Sunday, December 16, 2012

Thoughts for the Old, Fat and Pregnant

Picasso
This is a comment turned post from here.*

A fat woman shared on a forum that she was unexpectedly pregnant in her 40s and was asking for resources and hints on pregnancy in this situation.  Several folks responded by recommending my sites (thanks for recommending me, folks!), which alerted me to the post.

I left a comment about things to think about as a fat, old pregnant person.  Then it struck me that I really should expand on this for my blog!  Who knows this topic more personally than I do?

I know pregnancy as a fat and old person.  I had three of my four children at "advanced maternal age" (35 or over) and my last was at age 42.  I was "morbidly obese" for all four pregnancies.  I know pregnancy as an old, fat chick.

And having done it several times, I definitely have some suggestions for things to consider for those contemplating the journey.

Find Your Tribe

Honestly, pregnancy as an old fat chick was really no big deal, at least to me.  My babies were healthy every time, and everything was fine.  Did I worry?  Yes, but what mother doesn't?  I didn't obsess about age.

The doctors, on the other hand, were a different story.  Some saw me as a ticking time bomb.  They particularly feared what they saw as the additive risks of being both an older mom and a morbidly obese one.  They slated me for all kinds of extra tests, induction of labor, and extra monitoring. They assumed that I would develop a complication, not that I might develop one.

I was pressured into the high-tech, highly-tested route with my first child (ironically, the only one not born at advanced maternal age), and was traumatized by the fear-laden, interventive "birth" that followed. When I saw that even more interventions were being suggested for the next pregnancy, based on my age, I bolted.  I found that my sanity was better when I found caregivers who didn't freak out about my age or size, which for me meant midwives.  I also had way easier births when I saw less-interventive caregivers.

However, that was me.  You have to find the level of care that YOU are comfortable with. I found I strongly preferred the less-interventive care model, but not everyone does. Some older or bigger moms are comforted by more intervention. Some just want it. A few truly need it. There's no "right" or "wrong" approach here, just one that aligns with your personal birthing preferences and medical needs.

Therefore, I'd recommend exploring different birth options and figuring out ahead of time which care model you prefer and which is appropriate for your unique needs.  (You can read more about that here.)  Interview several types of care providers, ask lots of open-ended questions about their protocols for you given your age and size, then make a decision based on their answers and your intuitive reaction to the provider and his/her practice.

Be An Educated Consumer

Go into your provider interviews knowing that it's true that there is an increased risk for certain complications when you are an older mom.  There are higher rates of blood pressure and blood sugar issues, for example, and higher rates of birth defects.  And it's true that there is an increased risk for these things as well when you are "obese."

However, being at an increased risk for a problem does not mean that this risk will occur, only that it is a possibility.  The question is how your provider responds to this possibility.

Does the provider intend to order every test under the sun?  Is he/she comfortable with you declining tests?  Or wanting a particular test?  Does the provider truly provide informed consent about tests?  The key is to become an educated consumer about the various tests and procedures that may be suggested to an older obese mother, to know the benefits and risks of each, and to weigh them against your own values.

For example, there will be lots of pressure for prenatal tests because of the potential for birth defects.  Media reports make it sound like the risk is huge, but the absolute numerical risk of a birth defect is small.  So while it's important to know that the risk is increased somewhat, it's also important to keep that risk in perspective.  The vast majority of old moms, fat moms, and old fat moms will have healthy babies.  

Remember, all prenatal tests have pros and cons. Some providers downplay the potential risks (i.e., miscarriage), and women only come to appreciate these risks after they have experienced them. Some of these tests have high false-positive rates, and may create a strong fear that something is wrong when nothing actually is.

On the other hand, prenatal testing has potential benefits. It can be helpful to know about certain conditions ahead of time because some problems can be fixed in utero. Or additional plans can be made for the birth based on baby's condition, like giving birth in a hospital with a level III neonatal care unit, or having certain specialists immediately available at the birth.

Some couples feel it is best to know about problems ahead of time so they can become more informed about the baby's diagnosis, grieve the loss of a "normal" child, and therefore be more ready to welcome that unique baby into the world at its birth.

However, this knowledge can be a double-edged sword. Some parents feel like their experiences of pregnancy and birth were tainted by foreknowledge of a baby's problems, and that knowing of even very minor problems took much of the joy and anticipation out of their pregnancies. And all these tests raise the specter of what you would do if tests indicated a problem.

