When a too-small cuff is used, blood pressure readings are falsely elevated, sometimes by really sizable amounts. This can lead to medications and interventions that are unnecessary and which can carry significant side effects.
Blood Pressure Cuff Size And Pregnancy
In pregnancy, being vigilant about blood pressure cuff size is even more important, yet using the wrong cuff size (miscuffing) seems even more common in pregnancy.
Anecdotally, fat women report that obstetrics providers often don't carry the full range of cuff sizes and tend to be very cavalier about using the correct size, even more so than non-pregnancy healthcare providers. Even hospital labor wards don't always use the correct size consistently.
Yet it is particularly critical to have an accurate reading of blood pressure in pregnancy due to concerns about hypertensive disorders of pregnancy (like pre-eclampsia), which can be very serious indeed.
Unfortunately, many "obese" women are incorrectly diagnosed with BP issues and subjected to interventions like medications, inductions, and sometimes even unnecessary cesareans because of use of the wrong BP cuff size.
Hypertensive Disorders of Pregnancy/Pre-Eclampsia
Hypertensive Disorders of Pregnancy is one of the most common (and potentially serious) complications of pregnancy.
The term "hypertensive disorders of pregnancy" is an umbrella term used to cover a multitude of blood pressure issues that happen in pregnancy. The terminology for it varies a lot (toxemia, pregnancy-induced hypertension, gestational hypertension, etc.), but that's a discussion for another day. The main issue here is what is commonly known as "pre-eclampsia."
Pre-eclampsia is a rise in blood pressure after 20 weeks gestation in a previously normotensive woman, accompanied by protein in the urine. If it is accompanied by altered lab results (like elevated liver enzymes, uric acid, or low platelets), it becomes really serious.
Severe pre-eclampsia can become truly life-threatening to both mother and baby, sometimes very quickly, and is one of the leading causes of maternal mortality in the world. Thus, doctors take BP issues in pregnancy very seriously indeed, and with good reason.
Outside of pregnancy, a borderline BP number is not pursued that vigorously, but in pregnancy many OBs get nervous about even borderline blood pressures and often will start very aggressive interventions very quickly.
Furthermore, because "obese" women do tend to have higher rates of pre-eclampsia, doctors tend to be even more interventive with women of size at the first suggestion that there might be BP issues.
Therefore, it is extremely important for pregnant women of size to have accurate BP data....yet miscuffing seems to be particularly common in obstetrics.
As a result, pregnant "obese" women need to be particularly vigilant about checking cuff size.
My Anecdotal Stories
Sadly, in 3 out of my 4 pregnancies, miscuffing was an issue at some point or other. That's how common it is, especially in pregnancies of women of size.
Normally I am quite vigilant about cuff size, and during prenatals I always asked about whether they were using a large cuff.
However, during labor my mind was busy concentrating on coping with contractions and I didn't always ask about cuff size. As a result, at one point the nurse took my BP, became quite alarmed, and was about to initiate several big interventions as a result.
Luckily, I surfaced enough to ask if she had used the large cuff; she said she couldn't find it and it wouldn't make much difference anyhow. We fought about it for quite a while; she was really resistant to getting the larger cuff, and stated strongly that it didn't matter that much and we really needed to start these interventions sooner than later.
I became quite assertive and insisted she go get the large cuff. She huffed out (she was quite mad!) and finally managed to "find" one and re-took my BP.
It was totally normal, as my blood pressure had been throughout all my pregnancy.
During that entire hospital stay, very few staff members understood the importance of a large cuff, and many resisted the idea of getting one. Even when they were willing to get one, they often had trouble finding one, despite being in a hospital setting where they should be plentiful. The resistance to using the correct-sized cuff was considerable, both on an individual and institutional basis.
I managed to stave off the risky interventions that are standard with high blood pressure, but only because I knew about the importance of cuff sizes and was ready to be quite assertive about it.
In my second pregnancy and labor, I was extremely vigilant about checking on BP cuff size. Because I always asked and because my labor support people asked for me as well when I was preoccupied in labor, I did not have any cuff size issues in this pregnancy......until after the baby was born.
