Posts Tagged ‘pregnancy in women of size’

Welcoming All Families Series: Welcoming Women of Size In Your Birth Classes

November 6th, 2012 by avatar

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.  Are your childbirth classes friendly to women of size?  What special accomodations and resources do larger-sized mothers-to-be need if any? In today’s post, Pam discusses a check list of items that you might consider when teaching childbirth classes and on Thursday, Pam shares how to promote in your classes optimum outcomes at the births of these mothers.- Sharon Muza, S&S Community Manager


MatthiasKabel GFDL www.gnu.org/copyleft/fdl.html Wikimedia Commons

Although the exact numbers vary according to the source used, it is no secret that many women of childbearing age are “overweight” or “obese”* by government standards.  This means that, sooner or later, most doulas, childbirth educators and health care providers will have women of size as clients or patients.

Many birth professionals are unsure of how to address the unique needs of this group. At a time when the media messages around obesity and pregnancy are almost uniformly negative and scare-mongering, it is important that birth professionals create a place for women of size to discuss their unique concerns without judgment.


Research shows that many larger people find the terms “obese” and “overweight” stigmatizing. Although size-acceptance activists prefer the word “fat,” some people cannot hear this term neutrally, and euphemisms like “fluffy” can feel patronizing.

Birth professionals are encouraged to notice and adopt the terminology used by clients for themselves. Until then, use more neutral terms like “plus-sized” or “women of size.” (Further discussion of the relative merits of various terms can be found here.)

Create a Safe Space

Most larger women have been negatively judged by others for their weight, and the disapproval is never stronger than when they consider pregnancy. Women of size need a non-judgmental space where they can feel free to discuss their concerns for pregnancy without being shamed, lectured to, or made to feel like “bad mothers.”

Your job as a birth professional is to create this safe place. Examine your own biases about weight, eating, and health.  Question your assumptions and engage with each woman as an individual. Utilize reflective listening, assist them in researching special issues, and neutrally explore proactive behaviors that might help address their concerns.

Make Sure Facilities Are Size-Friendly

Ask yourself ─ are your facilities friendly to larger bodies?  Do you have armless chairs? Seating that is easy to get up from?  Restrooms that accommodate larger people?  Comfortable facilities set the tone for a space that is welcoming to all sizes.

Remember that getting up and down from the floor can be difficult for many women in pregnancy, not just heavier women.  Have a few low stools around that women can use to help boost themselves up.  Also be sure your birth balls are appropriate for heavier women; a little higher and a little more heavy-duty balls can be helpful.

Address Special Equipment Needs

The correct blood pressure cuff size is vital for larger people.  A too-small cuff can artificially inflate blood pressure readings and result in unnecessary intervention.

According to guidelines from the American Heart Association, people with upper arm circumferences above about 13.4 inches (34 cm) need a “large adult” cuff, while those with a circumference above about 17.3 inches (44 cm) need a “thigh” cuff.  If in doubt, measure the client’s arm and cross-check it against the reference range printed on the BP cuff.

Some care providers resist using larger cuffs, so women or their support people may need to be quite assertive about utilizing the correct cuff size.

Discuss Breastfeeding When Well-Endowed

Some high-BMI women are quite well-endowed. This can present special challenges in breastfeeding, yet many women receive no information on how to meet these challenges. Cover a variety of nursing positions and techniques, including the football hold, which may be more useful for well-endowed women.

Have Additional Resources Available for Women of Size

A consistent problem for women of size is the difficulty in finding resources for their specific needs. For example, finding maternity clothes or a nursing bra in a larger size can be a major problem. Many women appreciate having a list of companies that specialize in plus-size maternity products.

Address Potential Risks and Complications

While the possibility of complications must be acknowledged, remind women that having a risk factor for a complication does not inevitably mean developing that complication. An individual’s outcome cannot be predicted by risk factors alone. Treat women of size like any other pregnant woman by expecting normalcy as much as possible.

Share websites that examine weight-related research with a neutral, critical eye, which acknowledge that complications are possible and promote proactive prevention, but which also point out that larger women can and do have normal, healthy pregnancies and births.

