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Why the California Toolkit: “Improving Health Care Response to Preeclampsia” Was Created

February 6th, 2014 by avatar

by Christine H. Morton, PhD

Researcher and Lamaze International Board Member Christine H. Morton, Phd shares information about a just released Toolkit on educating professionals about preeclampsia and it’s potentially very serious consequences.  Dr. Morton discusses how you can get a copy, take a webinar introducing the features and help reduce the number of women impacted by this serious pregnancy illness. – Sharon Muza, Community Manager.

Screen Shot 2014-02-05 at 10.25.11 PMWhen my academic partner and I observed childbirth classes several years ago as part of our Lamaze International-funded research (Morton 2009, Morton et al, 2007), we noted that many childbirth educators included a list of signs and symptoms to watch out for during their initial class meeting with expectant couples.  Some of these signs and symptoms were signals of early labor (mucous plug, leaking amniotic sac, contractions) while others might portend a more serious complication such as placental abruption (bright red bleeding), or preeclampsia (blurred vision, extreme swelling, headache), or worse case scenario, fetal demise (reduced to no fetal movement).  At the time, we wondered about the seeming contradiction of classes ostensibly designed to promote confidence in women’s bodies to give birth while from the outset telling women about things to watch out for, or “warning signs.”  Some instructors advised students to post the list on the fridge or on the bathroom mirror.

Now, after five years working at the California Maternal Quality Care Collaborative, and reviewing hundreds of cases of maternal death, I understand the importance of sharing information with pregnant women (and their partners) so they can understand when a symptom or condition goes beyond normal.  I understand why it is so important for women to know their own bodies, including their normal blood pressure, so they (or their partners) can be effective patient advocates if they sense something doesn’t feel right.

It’s an important balance for educators and other birth professionals to discuss the normality of physiological birth alongside the reality that about 8-12% of women will have medically complicated births. (Creanga, 2014), (Fridman, 2013) I remember hearing from partners who wanted to know what to look out for, so they could fulfill their roles as “protectors” as well as “co-creators of sacred space,” as one educator referred to them. Screen Shot 2014-02-05 at 10.25.45 PM

Preeclampsia is the second leading cause of pregnancy-related death in California, accounting for 17% of all deaths. (Druzin et al, 2014.) Preeclampsia is a severe obstetric condition characterized by high blood pressure, which left untreated, can lead to stroke, prematurity and death of women and babies.  As part of the California Pregnancy-Associated Review (CA-PAMR), an expert committee analyzed the medical records of 25 women who died of preeclampsia.  The committee identified contributing factors, and opportunities to improve care. All of the California deaths due to preeclampsia had some chance of preventability, with nearly half having a good-to-strong chance to alter the outcome.  For every woman who dies, at least 40-50 experience severe complications requiring ICU admission and another 400-500 experience moderate-to-severe complications from preeclampsia or other hypertensive disorders.   One important factor in the deaths was delayed recognition and response to signs and symptoms of severe hypertension.

Screen Shot 2014-02-05 at 10.26.04 PMThe lessons we learned from reviewing those cases were used to inform the development of the California Toolkit: Improving Health Care Response to Preeclampsia.  CMQCC and the California Department of Public Health (CDPH), Maternal, Child and Adolescent Health (MCAH) Division collaborated to develop and disseminate this toolkit using Title V MCH funds provided by CDPH-MCAH. The goal of this toolkit is to guide and support obstetrical providers, clinical staff, hospitals and healthcare organizations to develop methods within their facilities for timely recognition and organized, swift response to preeclampsia and to implement successful quality improvement programs for preeclampsia that will decrease short- and long-term preeclampsia-related morbidity in women who give birth in California. (Druzin et al 2014).