It was only postpartum that the cuff size issue arose....because I was doped out on drugs, post-cesarean, and my support people had gone home to get some sleep.
A nurse came in in the middle of the night to check on me and take my vitals. I was so wiped out and groggy from drugs I didn't bother to ask about cuff size. She took my BP and commented that it was really up.
[It is unusual....but possible....to have normal BP throughout pregnancy and all of labor, and yet still develop pre-eclampsia after the baby is born. That's why they are careful to monitor BP throughout the postpartum period too.]
Fortunately, I surfaced enough to ask whether or not she had used the large cuff. She said no, it was broken, and it didn't really matter that much anyhow. It's a little blurry now but I think she told me I wasn't fat enough for it to be that important anyhow, that the regular cuff fit around my arm just fine.
I think I pointed out that it's not whether the cuff fits or not, it's the size of the cuff/bladder in proportion to your arm size that makes the difference, and that she needed to get the larger cuff.
At that point, she got really snotty. She asked me where I had gotten my medical degree from, implying that she was the medical professional and I was just a lowly ignorant patient, and what did I really know about it anyhow.
[This is typical of medical bullying; when you don't do what they want you to do, they bring out the old "*I* am the medical professional and know more than you," and try to intimidate you into submission.]
I still insisted. She rolled her eyes and snapped that she had so many patients to check on, she couldn't take the time to go get the other cuff, yadda yadda. I still insisted. She was pissed.
Eventually, she did come back with a larger cuff she somehow "managed" to find....and of course, my blood pressure was just fine.
In this pregnancy, I wanted to avoid the hospital and OBs from the get-go. I chose a homebirth midwife, but she did not own a large BP cuff.
She had not attended many women of my size before so she was not fully familiar with the importance of a large cuff, but she was very open to learning about it from me. We both agreed we needed to have accurate readings to make sure I stayed low-risk enough for a homebirth. I was nearing 40 at that point and the risk for blood pressure issues goes up with age, so even though I'd never had an issue with blood pressure before, we still needed to watch carefully in this pregnancy. After listening to the evidence, she agreed that a larger cuff would be important.
It's been quite a while so I'm a bit hazy on the details of how we got one, but she either bought one or we managed to borrow one. Either way, we managed to find a way to get a large BP cuff so we could have accurate readings.
Fortunately, my BP stayed normal throughout the pregnancy, despite my age. But if I had not been so familiar with cuff size issues, she would not have known that it was so important for someone of my size and I probably would have gotten risked out for no good reason. Luckily, she was open to learning about it.
I did transfer to the hospital during that labor and had my VBAC in the hospital after all. Fortunately, I never had an issue that time with cuff size at the hospital. I always asked, and they either always had the right cuff already, or were willing to go get it without arguing about it. That was a refreshing change!
This was the only pregnancy that I did not have cuffing issues. I selected a homebirth midwife for this pregnancy (a different one than with #3), but because she is a woman of size herself, she knew about the importance of a larger cuff and already owned one.
I can't tell you what a relief it was to just sit back in prenatals and in labor and know that I didn't have to be so constantly vigilant about blood pressure cuff sizes! She not only had the proper cuff size, but she also knew how to take it properly in all the "little" details (which a lot of medical workers don't do correctly either.....things like having you seated with back support, legs uncrossed, raising the arm to the correct height, not talking to you while taking the BP, etc.).
My baseline BP was a little higher in this pregnancy because of my age (early 40s) but with the correct cuff we were able to document that it stayed normal throughout.
I had my home waterbirth after all and it was wonderful.
Other Women's Stories
I have collected stories on my website of pregnant women of size who were almost forced into immediate cesareans because of high blood pressure readings brought on by miscuffing. Here are two. (If you have additional stories, I urge you to submit them to me for documentation on my website.)