Find Positive Images and Stories of Women of Size

photo courtesy of Diaz Family

Media images of heavy people in our society are highly stigmatizing.  Most pictures of fat people are headless (dehumanizing them), unflattering (focusing on bellies or behinds in tight clothes), or reinforce stereotypical behavior (eating junk food or being sedentary).

Media discussions of pregnancy and obesity focus only on the risks for complications, tell apocryphal stories of worst possible outcomes as if they are commonplace, or compare fat pregnancy to child abuse.

Books that focus on obesity and pregnancy pay lip service to being size-friendly, but contain a preponderance of negative stories, highly-interventive births, and scare tactics about complications.  As one doula reviewer on Amazon wrote, “More time was spent telling me how much more likely I am to have a cesarean than to tell me how I can best avoid one.”

It’s very important to counteract these negative messages and images with positive ones.  Direct your client to websites which have plenty of positive images of women of size pregnant, giving birth, and breastfeeding (see list below).  Connect them with a community of like-minded women if they are interested.

Respect Patient Autonomy

Different people will look at the same information with differing values and make varying choices.  The same is true for women of size.  Some will respond to information about obesity-related risks by choosing a more-interventive childbirth model, and some will respond by choosing a less-interventive model.  Neither choice is right or wrong. Respect each person’s right to choose for themselves.


“All in all I think I just want to be treated the same as anyone else. Give me the information, not opinions, not value judgments. Let me decide what to do with it. Give me all the information, not what you perceive or decide I need. Treat me as thinking adult. Treat me with respect. Don’t belittle me, and do not treat me with kid gloves either.” Lexi Diaz, plus-sized mother of four.

Do you do anything different when women of size attend your classes?  Do you feel like your classes already accomodate any special needs they might bring? Do your visual aids and resource lists include pictures of women of size and resources designed for their needs?  Do you feel that any woman of size attending your class feels welcome or alone?  What have been your experiences with larger sized women taking your classes or being your client or patient.  Let us know your experiences in the comments section and share additional resources if you would like.  Read on Thursday, when Pam shares how CBEs can help women have optimum outcomes at their births.- SM

Plus-Sized Resources

Plus-Sized Pregnancy Information


Finding Maternity Clothing in Plus Sizes

Plus-Size Maternity Clothing FAQ – help for finding maternity clothing, nursing clothing, nursing bras, and maternity-related products in plus sizes, both in the U.S. and abroad
http://plus-size-pregnancy.org/BBWBabyCarriers.html – help for finding baby carriers and slings in plus sizes
www.plusmaternity.com.au – resources on plus-sized maternity and nursing clothing in Australia
http://plussizebirth.com/2012/04/babywearing-for-the-plus-size-mom.htm – info on finding baby carriers for plus sizes

Positive Images of Plus-Sized Pregnant Women

*Do not use any of these photos without asking permission first

Plus-Sized Pregnancy Photo Gallery – series of blog posts with many pictures of plus-sized pregnancy and birth
Plus-Sized Pregnancy Breastfeeding Gallery – pictures of women of size breastfeeding
http://plussizebirth.com/gallery– gallery of plus-sized baby bumps, birth pictures, breastfeeding pictures, and babywearing pictures
http://oneyawn.blogspot.com/2012/06/belly-pictures-baby-number-three.html – belly diary of a plus-sized mom, week to week in pregnancy
http://www.facebook.com/theamplemother/photos_stream – plus-sized pregnancy photos
http://birthislife.blogspot.com/2012/08/nursing-portrait-session.html – lovely breastfeeding photos of a woman of size
http://www.yaleruddcenter.org/press/image_gallery.aspx – free for educational purposes with attribution to the Rudd Center for Food Policy and Obesity (no pregnancy images)

Birth Stories of Plus-Sized Women

http://www.plus-size-pregnancy.org/BBWBirthStories/bbwstrindex.html – stories with a wide range of outcomes and experiences
http://www.plus-size-pregnancy.org/BBWBirthStories/bbwvagnlstories.htm – stories of normal vaginal births in women of size
http://www.plus-size-pregnancy.org/BBWBirthStories/bbwspecvagstories.htm – stories of normal vaginal births in women of size despite special circumstances

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

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.




Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Obesity, Maternal Quality Improvement, Maternity Care, Series: Welcoming All Families , , , , , , , , ,

Maternal Obesity from All Sides

[Editor’s note:  in this  installment of our maternal obesity series, Dr. Kathleen Kendall-Tackett will guide us through a review of maternal obesity as it pertains to breastfeeding.  To read this series from the beginning, go here.  Tomorrow, we will finish up with some final thoughts from Well Rounded Mama’s, Pamela Vireday, on prevention strategies.]

I remember the moment quite clearly. I was at a large, international breastfeeding conference and stopped to read the research posters. As I did, I grew more and more irritated. There were several posters describing special interventions for “obese women.” Some of these interventions involved sending “obese women” to breastfeeding classes designed to address their “special” needs. Excuse me? First of all, the design of these studies appeared to assume that “obese women” are a homogeneous group, which they obviously are not. Second, why a class? Does the fact that they are heavy mean that they need special instructions? I’m certain that these colleagues meant well, but we have to ask whether this approach is a good idea.

OK, I’ll admit it: I’m a radical on this issue. My stand is due, in part, to the treatment that fat people—and fat women, in particular—receive in health care settings. The story goes something like this. Fat girl goes in for a medical exam because she’s been having concerning symptoms. Health care provider attributes all her health care problems to her size and sends her away with admonitions to lose weight. Only later, does it turn out that she has something awful, like cancer—a condition her HCPs missed completely because they made assumptions based on her physical appearance. Think I exaggerate? This scenario recently happened to the daughter-in-law of one of my friends.

Yes, but what about diabetes, heart disease, and the increased risk of complications following surgery, you might ask? Fortunately, I actually study diabetes, metabolic syndrome and heart disease. Obviously, health care providers do need to address any increased risk their patients might experience. So if their patients have high blood pressure, triglycerides, or LDL cholesterol, by all means address that. But we need to address those concerns without making sweeping assumptions about women who happen to have a higher BMI. For example, one colleague told me that she tells her obese patients that they need to lay off the soda and potato chips. The question I asked was whether she knew–for sure–that her fat patients were drinking soda and eating potato chips. Or that her slim patients weren’t? Did she know this or was she making assumptions based on prejudice against fat people?

Most of the proposed policy changes designed to address the “obesity epidemic” are, in my opinion, good ideas—for everyone, not just fat people. Get fast food and soda machines out of the schools? Great idea. Encourage more physical activity? Also good. Encourage increased consumption of whole grains, fruits and vegetables instead of highly refined and calorically dense junk food? Fabulous.

These approaches to obesity are all good. But we need to recognize a couple of things. First, even with all these interventions, some people are still going to be bigger than others. That isn’t necessarily a health problem. Second, someone can fall into the “obese” range on the BMI and still have good, sometimes even better cardiovascular health than someone who is smaller. Is size really an indicator of overall health, or is it perhaps simply one marker of many? Further, when someone brings up the issue of obesity to me, one of the first questions I ask in response is “how obese?” That makes a difference in terms of what type of problems we are likely to encounter. Assuming that all women who cross the “obesity” threshold have more health problems is simply wrong. Sometimes they do, sometimes they don’t. Third, providers sometimes assume that obesity is simply due to eating too much; that it’s just a matter of getting these women to take their faces out of the feeding trough. We’ve learned relatively recently, however, that it’s not quite that simple. In the past five years, there have been numerous studies demonstrating the role of depression, psychological trauma (particularly childhood abuse), and sleep disorders in weight gain and obesity. Yes, depression (and trauma and sleep problems) can make you fat. And there is also the matter of genetics. Some people are genetically programmed to be larger than others. Steps that these patients take to improve their health will improve their health. But these interventions may not significantly change their size.