Experts from obstetrics, perinatology, midwifery, nursing, anesthesia, emergency medicine and patient advocacy relied on best evidence, expert opinion and the Toolkit includes:

  • Compendium of Best Practices: eighteen articles on multiple topics around hypertensive disorders
  • Appendices: Collection of all Care Guidelines including tables, charts and forms that are highlighted in Article Sample forms for policy and procedure
  • Slide set for Professional Education: slides that summarize the problem of and the best practices for preeclampsia to be used for local education and training

Of particular interest, the toolkit addresses the management of severe preeclampsia < 34 weeks, the importance of recognition and treatment of delayed postpartum preeclampsia/eclampsia in the emergency department and early postpartum follow-up upon discharge for women who were diagnosed with severe hypertension during childbirth.  The Preeclampsia Foundation was a partner on the Task Force, and has created educational material for pregnant women and their families, in English and Spanish.  Hospitals, clinics and childbirth educators can order these materials at no cost (shipping and handling only) from the Foundation.  There is a free webinar available on February 25th introducing the toolkit to professionals.preeclampsia

Thinking back to my childbirth education observations, I am struck that the educators never mentioned preeclampsia or defined it.  Not one suggested women should know their normal blood pressure.  The Preeclampsia Foundation commissioned a report in 2012 which reviewed the top pregnancy and childbirth advice books and found that many either failed to mention the condition or contained misleading or incorrect information about preeclampsia, HELLP or eclampsia.  With hypertensive disorders of pregnancy on the rise (as well as other maternal morbidities) (Fridman et al 2013; Creanga et al 2014) it’s important for childbirth educators and birth professionals to help women understand signs and symptoms and to know what those signs and symptoms might mean.

Even as we know most women are healthy and are highly unlikely to experience a severe complication in pregnancy and childbirth, we must also acknowledge that some women do, and by leaving them out of the classes and books, we silence their reality.  As one woman noted in a research study on experiences of severe pregnancy complications said:

There’s a lot of information out there or bad information that can make you feel like you did this to yourself. But there’s every kind of woman that has gone through some sort of thing. You don’t see red flag kind of behaviors in the population of women who get preeclampsia or a lot of the other kinds of issues that can cause childbirth injury and the bad childbirth experiences. I understand the way the books put it is that they want to reassure you that it’s not going to happen to you, but the kind of flipside of that is to say that when it does happen to you, where are you then? You know? I think they set you up for PTSD, for postpartum depression. They kind of make it seem, like, “Oh hey! You’re fine. Everything’s going to be great. It’s not going to happen to you” so what are you left when it does happen? (Lisa, in Morton et al 2103).

We owe it to pregnant women to give them the information they need to understand the fullness of their pregnancy and childbirth experiences, whether normal or complicated.  The Preeclampsia Toolkit will hopefully help those clinicians who care for childbearing women better manage and reduce the severity of complications when they arise.  Since its release last month, the Toolkit has been downloaded over 1376 times in all 50 states states (plus District of Columbia and Puerto Rico) along with 5 countries; Australia, Canada, Wales, Mexico and Malaysia.  The response to this Toolkit has been incredible and it is clear that there is a need for practical tools that hospitals and clinicians can use to improve their response to hypertensive disorders of pregnancy. 

Do you share information about preeclampsia in your classes and with your clients?  How do you discuss it?  What are your favorite learning tools?  Let us know in the comments. – SM

References

Creanga, MD, PhD, Andreea A. ; Cynthia J. Berg, MD, MPH, Jean Y. Ko, PhD, Sherry L. Farr, PhD, Van T. Tong, MPH, F. Carol Bruce, RN, MPH, and William M. Callaghan, MD, MPH, Maternal Mortality and Morbidity in the United States: Where Are We Now? JOURNAL OF WOMEN’S HEALTH, Volume 23, Number 1, 2014, DOI: 10.1089/jwh.2013.4617

Druzin, MD Maurice; Laurence E. Shields, MD; Nancy L. Peterson, RNC, PNNP, MSN; Valerie Cape, BSBA. Preeclampsia Toolkit: Improving Health Care Response to Preeclampsia (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative, January 2014.

Fridman, PhD, Moshe; Lisa M. Korst, MD, PhD, Jessica Chow, MPH, Elizabeth Lawton, MHS, Connie Mitchell, MD, MPH, and Kimberly D. Gregory, MD, MPH, Trends in Maternal Morbidity Before and During Pregnancy in California, Am J Public Health. Published online ahead of print December 19, 2013: e1–e9. doi:10.2105/AJPH.2013.301583)

Morton, C. H. (2009). A fine line: Ethical issues facing childbirth educators negotiating evidence, beliefs, and experience. The Journal of perinatal education, 18(1), 25.

Morton, C.H., A. Nack, and J. Banker, Traumatic Childbirth Experiences: Narratives of Women, Partners, and Health Care Providers. Unpublished manuscript. 2013.

