Showing posts with label bariatric obstetrics. Show all posts
Showing posts with label bariatric obstetrics. Show all posts

Sunday, August 3, 2014

Very Low Weight Gain or Gestational Weight Loss in Pregnant Obese Women Risky

[Actual news headline and picture from 2009 media release
because, you know, all obese pregnant women are
constantly stuffing their faces with chocolate]

Here is yet another study that confirms the potential risks of extreme restrictions of prenatal weight gain in women of size.

In this study done by the prestigious MFMU Network, gestational weight loss or a very low weight gain (less than the 11-20 lbs. recommended by the Institute of Medicine) in "obese" women was associated with about twice the rate of Small-for-Gestational-Age (SGA) babies.

This is a concern because SGA babies are at higher risk for metabolic disease as they grow older, including insulin resistance, diabetes, abdominal fatness, the metabolic syndrome, and cardiovascular disease.

In the rush to "cure" obesity, are care providers increasing the next generation's risk for the very conditions they are trying to prevent?

Alarmingly, many clinicians continue to advise high-BMI women to gain little or no weight in pregnancy (even with twins), and some are still telling women of size to lose weight during pregnancy.

This study joins several others that should indicate that extreme prenatal weight gain restriction is not advisable.

Reference

Am J Obstet Gynecol. 2014 Feb 11. pii: S0002-9378(14)00121-5. doi: 10.1016/j.ajog.2014.02.004. [Epub ahead of print] Inadequate weight gain in overweight and obese pregnant women: what is the effect on fetal growth? Catalano PM1, Mele L2, Landon MB3, Ramin SM4, Reddy UM5, Casey B6, Wapner RJ7, Varner MW8, Rouse DJ9, Thorp JM Jr10, Saade G11, Sorokin Y12, Peaceman AM13, Tolosa JE14; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. PMID: 24530820
OBJECTIVE: We sought to evaluate inadequate gestational weight gain and fetal growth among overweight and obese women. STUDY DESIGN: We conducted an analysis of prospective singleton term pregnancies in which 1053 overweight and obese women gained >5 kg (14.4 ± 6.2 kg) or 188 who either lost or gained ≤5 kg (1.1 ± 4.4 kg). Birthweight, fat mass, and lean mass were assessed using anthropometry. Small for gestational age (SGA) was defined as ≤10th percentile of a standard US population. Univariable and multivariable analysis evaluated the association between weight change and neonatal morphometry. RESULTS: There was no significant difference in age, race, smoking, parity, or gestational age between groups. Weight loss or gain ≤5 kg was associated with SGA, 18/188 (9.6%) vs 51/1053 (4.9%); (adjusted odds ratio, 2.6; 95% confidence interval, 1.4-4.7; P = .003). Neonates of women who lost or gained ≤5 kg had lower birthweight (3258 ± 443 vs 3467 ± 492 g, P < .0001), fat mass (403 ± 175 vs 471 ± 193 g, P < .0001), and lean mass (2855 ± 321 vs 2995 ± 347 g, P < .0001), and smaller length, percent fat mass, and head circumference. Adjusting for diabetic status, prepregnancy body mass index, smoking, parity, study site, gestational age, and sex, neonates of women who gained ≤5 kg had significantly lower birthweight, lean body mass, fat mass, percent fat mass, head circumference, and length. There were no significant differences in neonatal outcomes between those who lost weight and those who gained ≤5 kg. CONCLUSION: In overweight and obese women weight loss or gain ≤5 kg is associated with increased risk of SGA and decreased neonatal fat mass, lean mass, and head circumference.

Thursday, July 24, 2014

Induction or Waiting in Obese First-Time Mothers?


This is a follow-up post about a study reported on briefly here earlier this year.

It is about the question of whether "obese" women should have their labors induced proactively at term or be expectantly managed, and whether elective induction increases their risk for cesarean and other poor outcomes (like fetal distress, more Neonatal Intensive Care Unit utilization, etc.).

Induction of Labor: Help or Harm?

Induction of labor is an increasingly common intervention in women of all sizes. The question is whether it does more harm than good.

Much research shows it is associated with an increased risk for cesarean, but other research does not always show this. A definitive answer still eludes us on whether/when induction is appropriate.

Complicating this question is the whether or not the mother's cervix is ripe. Inducing on a very ripe cervix is much less likely to lead to a cesarean than inducing on an unripe cervix (Bishop Score less than 5-7, or cervical dilation more than 3 or 4).  And this is especially true in first-time mothers (nulliparous women).