So back to the question of a special breastfeeding gulag for fat girls. These interventions assume that women over a certain BMI will automatically have breastfeeding problems. When I’ve raised this issue with my colleagues, I’ve heard arguments about how larger breasts can cause problems, or that fat women have lower prolactin levels after birth.  They also assure me that fat women feel more shame about their bodies and will be reluctant to breastfeed when outside their homes, something we know is related to earlier breastfeeding cessation. OK, these things might possibly be problems. But women overcome breastfeeding problems all the time. The question we need to ask is whether we are creating self-fulfilling prophecies about these women. Breastfeeding is largely a confidence game. If we communicate to women that they think they will fail, whether we say this directly, or indirectly by sending them to a special class¸ are we setting them up for failure? This is a lesson we had to learn about mothers with issues such as flat nipples. Yes, these women can have more problems, but they don’t always. When we make flat nipples an issue, and communicate that mothers will likely fail, we can increase the rate of breastfeeding failure.

As for the shame issue, keep in mind that while there are discernable physical markers of obesity (such as BMI), obesity is also a social construct. Not everyone who is fat feels badly about it. In fact, in some ethnic minority populations, fat women are considered attractive. (And from an evolutionary standpoint, carrying some extra poundage is actually a survival advantage.) The question we need to ask is whether obese women with positive body images are having more breastfeeding problems than their smaller peers. I strongly suspect that they are not.

Frankly, it’s time for empowered fat girls to speak out on behalf of our sisters who do not yet know that they have a voice.  Women of size deserve respectful care, not shaming.  Is packing these women off to a breastfeeding fat camp a good idea?  Personally, I don’t think so. And I can’t imagine how you would market these classes to mothers. How many would willingly sign up for classes designated for obese women? (“Oh yes, that’s me. Please sign me up!”) While we want to proactively address any problems we think that these women may encounter, we need to plan our interventions with circumspection and care. Women of all sizes deserve no less.

Posted by:  Kathleen Kendall-Tackett, who is a health psychologist and board-certified lactation consultant. She is a clinical associate professor of pediatrics at the Texas Tech University School of Medicine in Amarillo, Texas. The views expressed in this posting likely do not reflect the official views of the Texas Tech

Maternal Obesity, Uncategorized , , , , ,

Maternal Obesity from All Sides

June 8th, 2011 by avatar

[Editor’s note:  This is the third in a series of seven posts on maternal obesity.  If you missed the first two installments, go here to begin reading.]


The CA-PAMR (PAMR) points to disparities in maternal outcomes by ethnicity and in conjunction with weight categorization:

“Obesity among the women who died from pregnancy-related causes was fairly evenly distributed by age and did not differ significantly by insurance type. However, greater proportions of African-American (83%) and U.S.-born Hispanic (80%) women who died were either overweight or obese at the beginning of pregnancy compared to Whites (50%), foreign-born Hispanics (44%), and Asian/Pacific Islanders (20%). African- American women had significantly higher mean BMI (mean=32.6) than foreign-born, Hispanic women (mean=25.5) (p<0.05), but did not significantly differ from the other racial/ethnic groups (range of means=25.9 – 31.0).” (2011 CA-PAMR, pg. 32)

The difficult to digest conclusion made in the report is that of the 98 pregnancy-related maternal deaths (2002-2003) analyzed in the PAMR, 60% (n=58) of those women were overweight or obese.  Due to confidentiality, specific characteristics linked to each woman who died are not relayed in the report, so we can only postulate on how much of those maternal deaths in women of size were directly correlated to their weight.


Cardiovascular disease, including cardiomyopathy (20%)
Pre-eclampsia/eclampsia (15%)
Amniotic fluid embolism (14%)
Obstetrical hemorrhage (10%)
Sepsis/infection (8%)

In the ensuing Recommendations section, the report goes on to advise:

“Practice guidelines and best practices for the preconception management of obese women need to be established, as well as for management of gestational weight gain.

“National and State education campaigns should target adolescents and women of child-bearing age to promote attainment of a healthy pre-pregnancy weight and appropriate weight gain during pregnancy through better nutrition and increased activity.”