So the prenatal testing decision is a complex one. Parents need to be sure they really understand the following issues before any prenatal test takes place:
  • What is being tested for
  • What the test measures and how accurate it is
  • The difference between a screening test and a diagnostic test
  • What it means if they get a non-reassuring screening test result
  • What their choices would be if they had a non-reassuring test result
  • What further testing might be available
  • What kind of possible treatment might be available if a condition did exist
  • Whether this information before birth would be an advantage or disadvantage to them
  • What they would do with the information once they got it
Some older and larger moms choose to have these tests, some don't. Some love the tests, some do not.   It's really a very personal thing.

I was pressured into having all the prenatal tests in my first pregnancy and had a terrible experience with them, so I chose much more limited testing in future pregnancies, despite an older age each time.  However, I did choose to have at least an ultrasound each time, so I didn't refuse all testing either.  I found a middle ground that met my comfort level and needs.

Like me, some women feel that these tests are a mixed blessing and choose to opt out of them or to use them in limited ways.  Other women have good experiences with these tests and felt very reassured by having them.

No one can tell you what's right for you in the prenatal testing realm, but do know that it's always YOUR choice how much and what testing to do.  You don't "have" to do anything just because of your age or weight.  Research the issue and then find a provider who is supportive of your choices.

(You can read more about certain types of prenatal testing and how they are impacted by a high BMI here.)

Consider Delivery Protocols

Pressure for early delivery can be intense in both older pregnancies and in the pregnancies of women of size.  This intense pressure to deliver no later than the due date means the induction rate in both groups is very high, and is intricately related to the high cesarean rates in these groups.

Much of the pressure for early delivery is because of the fear of stillbirth. Providers rightly point out that the risk of stillbirth at term is higher in older mothers, and is probably higher in high-BMI women too (although some research suggests that this risk may be more limited to those with growth-restricted babies, or is particularly strong in black women).

However, while elevated, the risk for stillbirth in these groups is still relatively low in absolute numerical terms, even for the oldest mothers.  It is a concern, but one that must be kept in perspective.

This concern over stillbirth leads many providers to routinely induce all older women and heavier women at 39-40 weeks, even when there is no other medical indication for induction.  The question is whether early induction helps lower the risk for stillbirth, or whether it stresses the baby and leads to more complications than it alleviates. Certainly, it likely strongly increases the chances for a cesarean.

In other words, is the risk of continuing the pregnancy higher than the risks of an induction?  Frankly, that is not clear at this point.  Most care providers simply assume inducing early will lower stillbirths in these groups, but more research is needed.  However, there are alternatives.  For some providers, the increased risk for stillbirth is simply seen as an indication for more prenatal monitoring, with early delivery only being considered if the results are not reassuring. This will likely catch some cases where stillbirth might be preventable, but realistically, will not prevent all stillbirths.

Some women are uncomfortable with any possibility of increased risk of stillbirth, and are happy to agree to early induction or even elective cesareans, despite the known potential harms of inductions and cesareans.  And of course, that's their right.  These women will be most comfortable with the delivery protocols of most OBs, and will probably feel reassured by frequent prenatal monitoring near term.

On the other hand, many women recognize that even with a somewhat elevated risk, the likelihood of stillbirth is still quite low and they are comfortable not rushing the birth process at all.  These women are more likely to be comfortable with a hands-off midwife or OB, one who won't require delivery by a certain date on a calendar.

Either way, it is very important for you to be "in sync" with your provider's philosophy and protocols for due dates in older or heavier women.  Ask about their concerns and protocols ahead of time so there are no surprises.  Don't be afraid to switch to a provider that is more in line with your preferences.  It's better to switch now than to try and fight a protocol you don't want later on.

If you choose induction at 39 or 40 weeks, remember that inductions are more successful if done when the cervix is ripe and the baby is in a good position for birth.  Ask what your Bishop's Score is and if the baby is anterior.  See if you can hold off inducing if your Bishop's Score is low, and do what you can to ripen the cervix ahead of time.  Serial induction (doing a slow induction over several days) and avoiding breaking the water too early may increase the chances for a vaginal birth.  There is also research to suggest that more patience may be needed in the labors of induced mothers; as long as baby is doing well, make sure your provider is not too quick to intervene surgically.