An increased maternal BMI complicates this debate because of a perceived heightening of risk. One of the biggest dilemmas facing maternity care providers who are caring for "obese" women is how to manage them at term. Should they electively induce labor at 39 or 40 weeks, or should they wait for labor to start on its own if no complications occur?

Many care providers these days seem to be electively inducing obese women at 39 or 40 weeks, sometimes regardless of cervical ripeness (when they are not trying to talk them into a planned cesarean).

Many have the best intentions with this; they think inducing a smaller baby will lessen the risk for cesarean or shoulder dystocia, or they think that baby will have better outcomes if they induce before complications might develop. But do these assumptions hold up under scrutiny?

The problem is that little research has actually examined the question of whether it is beneficial to routinely induce obese mothers without specific medical indications for induction.

Care providers usually go ahead and do so, assuming that inducing obese women at term is beneficial, but there has been little direct evidence one way or the other in a study specifically designed to look at the benefits and risks of routine elective induction in high-BMI women.

Sadly, there is still no large study that rigorously examines this question.

However, we now have a small study that begins to address it. The study looks at the outcomes of elective induction or expectant management of obese first-time mothers with an unripe cervix.

The Study

This retrospective study was conducted by doctors at a hospital in Washington D.C. They studied obese (BMI 30 or more) first-time mothers with no chronic medical co-morbidities (like chronic hypertension, pre-existing diabetes, etc.). Women were admitted to the study between 39 and 41 weeks, and only if they had an unripe cervix (Bishop score less than 5) that was documented during week 38.

The researchers compared the results of electively inducing obese first-time mothers with an unripe cervix (n=60) at 39-41 weeks with expectant management (waiting for spontaneous labor or inducing only if medical indications arose, n=410). Age, BMI at delivery, and prenatal weight gain were similar between groups.

It's important to note that the authors did not compare elective induction to only spontaneous labor. They compared elective induction to expectant management, many of whom eventually were induced if medical indications for induction of labor arose.

The results of this study would probably be even more striking if they compared elective induction only to spontaneous labor, but the authors felt that this was not an appropriate comparison, stating,
"Because spontaneous labor is not something a provider can choose for a patient, it is not realistic to use this as a comparison control group; it is more appropriate to compare the induction of labor to expectant management."

Even so, the bottom line was that the researchers found that electively inducing labor in high-BMI first-time mothers with an unripe cervix raised the risk for cesarean. By quite a bit.

The cesarean rate was 25.9% in the obese women in the expectant management group, and the cesarean rate was 40% in the elective induction group.

That's a significant increase in risk for cesarean.

Only 10.7% of women in the expectant management group were still pregnant by 41 weeks; all the others had either gone into labor spontaneously (36.8%) or had been induced for commonly-accepted medical indications (rupture of membranes, gestational hypertension, non-reassuring fetal heart rate tracings, etc.). So quite a few of the expectant management group were eventually induced, yet the difference in the cesarean rate was still quite marked.

Another important finding was that the elective induction group had three times the rate of admission to the Neonatal Intensive Care Unit (NICU) after the birth (18.3% vs. 6.3%).

This suggests that instead of reducing harm to the baby (as many care providers believe), elective induction in this population may actually increase the risks of poor outcomes.

Now, of course the study had a relatively small sample size, especially in the electively induced group. It was also a retrospective study. So the authors point out that further research on this topic is needed, preferably with a large prospective study.

Still, even with the study's weaknesses, it suggests strong caution towards elective induction in obese women with an unripe cervix. As the authors note:
In a joint summary from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists, physicians are urged to perform labor induction primarily for a medical indication and if done for nonmedical indications...to ensure that the 'cervix should be favorable, especially in the nulliparous patient.' Our findings support this assertion.
Other studies 

This study echoes a number of studies which have found higher c-section rates and complications in obese women who were induced (especially first-time obese mothers).

Of course, these studies did not specifically examine the question of whether routine induction in obese women improved overall outcomes. Still, their findings seem to also suggest caution around the idea of routine induction in obese women.

Although a higher rate of complications like pre-eclampsia means that some obese women will be induced for true medical indications, many others are induced for more dubious indications, based on questionable beliefs. These must be examined carefully.

For example, many providers believe that inducing early when the baby is smaller will lessen the risk for cesarean. Yet a number of studies have shown that it actually increases the risk for cesarean.