To me, this advice is spot-on…and not just for California’s child bearing population, but for the provision of care for women of childbearing age, everywhere.  Accepting the status quo of increasing maternal overweight and obesity and patching together practice measures that are less than evidence-based is little more than a Bandaid approach.  And not always a very good one, at that.  Opting more frequently for labor induction or primary cesarean “just in case” places a whole heck of a lot of women at increased risk associated with those medical interventions which they may not even be candidates for.

But before going further down the path of preventative measures, I can’t leave out the justifiable concerns of maternity care providers:  The realities of caring for an obese or extremely obese pregnant woman can be extra-challenging:

•      Prenatal sonography in obese women is less accurate

•      Instrumentation available to maternity care providers may be inadequate

•      Assisting a poorly-mobile (due to epidural anesthesia) obese or morbidly obese woman from gurney to operating table can risk injury to nursing, care provider and other support staff

•      Excessive abdominal adipose tissue can make palpating fetal position/lie as a woman’s due date approaches difficult

•      During the (rare) need for a woman to be placed under general anesthesia (in a super-emergently necessitated c-section) intubation can be more difficult in an extremely obese individual

In her 2010 article, Obesity, risk and the challenges ahead for midwives, published in the British Journal of Midwifery (Vol. 18, Iss. 1, 01 Jan 2010, pp 18 – 23), Research Midwife Jo-Anne Irwin provides a list of equipment that a care provider should consider having on hand, to adequately care for a pregnant woman of size:

•      Hoists*

•      Heavy duty scales*

•      Higher working load

•      Extra width, beds, mattresses, [operating] tables and [gurneys]

•      Large blood-pressure cuffs

•      Extra long spinal needles, extra deep abdominal surgical instruments, extra large gowns

•      Large chairs and wheelchairs

•      Longer straps for fetal monitors

Once a large, pregnant woman presents for service, a doctor or midwife’s call is to care for her with the upmost compassion, knowledge and evidence-based practices possible.  Time cannot be reversed and comorbidities present must be dealt with.  And yet, Irwin makes the salient point in her article that I would like to finish with:

“A good starting point is the provision of preconception care, where dietary advice, weight management and activity levels could be discussed before pregnancy.”

Irwin goes on to reference guidelines recently published by the (British) National Institute of Health and Clinical Excellence (NICE), which offers advice for maternity care providers on weight management before, during and after pregnancy.  The emphasis here is on prevention.

The data on comorbidities associated with maternal overweight and obesity are extensive.  Obese women who become pregnant do have higher risks of developing certain complications compared to their normal weight counterparts.  This doesn’t mean that every overweight expectant mother will experience a dangerous or disastrous outcome—just as normal weight women are not 100% immune from pregnancy-related complications.  All women deserve compassionate and evidence-based perinatal care—large, small, or somewhere in between.  And yet, if we can take the steps to decrease the chances of developing certain risk factors–such as the recommendations for body weight and exercise guidance offered in the SOCG clinical practice guidance–why not put considerable effort toward that goal?

In a perfect, Wallgreens-esque world, here’s what I would love to see implemented within our women’s healthcare system:


•      Referrals to registered dieticians (or successful implementations of wildly popular community classes) for every woman of childbearing age with the goal of teaching teens and young women how to optimize their health, through dietary choices, well before becoming pregnant.

•      Referrals to group or individualized exercise programs for women who lack background understanding of healthy exercise options…before their first pregnancy

•      Implementation of healthy body weight discussions at every well-woman exam appointment.  This might include discussion of individualized genetic risk factors and socioeconomic issues that add a greater degree of challenge to the woman’s overall scenario

•      Implementation or promotion of community-based nutrition support programs for families that can’t afford to buy good, healthy food (and perhaps fall above the income level that dictates inclusion into the WIC program)

To the healthcare provider who responds, “I barely have enough time to get through the basic well-woman exam, let alone all that patient counseling,” I respond:  “Yeah, I get it.”  Fifteen minute appointments that optimize clinic efficiency and income generation don’t allow for this type of in-depth patient-provider interaction.  In the same token, if we can’t rearrange our patient scheduling and make time for preventative care, how can we expect issues, like the world-wide obesity epidemic to get any better?  We’ve got to go back to the drawing board, folks, and start caring for these mamas and their babies well before conception ever takes place.