If you think induction is likely because of a medical issue or a strict due dates protocol from your provider, acupuncture can help gently prepare your body for labor. That way, if an induction happens, it is more likely to be successful.  The key with acupuncture is to allow it enough time to work.  It's not like medical induction, meant to work in a short period of time. It's most effective when it's done gradually, over a period of several weeks, rather than done once or twice near the very end of pregnancy when there's no time left.

It's important to know that there are also providers who are supportive of waiting for spontaneous labor, even in older, heavier women.  You may have to ask a lot of questions and interview a lot of providers to find one, but they are out there if you want one.

Because I was healthy (no blood pressure or blood sugar issues) and my baby looked good, the midwives in my last pregnancy were comfortable waiting for spontaneous labor, even though I was 42 and "morbidly obese."  Baby was born at almost 43 weeks by LMP; just over 41 weeks by adjusted due date.  We were both fine, and it was my easiest birth by far.  However, my choices are my own and may not be right for you.

It's not easy to know what to do about due date protocols when you are in a group that is at increased risk for stillbirth.  Early intervention may sometimes save lives, but that may come at a price of a very high c-section rate and all the harms that can come from inductions and cesareans.  Bottom line, it is a question that deserves careful contemplation and great care when choosing a provider.

Be Proactive

Although no one can promise mothers of any age a perfectly healthy pregnancy, being proactive in your health habits may increase your chances of avoiding the more common complications.

Primary among these is the importance of getting good nutrition and regular exercise. Older women and fatter women are both at increased risk for blood pressure and blood sugar issues, so a woman who is both older and fat is at significant risk for these issues.  The good news is that nutrition and exercise can go a long way towards reducing those risks.

For example, some research suggests that regular, daily exercise can lower the risk for blood pressure/pre-eclampsia issues.  Some research also suggests a similar effect for blood sugar issues.  The beneficial effect is marginal in average-sized women but may be more powerful in women of size, so that's even more reason for older, heavier women to be proactive about this.

Sensible nutritional hints, like avoiding large amounts of simple carbohydrates at once, eating a lower-glycemic or moderate carb diet, and eating protein with your carbs may also lower your chances for blood sugar issues. There is no need to be neurotic about this, but a sensible, moderate approach is a reasonable goal that may help reduce risks.

For those at particularly high risk for pre-eclampsia (i.e., women with a history of prior pre-eclampsia, a family history of it, those with blood clotting issues), there may be other options to consider as well.  For example, some research suggests that low-dose aspirin or supplemental calcium may be helpful in lowering the risk for pre-eclampsia in high-risk women.

For those women at particularly high risk for gestational diabetes (i.e., women with severe PCOS, a strong family history of diabetes, or preexisting impaired glucose tolerance), other choices might include considering metformin or supplements like chromium, d-chiro inositol or myo-inositol prophylactically.

However, decisions on medications and supplements are ones that should only be considered in conjunction with your care provider, since they also may carry risks as well as benefits. Discuss these carefully before proceeding with any of them.

The benefit of a strong focus on nutrition and exercise is that a reasonable lifestyle approach has many potential benefits and very little risk.  For those at particular risk for complications, further interventions may be helpful, but pros and cons have to be weighed first.  Good nutrition and regular exercise doesn't have that downside.  It's one of the strongest and most effective things you can do to increase your chances of a healthy pregnancy and baby.

If you can avoid complications like gestational diabetes or pre-eclampsia, that goes a long way towards giving you more choices during your birth.  Develop those complications, and your choices are more limited. So it is vitally important to be as proactive about your health as possible during pregnancy.

Consider Body Work in Pregnancy

There's no question that pregnancy is harder on a 40-year-old body than it is on a 25-year-old body.  Life is just harder on an older body than a younger one, so you usually have more aches and pains to deal with when you are pregnant at an older age.  However, that doesn't mean that pregnancy in a 40-year-old is all that bad.  The key is to stay as active as you can, and to not be afraid to use bodywork to help you be more comfortable.