The combination of a suspected big baby and a high-BMI mother is a particularly potent combination that leads to many cesareans. A 2006 Massachusetts study found that the combination of induction, a suspected big baby, and first-time mother doubled the cesarean rate in the high-BMI women studied.

Many women of size are induced labor at term ostensibly to prevent a shoulder dystocia. Yet a recent New York study found that induction of labor actually increased the risk for shoulder dystocia (2.85x the risk), and especially so in obese women (5.64x the risk). By inducing women of size, providers may often be creating the very situation they are trying to avoid.

Other care providers induce because they believe it will improve outcomes in high-BMI women. A 2005 Welsh study on obese women with no complications found that the cesarean rate was 19% in the group with spontaneous labor and 41% in the induced group. Like in the present study, the Welsh study noted that the induction of labor was the start of many problems for the obese women in the group, including more blood loss, more UTIs, more babies in the NICU, more feeding difficulties, more neonatal trauma, etc.

So while many care providers think they are doing obese women a favor by inducing them proactively at term, there is strong reason to suspect that they may actually be doing more harm than good.

So much so that a 2013 Irish study (which found higher rates of emergency cesarean in induced obese first-time mothers) concluded:
Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
Conclusion

Research is clear that induction of labor is an extremely common intervention in obese women.

These and other studies suggest that perhaps a little more time and patience is needed at the end of pregnancy in obese women, and that induction should only be undertaken for strict medical indications.

Furthermore, it is time that larger studies directly address the question of whether routine induction at term improves or harms outcomes in obese women and their babies.

These potential studies should particularly look at outcomes among subsets of high-BMI populations, including obese women with complications and those without, those with differing levels of obesity, obese first-time mothers with an unripe cervix, obese multips with a prior vaginal birth, obese women where a big baby is suspected, etc.

Only then will care providers receive clearer guidance on the best management of women of size at term in many of the scenarios they are likely to encounter. It's FAR past time for such targeted research to occur.

We need care based on real evidence, not simply on assumptions about what's best for obese women.