*On a personal level, I would hope that any maternity care provider and/or facility would do everything in their power to avoid the use of such implements–purely from the perspective of maintenance of dignity.  Having heard stories of obese patients taken to a hospital’s loading dock for weight measurement on an industrial-sized scale holds the potential to be extremely damaging to a person’s self esteem.

[Tomorrow, you will hear from UNC-Charlotte Nursing Professor Kristen Montgomery, regarding dietary education in maternity care, and the sociocultural issues that come into play.  Following Kristen’s post, look forward to reading thoughts and evidence presented by Kmom, from The Well Rounded Mama.]

Posted by:  Kimmelin Hull, PA, LCCE

Maternal Obesity , , , , , , ,

Maternal Obesity from All Sides

June 7th, 2011 by avatar

[Editor’s note:  This is part two of a seven-part series on maternal obesity featuring Kimmelin Hull, UNC-Charlotte Assistant Professor of Kristen Montgomery, childbirth educator and expert blogger on maternal weight issues, Pamela Vireday, from the Well Rounded Mama blog site, and health psychologist, Certified Lactation Consultant (IBCLC) and La Leche League leader,  Kathleen Kendall-Tackett.  To read the first post in this series, go here.]

Complications of Maternal Obesity:  A Closer Look
Let’s examine a few of the individual complications highlighted in yesterday’s post—including their real and purported impact on the perinatal outcome of the mother/fetus(child) dyad, as well as the habitual vs. evidence-based methods for handling these complications in common practice:

Gestational Diabetes
According to Dr. Mahmood’s review, the relative risk ratio of developing GD for an overweight woman is 1.7 compared to her normal weight counterpart.  An obese woman has a 3.6 relative risk of developing GD compared to her normal weight counterpart.  A 2007 meta-anlysis by Chu, et al demonstrated similar results:  odds ratios for developing GD, compared to their normal weight counterparts were 2.14 (overweight), 3.56 (obese) and 8.56 (morbidly obese) (Diabetes Care August 2007 vol. 30 no. 8 2070-2076). The Cochrane Pocket Book –Pregnancy and Childbirth (Cochrane Collaboration and John Wiley & Sons, LTD. pg 92) describes the incidence as affecting between 3 and 6% of pregnancies—that comes out to 30-60/1,000 women.  (Some resources suggest a higher incidence of GD—upwards of 18% of U.S. pregnancies.)

Once a woman has undergone a glucose tolerance test—typically around the 24th – 28th week of gestation—and is deemed positive for gestational diabetes, the question then becomes, “How do we handle this?” The list of information imparted from care provider to patient should look something like this:
1.  Dietary modification
2.  Exercise program
3.  Insulin therapy and/or an oral hypoglycemic agent if the above two measures fail to bring blood glucose levels under control.

Now, there’s a big difference between telling a woman,


“You need to watch your sugar intake, you need to get some regular exercise, and we might have to put you on medication to lower your blood sugar if those first two things don’t work.  If we don’t get this under control, you’re likely to have a big baby that can’t be delivered vaginally…”




“…I’m going to refer you to a registered dietician for dietary counseling so you can learn how to reduce your overall dietary sugar intake and make the best food choices possible, as well as to a physical therapist who can design an appropriate exercise program for you.  If we can decrease your blood sugar levels—preferably without medication—we can decrease other complications associated with gestational diabetes, like too much insulin in his bloodstream and excess growth problems with your baby.”


The latter approach to these talking points could be a good segue into describing how fetuses that are exposed to chronically high levels of blood glucose become newborns with high insulin levels.  Following birth, when baby’s blood sugar levels equalize (faster than insulin levels) the newborn can experience a dangerously rapid hypoglycemia.  This explanation becomes a fact (not judgment)-based reason for motivating the woman to make whatever changes she can during the remainder of her pregnancy.  Because, of course, overweight women care about the well-being of their babies just as much as normal-weight women do.