Morton, C. H., & Hsu, C. (2007). Contemporary dilemmas in American childbirth education: Findings from a comparative ethnographic study. The Journal of perinatal education, 16(4), 25. Chicago

 

Childbirth Education, Guest Posts, Maternal Mortality, News about Pregnancy, Pre-eclampsia , , , , ,

Pregnancy and Childbirth Advice Books through the Lens of Preeclampsia

July 3rd, 2012 by avatar

Guest post by Science & Sensibility contributer Christine H. Morton, PhD

(Full disclosure:  the organization I work for, CMQCC, has been working with representatives from the Preeclampsia Foundation over the past year on the CMQCC task force developing a Preeclampsia Toolkit, and I am a big fan of their executive director, Eleni Tsigas, and frequent re-tweeter of @preeclampsia).

The Preeclampsia Foundation released a new guide to pregnancy and birth books last month, a comprehensive report distilled from a review of more than 60 such books, on their accuracy, coverage and clarity of information on hypertensive complications in pregnancy.    As readers of S&S are well aware, there are numerous books geared to expectant couples, pregnant women, and male partners; by authors who claim their authority by virtue of their clinical degrees and practice, their teaching and research credentials, as well was their personal and celebrity experience.   This is the first time I’ve seen a guide to pregnancy and birth advice books from the lens of a serious disorder in pregnancy:  preeclampsia.

May was Preeclampsia Awareness Month. Hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies each year.1 Preeclampsia is a leading cause of pregnancy-related death in the US and in the state of California, and one of the most preventable. Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension. Care guidelines have recently been developed in many countries, including the UK, Canada and Australia, with a revised practice bulletin to be released from ACOG later this year. A key focus in many of these guidelines is accurate measuring of Blood Pressure, and standardized pathways of care, depending on the clinical situation. These guidelines note that one reason for their creation is the clear evidence that the surveillance of women with suspected or confirmed preeclampsia is variable between practitioners.2,3
 Seeking to understand their experience, women turn to books, their childbirth educators and doulas to help them navigate through this new and unexpected turn into complicated pregnancy.   While many women have healthy pregnancies and births, those who are having symptoms, or have been diagnosed with preeclampsia, eclampsia or HELLP syndrome, need accurate and clear information.    Early detection, and treatment, is a proven way to lessen the severity of the disease, and mitigate its impact.  Are some pregnancy and childbirth guidebooks better than others in informing readers about these issues?

To answer this question, researchers Jennifer Carney, MA and Douglas Woelkers, MD reviewed more than 60 pregnancy and childbirth advice books and ranked them using a consistent set of criteria in five categories: Depth of Coverage, Placement of Coverage, Clarity and Accuracy of Information, Description of Symptoms, and Postpartum Concerns.  In their methods section, they note that

“Books were downgraded for out-of-date information, missing or inaccurate information and placement issues, including inaccurate or inadequate indexing.    Of the more than 60 books reviewed, none ranked above “8” in all five categories. In fact, only a handful of books scored above “8” in the category of “Postpartum Concerns,” since many books routinely state that the cure for preeclampsia and related disorders is the birth of the baby.”

Childbirth educators and doulas have strong views on the ‘best’ books to guide women through pregnancy and childbirth and might be surprised to find that even best selling books like Ina May’s Guide to Childbirth (2003) scored only a 2.6, while the much excoriated, yet highest selling advice book: What To Expect When You’re Expecting (2009) ranked last in the Preeclampsia Foundation’s TOP TEN list, with a score of 7.2.  All books reviewed are listed in the Appendix of the report.

One helpful feature of the report is a sampling of questionable claims found in pregnancy guidebooks:

“Preeclampsia never happens before the twentieth week, but your blood pressure may start to rise steadily after this. Delivery of the baby and placenta ends the problem.” From Conception, Pregnancy, and Birth by Miriam Stoppard. In rare instances preeclampsia can occur prior to 20 weeks; it can also occur up to six weeks postpartum.