References

Am J Obstet Gynecol. 2014 Jul;211(1):53.e1-5. doi: 10.1016/j.ajog.2014.01.034. Epub 2014 Jan 31. Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m(2) or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks...RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.
Acta Obstet Gynecol Scand. 2013 Dec;92(12):1414-8. doi: 10.1111/aogs.12263. Maternal obesity and induction of labor. O'Dwyer V1, O'Kelly S, Monaghan B, Rowan A, Farah N, Turner MJ. PMID: 24116732
...Of 2000 women enrolled, 50.4% (n = 1008) were primigravidas and 17.3% (n = 346) were obese. The induction rate was 25.6% and the overall cesarean section rate 22.0%. Primigravidas were more likely to have labor induced than multigravidas (38.1% vs. 23.4%, p < 0.001). Compared with women with a normal BMI, obese primigravidas but not obese multigravidas were more likely to have labor induced. In primigravidas who had labor induced, the cesarean section rate was 20.6% (91/442) compared with 8.3% (17/206) in multigravidas who had labor induced (p < 0.001). In obese primigravidas, induction of labor was also more likely to be associated with other interventions such as epidural analgesia, fetal blood sampling and emergency cesarean section. In contrast, induction of labor in obese multigravidas was not only less common but also not associated with an increase in other interventions compared with multigravidas with a normal BMI. CONCLUSIONS: Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
BJOG. 2005 Jun;112(6):768-72. Outcome of pregnancy in a woman with an increased body mass index. Usha Kiran TS1, Hemmadi S, Bethel J, Evans J. PMID: 15924535
...The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999. POPULATION: Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation... METHODS: Comparisons were made between women with a body mass index of 20-30 and those with more than 30...RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events....
J Midwifery Womens Health. 2006 Jul-Aug;51(4):254-9. Maternal body mass index, delivery route, and induction of labor in a midwifery caseload. Graves BW1, DeJoy SA, Heath A, Pekow P. PMID: 16814219
...This retrospective cohort study examined the outcomes of 1500 consecutively delivered women who were cared for by two midwifery practices and delivered between January 1, 1998, and December 31, 2000. Cesarean delivery was significantly associated with the obese BMI (P < .001), nulliparity (P < .02), and newborn birth weight (P =.006). Prenatal weight gain did not have a significant correlation with cesarean birth (P = .24). In multivariable modeling, obese BMI, high newborn birth weight, nulliparity, and induction of labor increased the risk of cesarean birth. There was also a significant association between higher BMI and risk of induction of labor (P < .001). In a secondary analysis, obese BMI was associated with increased risk of induction in cases with ruptured membranes (OR 2.2; 95% CI 1.4-3.4) and postdates pregnancy (OR 2.0; 95% CI 1.1-3.4).
Obstet Gynecol. 2014 May;123 Suppl 1:172S. doi: 10.1097/01.AOG.0000447182.21511.09. Shoulder dystocia and labor induction stratified by maternal weight: to induce or not to induce? Sirota I1, Francis A, Chevalier M, Ashmead G. PMID: 24770084
...Retrospective study of all shoulder dystocia patients who delivered from 1998 to 2010, women in a control group without shoulder dystocia were matched two to one by maternal BMI, age, parity, and diabetic status...RESULTS: Included in the study was 57,259 deliveries; 144 shoulder dystocia cases and 288 women in the control group met study criteria. One hundred seven (74%) shoulder dystocia cases were induced or augmented; 37 (26%) labored spontaneously. One hundred thirty-six (47%) women in the control group were induced or augmented; 152 (53%) labored spontaneously... Across all BMIs, induced patients were 2.85 times more likely to have shoulder dystocia than noninduced patients (95% confidence interval 1.57-6.14; P<.001). After stratifying by BMI, induced normal-weight patients were 2.11 times more likely to have shoulder dystocia than spontaneously laboring normal-weight patients; induced or augmented overweight patients were 4.74 times more likely to have shoulder dystocia than their spontaneously laboring counterparts; and induced or augmented obese patients were 5.64 times more likely to have shoulder dystocia than their noninduced cohorts...CONCLUSION: Induction or augmentation appears to be associated with an increased shoulder dystocia risk with increasing maternal BMI.
Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A114-5. doi: 10.1136/archdischild-2014-306576.330. PLD.30 A 5-year review of maternal obesity and induction of labour on mode of delivery and risk of labour, anaesthetic and neonatal complications. Joannides C, Hon M, McGlone P, Parasuraman R, Al-Rawi S. PMID: 25020968
...Retrospective analysis of women with a booking BMI >45 between January 2009 and October 2013...RESULTS: 158 patients were analysed (mean BMI 49). 68% of all patients were either induced or required labour augmentation (background rate of 39%). 64% of these women achieved a vaginal delivery, increasing to 70% if no induction or augmentation. 71% of multiparous women who spontaneously laboured and had previously achieved a vaginal delivery, delivered vaginally again. Half of primiparous women requiring induction or labour augmentation had an emergency caesarean. 49% had intrapartum regional anaesthetic. 42% required multiple attempts, 19% needed an epidural re-site or spinal for theatre. CONCLUSION: These results mirror the UKOSS study findings. Higher maternal BMI is associated with an increased incidence of induction and augmentation of labour. Despite this the vaginal delivery rate is high. Primiparous women requiring induction or augmentation of labour were most susceptible to obstetric intervention....

Monday, July 14, 2014

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions that some care providers* have suggested asking any provider you are considering during your pregnancy and birth.
  1. How do you define “normal birth”?
  2. Can you give me an example how you typically manage a normal birth?
  3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
  4. How long will you “allow me” to wait if I go overdue?
  5. What position(s) will you allow me to use when giving birth?
  6. How do you feel about IVs and continuous fetal monitoring?
  7. How do you feel about a woman eating and drinking in labor?
  8. What are your thoughts on pain relief in labor?
  9. How do you feel about cesareans?
Some childbirth educators would substitute different questions here and there from this list but it's a reasonable basic list to start with. Adapt as necessary for your own personal situation and concerns.

Also pay close attention to the provider's response to your questions. Of course, care providers have limited amounts of time to answer questions at most visits so it's important to be considerate and concise when you ask questions, but if they are impatient with your questions or dismissive of your concerns, that's a sign you might want to look elsewhere.

There are other additional questions you might want to ask if you are a woman of size, but more on that in future posts. If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Sample Answers to These Questions

So what are reasonable answers to the above questions? It really depends on the type of birth you are looking for and how interventive you want your care provider to be.

Some people want a totally natural birth, and some want all the interventions and machines that go PING that technology can give them. Neither approach is right or wrong; it's more a matter of what you prefer and the unique needs of your pregnancy.