I personally found that regular chiropractic care (from a chiropractor with special training in pregnancy, like those with Bagnell or Webster Technique training) was important in helping my old pregnant body be more comfortable. It was also key in promoting a good fetal position (which makes birth a LOT easier, trust me). I think it's especially important for those with a history of car accidents, significant falls, sports injuries, or other body trauma.  Honestly, chiropractic care was one of the most important things I did for myself as an old, fat pregnant chick.  However, as always, it's a choice up to the individual.

Prenatal massage is definitely a wonderful treat for any pregnant body, young or old, and can also help with aches and pains.  There are many massage therapists who specialize in prenatal massage, and it's well worth looking into if you can afford it.  If you can't afford it, you might be able to find a massage-therapist-in-training who would work on you for free or for a reduced fee.

If you have a history of body trauma or experience significant pain in pregnancy, gentle myofascial work may be a good addition to traditional relaxation massage.  Craniosacral Therapy is another complementary bodywork technique that many women find helpful.

Acupuncture can be useful for the aches and pains of pregnancy in an older body too. It can also be extremely effective for other pregnancy complaints like blood pressure issues, heartburn, morning sickness, and headaches. I used acupuncture in my last pregnancy and found it helpful for aches and pains, for heartburn, and for headaches. I also used acupuncture during my labor for pain relief and encouraging a good labor pattern.  Although I didn't use it for ripening the cervix, it can be helpful in preparing the body for labor, for those being pressured to give birth by a certain date, as noted above.

(Not all acupuncturists see pregnant women, so check around with your local doulas and midwives to get a recommendation for one comfortable with pregnancy.)

Bodywork is one of the kindest things you can do for your body in pregnancy, especially as you get older.  If your budget allows it, it can be a wonderful addition to your prenatal care.  If your budget is strained, remember that many bodyworkers will utilize a sliding scale fee or bartering if asked, because they feel it is so important for pregnant women to receive this work.

Other Issues to Think About

Older women and heavier women may be more prone to thyroid issues during and after pregnancy, so ask your provider to watch your thyroid levels carefully, especially if you have a history of depression or PCOS.  Thyroid levels can quickly go out of whack in pregnancy or postpartum in some folks, even those who never had a problem with it previously, so it's worth monitoring for carefully.

If you tend towards depression and are concerned about post-partum depression (PPD), some people swear by placenta encapsulation for preventing PPD.  However, this is a little more on the "alternative" side of the spectrum, so you might want to choose a midwife if you are interested in this.

Final Thoughts

Don't let the scare-mongers frighten you away from being an older mother or a fat mother.  It's definitely doable, and many of us have done it.  You can too.

Certainly, it's important to be aware of the possible risks of being an older mom (or a heavier mom), but remember that being a member of a group at risk for something doesn't guarantee anything for an individual's outcome.

However, it is a call to be particularly proactive about your self-care and your choice of provider.
  • Find your tribe by finding a care provider who aligns with your birth preferences and will honor your birthing choices
  • Be an educated consumer by doing your research on prenatal testing, delivery protocols, and birthing choices
  • Be proactive in your health habits, with special emphasis on nutrition and exercise
  • Look into bodywork for making pregnancy more comfortable and your body optimally functional during this important time
Best wishes to anyone out there thinking about becoming a mother.  Although it can be scary to read about risks, remember that most mothers, regardless of age or size, do just fine.

Be aware of the risks, but focus your energies on proactive behaviors and the knowledge that most women will have good outcomes, whatever their risk factors.

Old or fat or both, you CAN do this. Enjoy your new direction in life, and don't spend much time worrying about what-ifs.  Being a mom can be a tumultuous journey, yes, but it's also one of life's greatest blessings.  Don't be afraid to embrace it whole-heartedly, whatever your age or size.


**Do you have any experience as an older mom of size?  Do you have any great websites with information for older moms?  Share your stories or resources in the comments section.

3 comments:

Janie said...

This is a great guide for moms in that situation!!

Couple of questions:

Do you have a facebook page?
And...
I am a recently trained childbirth educator and will be starting classes in Feb 2013, how/where can I advertise myself as a size friendly provider?

Anonymous said...

Great guidance discussed in the blog for the mom.Acupuncture treatment make possible impossible issues.

Pregnancy Acupuncture

Anonymous said...

I am so thankful that you posted this. I am in my early forties, morbidly obese and contemplating the possibility of pregnancy. It is nice to see something positive and informative in a sea of warnings. Thank you for an excellent post.