I came within an hour of having an emergency c/s at week 33 with my son. They even went as far to have the surgical resident (who would be assisting my regular OB) and the anesthesiologist speak with me. They were just waiting for my regular OB to get to the hospital and see me before they prepped me.
When he did come in and see me, the first thing he did was take my BP. When he reached for the BP cuff, he said, "Is this the cuff they're using to check your pressure with?" I said yes, then he went out and yelled up one side and down the other to the nursing staff about jeopardizing his patient and baby because they didn't use the large cuff. It made a huge difference! The readings went from [about] 180/104 to [about] 114/63. Surgery cancelled!
Usually I'm much more alert than that and demand the large cuff. I had requested it several times in the hospital and the nurses kept saying it didn't matter...[even after delivery] the jerks still wanted to use the small cuff!!!
And these are the stories of the women whose misreadings were discovered.
Having gone through two pregnancies with elevated BP, it became kind of crucial to me to have it done correctly.
When I was pregnant with [my daughter], I would have it done at my OB/GYN office, and have it either normal or slightly elevated. Then I would get to my perinatologist's office and have it skyrocketed.
The first issue was the cuff---until I insisted I get the right sized cuff (my OB didn't even own one, but I made sure the girl ran next door to borrow one from another doctor for each of my visits---the peri didn't have one and was the only doctor in the building).
The second thing was my OB always had me either sit in a chair and not speak while they did it, or they did it with me lying down. The peri always did it...on the exam table, legs dangling, no back support, while they were chatting with me. Finally, upon the recommendation of the peri, I got a unit for home. From that point on, I refused to let the peri's office do it. I would do it myself while I was out in the car, and bring them my reading.
Twice they suggested my OB take [my daughter] by c-section immediately due to high BP. Thank gosh my OB relied more on his own records than on the recommendation of the peri.
Oh, and I had to fight with the insurance company to get a large-sized cuff for my home unit.
How many "obese" women have been pushed into cesareans they didn't need because they were miscuffed and the error was never discovered? How many have had to get magnesium sulfate (good for pre-eclampsia treatment but it makes you feel like total crap) because they were miscuffed and the error never discovered?
Let's be fair; some women of size do truly experience pre-eclampsia and need these interventions as a result. You certainly cannot say that all fat women's experiences with pre-eclampsia in pregnancy have been spurious.
But because miscuffing is such a common mistake in women of size, chances are very high that some fat women have been diagnosed and treated in error. And because all of these interventions carry significant risks, that's a pretty big mistake to make, whether it's from ignorance or from laziness. It really highlights just how important cuff size is, especially in pregnancy.
Over the many years that I have been running my website on plus-sized pregnancy and reading stories from other pregnant women of size, this issue of blood pressure cuff sizes keeps coming up again and again.
Despite all the many years of research and training out there for medical professionals on the importance of the correct BP cuff size, miscuffing is consistently still a problem....both outside of pregnancy and in it. However, I have to say miscuffing seems particularly pervasive in obstetrics.
Because hypertensive disorders of pregnancy are a very serious potential complication of pregnancy and because the threshold for intervention is very low when a baby is involved, accurate blood pressure readings are particularly important during pregnancy.
This is even more critical for "obese" women, because many providers assume fat women are automatically going to develop pre-eclampsia anyhow, and because using the wrong blood pressure cuff is such a common error.
You would think that this would mean that attention to the proper cuff size would be particularly strong in obstetrics, but in reality, many women find that there is even less attention to it in obstetric offices and on labor wards.
Therefore, it's critical that pregnant women of size:
- know their own arm size (in centimeters!) and which cuff size they need
- ask about cuff size EVERY TIME blood pressure is taken in pregnancy, labor, or postpartum (and double-check the range printed on the cuff if they are borderline in size)
- train their partners and labor support personnel to ask about cuff size for them during labor if they are too preoccupied
- learn to be assertive about proper cuff size and not allow themselves to be bullied or dissuaded from the proper cuff
- consider purchasing their own cuff and bringing it to every appointment and to the hospital if they are supersized, borderline in arm size, or if they have very heavyset arms