woman C:	36	38	24	Y	N	Y
Woman D:	41	41.5	20	N	N	N
Woman E:	44	42	23	N	N	N

What type of relative risk of stillbirth would these women likely have?

I think it is fair to say that, assuming all other potentially confounding variables are controlled for, Woman A has the lowest ARR and Woman E has the highest.  This is where statistics from studies like that of Haavaldsen, et al come in to play.  But what of the other women?

Woman B falls into the age range and gestational weeks that earns her an ARR of 1.00 (very low) in the Haavaldsen study, but how would that risk look differently  when we consider her BMI (indicative of obesity) and her positive gestational diabetes status?  She’d have a higher risk of stillbirth, right?

Woman C presents a similar quandary:  If, again, all other potentially confounding variables had been controlled for, her age and gestational weeks would place her in a relatively higher state of risk compared to Woman B (ARR would be 1.60 in the Haavaldsen study) but would this be an accurate estimation of her stillbirth risk?  What about her smoking and thyroid disease status?  Wouldn’t these earn her an even higher ARR, suggesting the need for an even greater degree of attentiveness by her health care provider?

Woman D presents a loftier challenge, still.  At 41-years-old and 41 weeks, 5 days pregnant, the Haavaldsen study would lead us to automatically believe she is at a relatively high risk for stillbirth as each day of her pregnancy progresses.  But what of her other health factors?  Does the absence of obesity, smoking and thyroid disease discount some of the risk her age and length of pregnancy create?

Anecdote
As a childbirth educator, I witnessed the angst provoked by our (currently limited) categorical risk assessment.  I recall one woman in particular—a 43-year-old first time pregnant woman who was rapidly approaching her due date.  Her healthcare provider—offering guidance from the most current research, I’m sure—was working hard to get her to agree to a labor induction.  Having prepared extensively for a normal birth, she was extremely frustrated by her doctor’s attempts to treat her as an at-risk mother of an at-risk baby.

“I feel fine,” she kept telling me.  “I feel healthier than I have in years.  Why do they want to induce me when nothing is wrong?”

This woman was an avid hiker and skier, she had a low-stress job, she ate healthfully, didn’t smoke, had no underlying medical conditions and appeared to have been of normal weight (prior to and during pregnancy).

I found myself, her Lamaze class instructor, stuck between a rock and a hard place.  I understood (I think) the impetus of her doctor—recognizing statistical trends, she wanted to save her patient from the potential heartache of a stillborn baby.  And, yet, this mother’s intuition kept telling her everything was fine with the baby, as well as with her own health status.

What really was the most appropriate approach to this woman’s care?

Other Factors to Consider
Other elements of the Haavaldsen study I feel compelled to mention include the suggested role labor inductions played in the cohort:

Term predicted by ultrasonographic examination may, for many obstetricians, be more trustworthy than term predicted by last menstrual period.  Hence, induction of labor may have been more common in pregnancies estimated to be postterm by ultrasonographic examination, than by [LMP].

Despite the mention of induced labors being included in the cohort, there are no numbers on how many of the 2 million + pregnancies ended in induction—leaving a potentially HUGE confounding variable unchecked.

Lastly, I appreciated the authors’ mention of the role cervical cone excision may have played in the early pregnancy stillbirth risk as well as preterm labor risk.   As the researchers described,

The relative risk of preterm delivery associated with cervical cone excision, increases with decreasing duration in pregnancy.  In preterm deliveries, fetal deaths are likely to happen during labor and are caused by immaturity.

Conclusion
The Haavaldsen study included a review of 37 similar works of research which, according to study authors, “demonstrated a significant increased risk of stillbirth in women of advanced maternal age.”  Because of that, (but despite the fact I, personally, hate the term “Advanced Maternal Age”) I don’t believe we can discount any and all motions to induce labor in women who fall into the highest of high risk categories.  But I also believe there is much more work to be done to further validate this data in terms of the multiple other risk factors associated with stillbirth.  Until we can complete this picture, in my mind, the jury is still out.

Kimmelin Hull New Research, Practice Guidelines, Research, Science & Sensibility, Uncategorized ACOG, advanced maternal age, BMI calculation in pregnancy, causes of fetal death, cervical cone excision, Cox Regression, Haavaldsen, induction for post dates, induction to reduce risk of stillbirth, Journal of Obstetrics and Gynecology, March of Dimes, obesity in pregnancy, Relative Risk, risks of stillbirth, smoking in pregancy, The Green Journal, thyroid disease in pregnancy