The report further explains why it’s important for books on childbirth to also mention preeclampsia, eclampsia and HELLP Syndrome, since this disease can develop immediately prior to, during or after delivery.  Among the childbirth books, the reviewers found,

Only Penny Simkin’s book The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions (2007) provides adequate information about preeclampsia, eclampsia, and HELLP syndrome. Although this book incorrectly uses the term pregnancy-induced hypertension (PIH) to describe preeclampsia and eclampsia, it provides a useful list of symptoms and the possible treatments, including cesarean delivery. It also presents some of the emotional issues that might arise from a diagnosis of PIH and includes some information on HELLP syndrome. It acknowledges the possibility of postpartum preeclampsia and eclampsia, something that many of the general pregnancy books omit.

The report can help childbirth educators and doulas point women to the best information about hypertensive disorders, but its authors also hope these results will guide authors in future revisions.  At the very least, up to date terminology, accurate information and complete indexing is critical in revisions. Books geared primarily to women with relatively healthy pregnancies always face the challenge of balancing reassurance, the optimality of physiological birth and the diverse range of potential complications in pregnancy.  Yet such books can point readers to resources like the Preeclampsia Foundation for up-to-date and user-friendly information and community pages.

Take-away points for Childbirth Educators and Doulas:

  • Check your website and be sure to link to Preeclampsia Foundation website for unbiased, evidence-based information on this disease.  They are on Facebook too.
  • Tell your students to ask about their blood pressure at all prenatal visits and during labor.  They should know what their ‘normal’ range is, and if their BP is ever above 140 systolic or 90 diastolic, to be alert to signs and symptoms of preeclampsia, and report these changes to their care providers.
  • Many factors can affect BP readings:  BP cuff size should be appropriate, especially among women with a high BMI; the measurement should be taken while sitting, with arm at heart level; automated BP machines may underestimate the BP.
  • Remind pregnant women (and their partners) that although lots of attention will naturally be focused on the baby, they have to be alert to the new mother’s health symptoms postpartum too.  While postpartum is a whole new normal, women need to know that any significant bleeding, fever, headaches, nausea, or visual disturbances, are NOT normal, and they should follow up with their health care provider immediately.

Preeclampsia is a serious, if unlikely, complication of pregnancy.  Women diagnosed or at risk for developing hypertensive disorders of pregnancy can find accurate information for all literacy levels (and some Spanish language resources), as well as a supportive community at the Preeclampsia Foundation, a US-based 501(c)(3) not-for-profit organization whose mission is to reduce maternal and infant illness and death due to preeclampsia and other hypertensive disorders of pregnancy by providing patient support and education, raising public awareness, catalyzing research and improving health care practices.

 References

1. American College of Obsetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167.

2. Repke JT PM, Holzman GB, Schulkin J. Hypertension in Pregnancy and Preeclampsia: Knowledge and Clinical Practice Among Obstetrician-Gynecologists. Journal of Reproductive Medicine. 2002;47(6):472-476.

3. Caetano M OM, von Dadelszen P, Hannah ME, Logan AG, Gruslin A, Willan A, Magee LA. A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy. Hypertens Pregnancy. 2004;23(2):197-209.

4.  Hogan JL, et al.  Hypertens Pregnancy. Body Mass Index and Blood Pressure Measurement during Pregnancy. 2011;30(4):396-400.  PMID: 20726743

Read more about Christine H. Morton, PHD on our contributor page.

 

 

 

 

Book Reviews, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, Patient Advocacy, Practice Guidelines, Pre-eclampsia, Pregnancy Complications, Uncategorized , , , , , , , , , , , , , , , ,

Maternal Obesity from All Sides

June 15th, 2011 by avatar

[Editor’s note:  In this, our last segment of the Maternal Obesity from All Sides series, Pamela Vireday shares with us some thoughts regarding prevention, and lived experiences of women of size.  To read the series from the beginning, go here Thank you to ALL of our contributors to this important series. Haven’t shared this conversation with your social media circle yet?  Take a moment to Tweet it or share it on Facebook!]


Rethinking Prevention and Treatment

Maternity care providers usually consider only 3 ways to improve patient outcomes: weight loss before or between pregnancies, restricting gestational weight gain, or incorporating high-intervention care models.  Let’s look at these approaches first, and then examine some alternatives as well.

Weight Loss Before/Between Pregnancies

The Holy Grail of Prevention in most researchers’ minds is weight loss before or between pregnancies.  But is this wise?