Additionally, getting a jump-start on treating a pregnant woman’s high blood glucose levels through diet and exercise changes, can also influence her own long term well-being.  Because upwards of 50% of women who experienced gestational diabetes will go on to develop Type II Diabetes later in life (without treatment interventions) guiding a woman toward improving her dietary intake and activity levels sooner, will support a healthier existence, later. (Chu, et al)

However, by taking the short cut and simply telling a woman to ‘eat better and exercise more,’ a lot is being taken for granted:  we are assuming the woman knows about complex carbohydrates and simple carbs and their individual impact on blood glucose levels.  We are assuming she’s aware of the different glycemic loads of different foods.  We are assuming she knows how much constitutes a single serving, what her daily caloric intake is (or should be) and what changes in her diet would be optimal—along with which ones would be risky—for improving her outcome.  In using the former approach, we are also risking making our patient feel bad about her gestational diabetes status.  When people are made to feel ashamed of themselves, they tend to shut down and proverbially stick their fingers in their ears and cry, “Nah-nah-na-nah-nah…I can’t hear you!”  Conversely, giving our patients the tools to make themselves healthier prompts a sense of partnership between consumer and care giver that, ultimately, keeps the lines of communication open.

(More to come on influencing diet and exercise measures–including sociocultural issues– in a later post by Kristen Montgomery.)

Fetal Macrosomia
Both GD and maternal overweight/obesity are predictors of fetal macrosomia as described in this review article, published in the British Journal of Obstetrics and Gynecology (Volume 113, Issue 10, pages 1126–1133).  Unfortunately, suspected fetal macrosomia has been the impetus for elective induction—and sometimes elective cesarean delivery—when recent evidence does not support these practices.

In a cohort analysis of 11,681 deliveries (n=8,379 after inclusion criteria employed) by D.A Beyer, et al, the impact of maternal obesity on labor and delivery was assessed.  The study groups were broken into Control Group (BMI of 18 – 24.9) and Test Group (BMI > 25).  Results described a prolongation of labor of 1.6 hours between the normal weight and obese study participants, and newborn weight differences as follows:

Table 2. Maternal BMI and associated newborn weight

Group (mothers) Weight (newborn)
Control (BMI 18 – 24.9) 3,413g (7.52lb)
Overweight (BMI 25-29.9) 3,535g (7.79lb)
Obese (BMI 30-34.9) 3,508g (7.73lb)
Morbidly Obese (BMI >40) 3,682g (8.11lb)

This study deemed the differences in birth weights listed above as “significant,” as well as other  outcomes, such as shoulder dystocia (n=4—or 0.1%–in the control group, and n=6—or 0.2%–in test group) and primary cesarean delivery (n=975—or 21%–in the control group, and n=1055—or 26%–in the test group).  And yet, I’m not sure that these numbers are significant enough to justify for all obese pregnant women an automatic labor induction or primary c-section due to a 0.1 % increased risk of shoulder dystocia, or a 5% increased likelihood that a secondary cesarean should come to pass.

This cohort study by CSE Homer, et al, out of the UK (n=591) looking at outcomes for planned vaginal versus planned cesarean delivery in extremely obese women (BMI > 50) came to a similar conclusion:
“This study does not provide any evidence to support a policy of routine cesarean delivery for extremely obese women on the basis of concern of higher rates of delivery complications, but does support a policy of individualized decision making on mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes.” [my emphasis]  (Under the “Results” section, the study authors describe previous c-section and pre-existing or gestational diabetes as increased risk factors for resultant c-section in the study group.)