However, it's far more difficult to find a provider truly supportive of natural birth than a provider that routinely uses lots of technology and interventions. So the slant of this post is going to lean more in the direction of finding someone supportive of natural birth, but readers should not infer any judgment of their own personal preferences. Again, adapt the questions to your own personal needs and preferences.

1. How do you define "normal birth"? 

To some care providers, "normal" birth means just about anything (including significant amounts of interventions), whereas to others it means an undisturbed, spontaneous labor resulting in a vaginal birth without any interventions. You can get some idea of a care provider's attitude towards birth and interventions by what they think of as "normal" in birth.

2. Can you give me an example how you typically manage a normal birth?

To some care providers, typical management includes inducing labor at 39 or 40 weeks, mandatory IV, epidural by 4 cm dilation, and active management of care (breaking the waters early in labor, aggressive management of contractions with oxytocin, etc.). To other care providers, induction is used only when medically indicated (concern over blood pressure, baby not growing well, etc.), IVs are not mandatory, epidurals are completely up to the mother's choice, and routine interventions in labor are not utilized unless medically indicated.

Again, neither is inherently right or wrong, just different ways of looking at and managing labor. By asking the question of how the care provider typically manages normal birth, they can begin to understand where the caregiver falls on the continuum of intervention.

3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?

This is an important question because it speaks to the caregiver's respect for patient autonomy and how they prefer to interact with patients. Some care providers never want their dictates questioned. Others give education on the pros and cons of procedures and make strong recommendations based on their training and knowledge, but respect the mother's right to choose for herself.

It's important to also point out that women vary greatly in their desire for informed decision-making. Some prefer to leave all the decision-making up to the care provider and don't want to be "burdened" with having to make those choices. Others want to be very involved in the decision-making. The question is designed to help you figure out which style of care you prefer, and whether that aligns with the care style of the provider you are interviewing.

4. How long will you "allow me" to wait if I go overdue?

There is a great deal of controversy about the safest time for women to go into labor. There is a small but significant risk for stillbirth as gestational age increases, but this risk has to be weighed against the significant risks of inducing labor earlier, which may increase the risk for harm from strong drugs or may increase the risk for cesarean. Current research varies quite a bit on whether a pregnancy should be induced to lower the risk for stillbirth or other poor outcomes. There is no "right" answer here, only an answer that reveals to you what your care provider routinely does.

Many care providers induce labor right at 39 or 40 weeks, some wait till 41 weeks, some wait till 42 weeks, some wait even longer as long as the baby's status is reassuring. Some prefer inducing earlier but will respect the mother's decision to wait if baby looks okay. The point is to know your care provider's preferences on this very important point and to explore how flexible they are about it.

5. What position(s) will you allow me to use when giving birth?

Most hospital births occur with the mother either flat on her back, propped up with her legs in stirrups, or with the mother pulling back on her knees ("supine" or "lithotomy" positions). This is our cultural expectation of birth, and nearly all media images of birth show this position.

In other cultures, however, many other birth positions are used, including kneeling, squatting, side-lying, hands-and-knees, and asymmetrical positions, and these labor positions have distinct advantages. Some providers are very comfortable allowing the mother to labor in positions like these, while other providers restrict the mother to only the typical hospital positions. The question is designed to help you find out how your provider feels about birth positions.

Be careful how you word the question, though. Many care providers tell you that they will "let" you labor in whatever position you want, but fail to reveal that when it comes time to actually push out the baby they want you in the usual positions. Many providers are extremely uncomfortable attending a birth in a position other than supine or lithotomy and will pressure you to change positions, even though there is quite a bit of evidence for the benefit of upright and other positions in birth.

Some women don't care about what position they give birth in or are uncomfortable experimenting with different positions. Others are adamant about having the freedom to move as their bodies dictate, especially as the baby emerges. The important thing is to find a provider that is comfortable with your preferences, so be sure to ask ahead of time about not only labor positions, but also what position they want you in for when the baby is actually coming out.

6. How do you feel about IVs and continuous fetal monitoring?

It is important to establish your provider's preferences about routine interventions like IVs and continuous fetal monitoring.

Some providers are fine with women laboring without an IV. Others mandate an IV for all their patients, while still others strike a middle course and only request that a heplock be placed so that emergency access would be faster if an IV became needed.

Although continuous fetal monitoring has not been shown to improve outcomes in low-risk women, it is still extremely common in nearly all hospitals. However, some providers are more flexible than others about when it starts, whether intermittent monitoring can be used instead, and whether mobile monitoring is allowed.