Research strongly supports the idea that significant weight gain before pregnancy increases the risk for complications, leading doctors to focus on the idea of weight loss preventing them. In fact, some research does support weight loss as prevention.  However, this weight loss can come at a price.

Many women of size who lose weight between pregnancies report gaining significantly more in the subsequent pregnancy; 41%  compared to 18% in one study.  Chronic dieters  also tend to have more excessive weight gains in their pregnancies. Furthermore, a history of weight loss or frequent weight cycling is a strong predictor of subsequent large gain outside of pregnancy, and long-term weight loss maintenance is rare.

This is not to say that the weight loss option cannot be discussed with women; some may be desirous of this approach. However, women also have the right to decline it.  An alternative approach may be to choose a “Health at Every Size” program ─ emphasizing healthy habits independent of weight loss status.

Therefore, the potential benefits of weight loss now have to be weighed against its potential to cause more weight gain and complications in the long run.

Prenatal Weight Gain Restriction

More and more, researchers have been focusing on restricting prenatal weight gain in high-BMI women in order to improve outcomes. However, recommendations for optimal prenatal weight gain in this group are hampered by study design issues, lack of uniform definitions of obesity and weight gain categories, and contradictory findings.

Research does suggest that high weight gains are associated with increased rates of cesareans, macrosomia and pre-eclampsia.  However, causal interpretations for this are questionable. Iatrogenic factors influence the cesarean rate because of the fear of macrosomia and lack of blinding about weight gain. And higher weight gain is most likely a side-effect of pre-eclampsia, not a cause of it. Only macrosomia seems closely tied to high weight gain.

Even so, many care providers are now pushing ultra-low gain policies for their obese patients. However, this is not without risk.  Research shows that there are increased rates of adverse outcomes with this approach, including small-for-gestational–age (SGA) infants, prematurity, and perhaps infant mortality.

At this time, the Institute of Medicine recommends a weight gain of 11-20 lbs. for all obese women.  Emerging research suggests that optimal weight gain may differ by class of obesity, but doctors must balance the risks of SGA and prematurity against the risks of macrosomia and cesareans carefully, especially for mid-sized obese women (BMI 30-40).   Placing a pregnant woman into a fat and protein-burning state for maintenance of energy levels may not be the best thing—for mother and fetus, alike.

Furthermore, studies that examine lifestyle interventions in obese pregnant women show mixed results.  Some show reduced gain, while others showed little difference or even increased gain instead.  Many show little difference in birth weight, complications, mode of delivery, or neonatal outcome.  If reduced gain makes little difference in outcomes, why risk it?

Remember, good nutrition should always be the priority over rigid weight gain goals; altering prenatal weight gain through scorched-earth interventions may cause more harm than benefit. And researchers must be careful that focusing on weight gain goals does not encourage punitive practices or overly restrictive advice among clinicians.

Ghettoizing Women of Size

Increasingly, research calls for high-BMI women to be managed as “high-risk” patients.  In practice, this means that obese women are often not considered eligible for low-intervention care models and “alternative” birth choices. Some care providers are even declining to see high-BMI patients at all.

Obese women increasingly report being “ghettoized” into “bariatric obstetrics” practices, unable to access local OBs, midwives, or community hospitals. Many report not being allowed to have a homebirth, birth center birth, waterbirth, or even a VBAC. Many are strongly pressured into a high rate of interventions with few alternatives.

Some providers assume that outcomes will be better with high-intervention protocols across the board, but this has not been proven. While sometimes interventions are needed, anecdotally many women of size find that high-tech care models result in poorer outcomes, more traumatizing births, and more interference with breastfeeding.

Research shows that outcomes are good for other women with midwifery care, even women with “moderate” risk factors.  And since many obese women do have normal pregnancies and births, obese women without serious complications should still be able to choose midwifery care, community hospitals, “alternative” care, and low-tech models of care. To paraphrase Susan Hodges of Citizens For Midwifery, how much perceived ‘risk’ does it take to supercede a mother’s right to patient autonomy?

Other Alternatives for Minimizing Complications

When researchers fixate on weight loss, weight gain restriction, and high-intervention care models as the only methods of preventing problems, they lose the opportunity to explore other sensible avenues of prevention.