Homer et al made an interesting point about should dystocia, in that dystocia is an inexact diagnosis. Some declare a dystocia if they have had to employ a particular maneuver to free the anterior shoulder from the mother’s pubic arch, while others define it as any delay between the delivery of the fetal head and the rest of his body.  This study reported a 2.2% incidence of dystocia in their study population (13/591), compared to general North American and UK rates of ~ 0.6%  and of the study participants in which a should dystocia was diagnosed, none led to lasting morbidities for mother or baby. 30% of the women who had planned a vaginal birth in this cohort went on to deliver by cesarean (slightly higher than the national rate of 24%).  When utilizing a study like this to determine practice guidelines, a clinician has a choice to make:  recommend primary cesarean deliveries for all obese or morbidly obese women because there is some risk of dystocia due to fetal macrosomy, or err on the side of supporting the pursuit of a vaginal delivery unless some other medical indication prompts an alternative decision (the presence of toxemia, for example).

The Cochrane Collabortation weighs in on the issue of elective labor induction to get a baby who is expected to be growing too large for gestational age through and out:  “Induction of labor for suspected fetal macrosomia is not supported with enough data to provide reliable evidence.” (Cochrane Pocketbook, Cochrane Collaboration and John Wiley & Sons, LTD. pg 222)

Statistically, the vast majority of overweight and obese women can deliver their babies vaginally. Barring particular medical complications suggesting otherwise, these mothers should be allowed to pursue a spontaneous delivery if that is their wish.

Many studies anecdotally report high cesarean delivery and induction rates in overweight or obese women yet do not relate the reasons for these outcomes.  Is it possible that provider fear or bias comes into play when an obese woman’s labor and delivery draws near?  Does the slightly longer labor length associated with obese women prompt clinicians to diagnose ‘failure to progress’ sooner than is warranted?  From the Baltimore Sun article referenced in our first post: “People don’t realize the risk we’re taking, by taking care of these patients,” said Dr. Albert Triana, [whose two provider practice does care for women of all sizes].  “There’s more risk of something going wrong and more risk of getting sued.”

Infection During and After Pregnancy for the Overweight or Obese Woman
This May 1st story on ScienceDaily.com brought to light new research out of Tufts University, postulating on the reason pregnant women of size have a harder time fighting off infection.

“Results showed that obese women had fewer CD8+ (cytotoxic T) cells and natural killer cells, which help fight infection, compared to lean women. In addition, obese pregnant women’s ability to produce [other] cells to fight infection was impaired.”  Additionally, recent research out of Guadalajara, Mexico informs us of the impact oxidative stress has on pregnancy:  namely, in the form of preeclampsia, when the oxidative stress reaches peak levels.  When this process progresses, maternal neutrophil levels spike—taxing the woman’s immune system.  Intuitively then, it makes sense that if pregnancy is a high oxidative stress state, (even more so, if pre-eclampsia develops) and obese women have a harder time fighting infection, putting this particular type of patient at an even higher risk for infection (namely via cesarean delivery) should be avoided whenever possible.  At the same time, women for whom cesarean delivery becomes a necessity, should be treated for infection prophylaxis according to their size, rather than standardized adult dosages, suggests new research like this by L. Pevzner et al out of the UC Irvine department of Obstetrics and Gynecology.

In its chilling maternal mortality report (CA-PAMR), the California Department of Public Health spends considerable time discussing the link between obesity and increased risk of both maternal morbidity and mortality.  But the report’s findings are not as simple as stating, ‘all obese women are at an increased risk of dying during our shortly after pregnancy.’  We must remember that not all women of size—whether in California, Colorado or elsewhere in the world—will develop pre-eclampsia, gestational diabetes, cardiomyopathy or other dangerous and potentially life-threatening illnesses.  And yes, larger than “average” women maintain the same types of desires as their leaner counterparts:  to bring forth a healthy baby into the world under the best possible circumstances.  To gain a better understanding of when obesity challenges that potential outcome, we must look at individual circumstances, like those reviewed above, as well as other non-medical factors.

[In tomorrow’s post, we will take a closer look at the CA-PAMR, as well as difficulties caring for obese or extremely obese pregnant women from a care provider’s perspective, and the role preventative medicine and education can take in improving care for this segment of our maternity population.]

Posted by:  Kimmelin Hull, PA, LCCE

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