7. How do you feel about a woman eating and drinking in labor?

Some care providers and hospitals have strict rules about whether a woman is "allowed" to eat food or drink during labor, despite a lack of evidence showing harm from this practice. Many allow only ice chips to be used during labor. It is important to understand your caregiver's policies before labor.

8. What are your thoughts on pain relief in labor?

Women vary greatly in their wishes towards pain relief during labor. Some prefer to go natural, some want an epidural "in the parking lot," some would rather take a wait-and-see-if-it's-needed approach.

Some care providers are very respectful of a woman's wishes about pain management in labor. However, some practically mandate that all their patients receive an epidural, while others can be judgmental about any use of pain medications. Still others know many "tricks" to help women lower their need for pain relief in labor but are supportive of whatever the woman chooses at the time.

Respect for one's wishes regarding pain management during labor plays a strong role in women's satisfaction with their birth experience. It is vitally important to find a care provider who is aligned with your preferences and who will be supportive of your choices.

9. How do you feel about cesareans?

Some providers truly believe that vaginal birth is dangerous and that cesarean birth is to be preferred. Others believe that cesareans are to be avoided at virtually any cost. Most providers fall somewhere in between, but most tend to "lean" one way or the other. Obviously, every caregiver is supportive of cesareans when they are truly life-saving but their attitudes towards other cesareans (and the current cesarean rate in first-world countries) can be revealing about their underlying philosophies of birth and likelihood to use a cesarean.

Beware: Nice Is Not Enough

Don't let a care provider's bedside charm and personality supercede your own commonsense about interventions. A care provider can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get care from them that doesn't put you at risk for more complications. 

One midwife told the story of the following doctor on her blog:
What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?
He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.
Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.
This bait-and-switch tactic is very common among some care providers. They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.

The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, the midwife above summarized one strategy for scoping out the possibilities:
I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.
Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.
Amen to that. "Nice" is wonderful, but some care providers use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued or because it's more convenient for him/her. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance. Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.

What's his/her induction rate, cesarean rate, episiotomy rate? 

Also observe how the provider responds to questions about these things. That's as telling as the actual intervention rate.

For example, "I only do them when necessary" is not a helpful answer; for some docs, interventions like these are seen as "necessary" 60% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be quite low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."

Moral of the story: Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers. Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch out for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method".....as if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, or who subtly deride anyone who asks questions about cesarean or episiotomy rates. All providers should have a general idea of their cesarean and episiotomy rates. If they don't, that suggests that they don't think these rates are important or aren't concerned about their use.

Also ask when/why the provider would want to induce labor. If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 39, 40 or 41 weeks, and research is mixed on the pros and cons of this practice

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications. You may want to find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.

Conclusion

You can have the "nicest" doctor or midwife in the world, and he or she can still coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough. You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

What questions were most helpful to you when you were interviewing providers? What questions do you wish you had asked? What advice do you have for other pregnant women looking for maternity care providers?


*July 2014 Update: These questions were originally shared in a much longer article ("In Search of Dr. Right: 11 Questions to Ask" by The Midwife Next Door) on another website, and I gave credit and linked to that article in my original post in 2010. Sadly, the original link has since been compromised and now goes to an extremely undesirable site, so I have stripped out all those links and am re-posting this article without them. The questions are helpful so I am keeping the post; but it's important to note that it originally arose from another's work.

Thursday, June 5, 2014

Bonehead Ideas: High Cholesterol Equals High Cesarean Rates in Obese Women

Periodically, the obstetric world comes up with some bizarre theories as to why "obese" women have higher cesarean rates than women of average size.

The reasons behind higher rates is a valid question, but the way in which the obstetric world examines the question reveals much of their biases and assumptions around obesity.

One of their more persistent theories is the "Fat Vagina" theory, where they theorize that the vaginas of high-BMI women are lined with fat pads that will prevent a baby from getting out. Sadly, many doctors and midwives are still taught this theory as if it is established fact, when in truth, there is no data to back it up.

And of course, the current favorite among many providers is the "High Prenatal Weight Gain" theory, where women who gain more than the approved amount of weight are blamed for cesareans. And since any gain at all in obese women is considered "too much" by many providers, this may play a particularly potent role in the cesarean rate in women of size. But providers making a causal connection between high gains and cesareans completely ignore the role that fear and bias around high gains can play in many labors. It may not be high gains per se that cause more cesareans but rather the fears and interventions common in high-gain women (especially "high" gain obese women) that result in more cesareans.