The most basic way to improve outcome is to emphasize the importance of a pre-conception check-up to check blood pressure, blood sugar, thyroid function, and prenatal vitamin/folic acid intake. These are vital because the most serious complications in obese women usually come from those with uncontrolled pre-existing conditions.  The importance of good nutrition and exercise for preventing complications should be discussed, but without lecturing and moralizing.

The importance of exercise is perhaps the most potent message for women of size to hear for minimizing complication rates. In one study, the risk for GD in obese women was cut nearly in half by regular exercise. Some studies suggest it may lower the risk for pre-eclampsia as well.  Studies in non-pregnant people show that exercise can improve health greatly, independent of weight loss.

Restrictive dietary advice is controversial.  Many care providers advise obese clients to limit high glycemic-index carbohydrates, but research on this approach is contradictory .  A Cochrane review found some benefits but overall inconclusive results. Since many women of size are insulin-resistant, it seems sensible to encourage complex carbs combined with protein, since this significantly improves glucose and insulin response.  That being said, caution should be taken in implementing a low glycemic index diet; severe carbohydrate restriction can result in a ketogenic state—putting both mother and baby at increased risk.

It has long been speculated that a higher dose of folic acid might lower the risk for birth defects in obese women, and some organizations recommend doing this.  Other resources recommend measuring red blood cell count folate concentration instead and giving additional supplementation only for those with low concentrations.

Some experts have also speculated that supplementation with higher doses of vitamin D before or during pregnancy might help prevent some cases of gestational diabetes, hypertension disorders, and cesareans.  However, research so far has been mixed.

Another preventive option that has been proposed by some organizations is daily low-dose aspirin after the first 12 weeks for those obese women most at risk for pre-eclampsia. Like folic acid and vitamin D, this too needs to be studied further for efficacy and safety but is an intriguing possibility. Because aspirin intake during pregnancy can result in deleterious outcomes in some mother/baby dyads, antenatal aspirin use should only be maintained under the careful guidance of the woman’s maternity care provider.

Care must be taken not to use a too-small BP cuff, which artificially inflates blood pressure readings and can result in over diagnosis of hypertensive disorders. Large arms over 34 cm need a large cuff, and some need a thigh cuff. Care must be taken with forearm readings, as these tend to overestimate blood pressure too.

Anecdotally, many women of size (like all women)  find that avoiding inductions is an important part of improving their outcomes. Indeed, one study of obese women found a c-section rate of 19% with spontaneous labor (vs. 41% for induced labor), and that induction was the start of many complications in this group.   Because induction rates can be as high as 50% in very obese women; avoiding induction may help lower cesarean and complication rates. Adjusting due dates for menstrual cycle length may also help reduce the number of inductions for postdates pregnancies in high-BMI women.

A tincture of patience in labor may be helpful too. Many cesareans occur because of a “failure to wait” among care providers.  Since their first stage of labor tends to be slower and because many care providers opt for cesareans more quickly in obese women, it’s important to allow a truly adequate labor before opting for surgery.

Many high-BMI women report having cesareans for fetal malpositions, and some research supports this.  This suggests that interventions such as manual rotation skills or prophylactic chiropractic care might help lower their rate of cesareans.  Anecdotally, many women of size report that chiropractic care was very helpful in pregnancy and labor.

The fear of big babies is another factor that leads to many inductions and cesareans. Avoiding fetal weight estimations may help avoid harmful interventions and a lower threshold for surgery.

Re-examination of surgical care regimens may also improve outcomes in those who do have cesareans.  For example, many clinicians were taught to use vertical incisions and subcutaneous drains in cesareans in very obese women, yet recent research finds these actually increase the risk of wound complications strongly.  Additionally, a higher dose of antibiotics may be needed in morbidly obese women, and those who develop infections may benefit from extended treatment with more frequent dosing regimens.

However, the most powerful measure for prevention in the pregnancies of women of size is simply having a care provider that does not see them as a ticking time bomb, who understands that large bodies can work “right” too, and who truly believes in their potential to give birth vaginally as well.  Remember the power of the self-fulfilling prophecy; be proactive about complications but expect normalcy.

Conclusion

Weight loss before pregnancy is something that can be considered on an individual basis for those who wish it, but we cannot place all our prevention eggs in one basket.

High-BMI women should probably avoid very high weight gains, but extreme interventions to restrict weight may increase the risk for some adverse outcomes as well and must be viewed with caution.

Forcing all obese women into a high-risk, high-intervention care model penalizes those without complications and may cause more harm than good. Women of size, like all women, deserve the right to patient autonomy and access to care that will improve their outcomes.

Clearly, the pregnancies of high-BMI women carry a higher risk for some complications.  It is important to care about lessening this risk and promoting proactive care. However, we must not let hyperbole about this risk rush us into unwise, ineffective, and even dangerous interventions. We must start examining other options for prevention as well.

Additional References and Links:

Subject Studies and Links
Weight Gain Before or Between Pregnancies and Complications Gethun 2007 http://www.ncbi.nlm.nih.gov/pubmed/17547882 LGA babies 

Villamor 2008 http://www.ncbi.nlm.nih.gov/pubmed/18375499 birth defects

Whiteman 2011 http://www.ncbi.nlm.nih.gov/pubmed/20640971 pre-term births

Paramsothy 2009 http://www.ncbi.nlm.nih.gov/pubmed/19305325 cesareans

Weight Loss and Prevention of  

Pregnancy Complications

Whiteman 2011 http://www.ncbi.nlm.nih.gov/pubmed/21544736 GD 

Glazer 2004 http://www.ncbi.nlm.nih.gov/pubmed/15475723 GD

Getahun 2007 http://www.ncbi.nlm.nih.gov/pubmed/17547882 LGA babies

Paramsothy 2009 http://www.ncbi.nlm.nih.gov/pubmed/19305325 cesareans

Prenatal Weight Gain Restriction in Obese Women Crane 2009 http://www.ncbi.nlm.nih.gov/pubmed/19208280 

Thornton 2009 http://www.ncbi.nlm.nih.gov/pubmed/19585925

Nohr 2008 http://www.ncbi.nlm.nih.gov/pubmed/18541565

Heude 2011 http://www.ncbi.nlm.nih.gov/pubmed/21258962

Riskin-Mashiah 2011 http://www.ncbi.nlm.nih.gov/pubmed/20642383

Low Gestational Weight Gain/Loss and  

Adverse Outcomes in Obese Women

Edwards 1996 http://www.ncbi.nlm.nih.gov/pubmed/8598961 SGA 

Chen 2009 http://www.ncbi.nlm.nih.gov/pubmed/18813025 infant death

Naeye 1979 http://www.ncbi.nlm.nih.gov/pubmed/474659 perinatal mortality

Dietz 2006 http://www.ncbi.nlm.nih.gov/pubmed/16477257 prematurity

Efficacy of Lifestyle Interventions in Obese Pregnant Women Guelinckx 2008  http://www.ncbi.nlm.nih.gov/pubmed/18221480 review of 7 trials 

Mottola 2010 http://www.ncbi.nlm.nih.gov/pubmed/20083959 less gain, no diff birth wt

Shirazian 2010 http://www.ncbi.nlm.nih.gov/pubmed/20013602 less gain, no less complctns

Wolff 2008 http://www.ncbi.nlm.nih.gov/pubmed/18227847 less gain, better glucose mtblsm

Polley 2002 http://www.ncbi.nlm.nih.gov/pubmed/12439652 more gain in ovwt group

Claesson 2008 http://www.ncbi.nlm.nih.gov/pubmed/17970795 less gain, no diff birth wt or CS

Guelinckx 2010 http://www.ajcn.org/content/91/2/373.long RCT, no diff in gain or outcomes

Quinlivan 2011 http://www.ncbi.nlm.nih.gov/pubmed/21466516 less GD, no diff in birth wt

Unequal Access to Lower-Intervention  

Care for Obese Women

Some Ob-Gyns in South Florida Turn Away Overweight Women” 

Midwife Group Won’t Accept Patient with BMI Over 40?”

Fat Mothers To Be Banned From Hospital

In Celebration of the Baby Bump

I Feel Victimized Because I’m Fat

Pregnancy and Doctor Doom – He Was Wrong, Wrong, Wrong!”

Too Fat For a Midwife/Birth Center

Too Fat to VBAC

So Why The BMI Restrictions in Waterbirth?”

Too Fat for a Homebirth VBAC

Too Fat for Vaginal Birth

Big Girth? Then You Can’t Give Birth

Woman Deemed ‘Too Fat’ for Pregnancy

Can They Refuse Me a Waterbirth?”