One of the more ludicrous theories that doctors have come up with in recent years to excuse abysmally-high cesarean rates in fat women is the "Cholesterol Inhibits Myometrial Activity" theory.

Sadly, this theory gained a lot of mention in obstetric literature in recent years, despite very limited and dubious evidence to support it.

High Cholesterol Causes Cesareans?

In the Cholesterol Theory, high cesarean rates in fat women are supposedly caused by high cholesterol rates (since, you know, all fat women have high cholesterol) because high cholesterol rates supposedly impair the contractility of the uterine muscle.

Say what? Yeah, I know, that was my reaction too.

But yes, it was an actual theory put forward by a number of researchers in recent years. (And its kissin' cousins, that leptin or some other substance are the guilty parties instead.)

Because, you know, all fat women are defective and this explains how.

So the theory goes, if we give fat pregnant women statin medications, maybe that will cut their cesarean rate. Yes, there are actually doctors who have proposed doing this.

Fortunately, there is a recent study out that casts serious doubt on this bonehead Cholesterol Theory.

Problems with the Cholesterol Theory

I've written about this issue before, pointing out that the Cholesterol Theory has a number of problems.

First of all, many fat women do NOT have high cholesterol at all. (I'm one of them.) Many fat women have perfectly normal cholesterol levels, particularly during childbearing years. The fact that researchers assume that nearly all fat people have high cholesterol is symbolic of the typical assumptions researchers make about fat people and how these impact their ability to reach sound conclusions.

Second, the studies on "poor contractility" in obese women are quite small. This certainly raises the question of how whether the findings could be related to coincidence or confounding factors, rather than showing a true causal relationship. But virtually no one raises this question. They are happy to just jump to conclusions.

Third, please note that many of the studies supposedly showing "poor contractility" in obese women were done on women having planned cesareans with NO labor. How does this prove how they might have labored in real life? They took samples of the uteri before labor even started, and then did some lab tests on them, testing "contractility" in the lab.

Sorry, this is hardly indicative of real-life labor and birth, and since they did pre-emptive cesareans on these women, how can they prove that these in vitro "contractility" tests really have any relationship to how labor would have gone? There is just no way that this proves that there is something wrong with fat women's uteri.

Furthermore, they did not look for any other explanations for lower contractility in vitro. Studies show that fat women tend to have longer menstrual cycles and longer pregnancies. Planned cesareans like these were often done at 38 or 39 weeks, and if obese women tend to go into spontaneous labor closer to 42 weeks (either due to inaccurate dating from longer cycles or because of a tendency towards longer pregnancies), doing such an early cesarean would not reliably show whether their uteri were inherently "less contractile." Rather, it would simply suggest that these obese women were not even close to spontaneous labor yet and therefore less responsive to stimulants.

The bottom line is that these studies have a lot of issues.

While it's not wrong to propose a hypothesis for an observed problem, you have to be careful about jumping to conclusions too quickly. These studies relied on very small sample sizes, speculated about an obese woman's response to labor based on in vitro testing from a pre-labor cesarean, didn't explore alternate causes for the findings, and generalized assumptions about obesity and cholesterol levels in a very broad and questionable manner.

The Cholesterol Theory is FAR from a proven connection, although you'd never know it, based on the way many researchers discuss it. And the research certainly does not support routinely putting fat women on statin medications.

The Newest Study on Cholesterol and Cesareans

My biggest question last time I wrote about this issue was whether they had done any studies to see if the fat women who delivered vaginally had better cholesterol levels than the ones who had cesareans, or whether thin women with high cholesterol had more cesareans.

Well, finally we have a study directly addressing some of this. A recent study from New Zealand compared delivery method (cesarean vs. vaginal birth) with women's cholesterol levels at 14-16 weeks to see if there was a correlation between high cholesterol and cesareans.

They found there was NO correlation between the mother's cholesterol levels in early pregnancy and her delivery method. 

However, surprise surprise, they found that induction of labor was connected to cesareans. Imagine!

They concluded:
Elevated maternal cholesterol in early pregnancy is not a risk factor for first stage caesarean for failure to progress in overweight/obese women. 
Conclusion

This "High Cholesterol Causes Cesareans in Obese Women" theory is the kind of bad science that makes fat people so distrustful of medicine and doctors.