Experiences of Women of Size in Pregnancy Furber and McGowan 2010 http://www.ncbi.nlm.nih.gov/pubmed/20483513 

Nyman 2008 www.pubmed.gov/19100667

Exercise for Prevention of Pregnancy Complications Dempsey 2004 http://www.ncbi.nlm.nih.gov/pubmed/15533588 

Rudra 2005 http://www.ncbi.nlm.nih.gov/pubmed/16286850

Vitamin D Levels and Complications Ringrose 2011 http://www.ncbi.nlm.nih.gov/pubmed/21631991 hypertension and preg 

Zhang 2008 http://www.ncbi.nlm.nih.gov/pubmed/19015731 GD

Merewood 2009  http://www.ncbi.nlm.nih.gov/pubmed/19106272 CS

Barrett and McElduff 2010 http://www.ncbi.nlm.nih.gov/pubmed/20832734 general review

Lapillonne 2010 http://www.ncbi.nlm.nih.gov/pubmed/19692182 general review

Nutrient Deficiencies and Obesity Schweiger 2010  http://www.ncbi.nlm.nih.gov/pubmed/19876694 

Carlin 2006 http://www.ncbi.nlm.nih.gov/pubmed/16925330

Folic Acid Recommendations and Obesity CMACE/RCOG Joint Guidelines http://www.rcog.org.uk/files/rcog-corp/CMACERCOGJointGuidelineManagementWomenObesityPregnancya.pdf
Blood Pressure Cuff Size Maxwell 1982 http://www.ncbi.nlm.nih.gov/pubmed/6123760 

Graves 2001 http://www.ncbi.nlm.nih.gov/pubmed/11248756

Pierin 2004 http://www.ncbi.nlm.nih.gov/pubmed/15199302

Improving Cesarean Outcomes in  

Obese Women

Ramsey 2005 http://www.ncbi.nlm.nih.gov/pubmed/15863532 

Chelmow 2004 http://www.ncbi.nlm.nih.gov/pubmed/15121573

Bearden and Rodvold 2000 http://www.ncbi.nlm.nih.gov/pubmed/10843460

http://wellroundedmama.blogspot.com/2010/08/antibiotic-underdosing-in-obesity.html

Long-Term Efficacy of  

Weight Loss Programs

Aphramor 2010 http://www.nutritionj.com/content/9/1/30 

Bacon and Aphramor 2011 http://www.nutritionj.com/content/10/1/9

Martin 2008 http://www.ncbi.nlm.nih.gov/pubmed/18787526

Hill 2005 http://www.ncbi.nlm.nih.gov/pubmed/15867898

Jain 2005 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1309653/?tool=pubmed

Sarlio-Lähteenkorva 2000 http://www.ncbi.nlm.nih.gov/pubmed/10702760

Ikeda 2005 http://www.ncbi.nlm.nih.gov/pubmed/16029691

Garner and Wooley 1991 http://psycnet.apa.org/?fa=main.doiLanding&uid=1992-13614-001

Miller 1999 http://www.ncbi.nlm.nih.gov/pubmed/10449014

Wt Loss/Wt Cycling as Risk Factor for Subsequent Weight Gain/High BMI Jeffery 2002 http://www.ncbi.nlm.nih.gov/pubmed/12080451 

Korkeila 1999 http://www.ncbi.nlm.nih.gov/pubmed/10584040

Field 2004 http://www.ncbi.nlm.nih.gov/pubmed/14981219

Exercise for Prevention Sanz 2010 http://www.ncbi.nlm.nih.gov/pubmed/20675173 

Lee 2005 http://jap.physiology.org/content/99/3/1220.abstract

Church 2004 http://care.diabetesjournals.org/content/27/1/83.abstract

Hamer and O’Donovan 2010 http://www.ncbi.nlm.nih.gov/pubmed/19770655

Health At Every Size Bacon 2005 http://www.ncbi.nlm.nih.gov/pubmed/15942543 

http://wellroundedmama.blogspot.com/2008/07/health-at-every-size-paradigm.html

Ernsberger and Koletsky 1999 http://onlinelibrary.wiley.com/doi/10.1111/0022-4537.00114/abstract

 

 

 

 

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