So often, it's all just based on ASSUMPTIONS about fat people and not on any real detailed study or logical questioning of theories.

Furthermore, the fact that several years ago they publicized this theory without having proven it and were even marketing the idea of giving statins was absolutely irresponsible.

Statins are CONTRAINDICATED in pregnancy; they are category "X" and may cause birth defects. Cholesterol and lipids play a very important role in fetal development. There is a reason why a pregnant woman's cholesterol rises during pregnancy; the baby needs it for development. Artificially lowering these levels may have devastating effects on the baby.

Critics responded that they were "only" suggesting putting fat women on statins in the last few months of pregnancy, so therefore there would be no risk of birth defects. But if these drugs can be so dangerous in early pregnancy, who knows what kind of harm they might cause late in pregnancy as well? There are other harms that can be caused to babies besides birth defects during organogenesis.

No one knows for sure what critical roles cholesterol and lipids play during late pregnancy. Pregnant women's cholesterol levels rise through pregnancy, suggesting that it has an important biological role to play in the end of pregnancy. Putting women on statins at the end of pregnancy may be just as harmful as at the beginning of pregnancy, just perhaps with more subtle problems than birth defects.

What it boils down to is that they were proposing using fat women's babies as lab rats to experiment on, based on extremely flimsy theories. This is UNACCEPTABLE.

There is completely insufficient evidence to support the idea that high cholesterol is the cause of the high cesarean rate in fat women, and the safety of statins in pregnancy at ANY stage is highly questionable. To suggest treatment with statins for anyone during any stage of pregnancy is risky and BAD science.

Furthermore, to be running stories in the media suggesting statin use in fat pregnant women before suitable research was done substantiating the Cholesterol Theory was reprehensible. It smacks of a few researchers looking for a "hook" to gain name recognition and funding (or a drug company looking for new revenue streams), rather than serious and responsible scientists pursuing a legitimate investigation.

You can read more about the original story here.

It is time for researchers to stop jumping to conclusions about fat women and pregnancy, time for them to examine their own faulty assumptions about obesity and how this distorts their research, time for them to stop using fat women's babies as lab rats for their own personal theories, and time for researchers to stop prematurely "spinning" preliminary research in order to get name recognition and research funding.

It's far too easy for care providers to blame the high cesarean rate in obese women on Fat Vaginas, High Cholesterol, High Prenatal Weight Gain or whatever other boogeyman is currently popular in the obstetric literature. This blames the victim and conveniently absolves themselves of blame.

It is long past time for obstetric researchers to stop blaming women and do the uncomfortable job of examining how their own practices and biases raise the cesarean rate in obese women.


References

BMC Pregnancy Childbirth. 2013 Jul 9;13:143. doi: 10.1186/1471-2393-13-143. Elevated maternal lipids in early pregnancy are not associated with risk of intrapartum caesarean in overweight and obese nulliparous women. Fyfe EM, Rivers KS, Thompson JM, Thiyagarajan KP, Groom KM, Dekker GA, McCowan LM; SCOPE consortium. PMID: 23835080 Full text available here.
BACKGROUND: Maternal overweight and obesity are associated with slower labour progress and increased caesarean delivery for failure to progress. Obesity is also associated with hyperlipidaemia and cholesterol inhibits myometrial contractility in vitro. Our aim was, among overweight and obese nulliparous women, to investigate 1. the role of early pregnancy serum cholesterol and 2. clinical risk factors associated with first stage caesarean for failure to progress at term. METHODS: Secondary data analysis from a prospective cohort of overweight/obese New Zealand and Australian nullipara recruited to the SCOPE study. Women who laboured at term and delivered vaginally (n=840) or required first stage caesarean for failure to progress (n=196) were included. Maternal characteristics and serum cholesterol at 14-16 weeks' of gestation were compared according to delivery mode in univariable and multivariable analyses (adjusted for BMI, maternal age and height, obstetric care type, induction of labour and gestation at delivery ≥41 weeks). RESULTS: Total cholesterol at 14-16 weeks was not higher among women requiring first stage caesarean for failure to progress compared to those with vaginal delivery (5.55 ± 0.92 versus 5.67 ± 0.85 mmol/L, p= 0.10 respectively). Antenatal risk factors for first stage caesarean for failure to progress in overweight and obese women were BMI (adjusted odds ratio [aOR (95% CI)] 1.15 (1.07-1.22) per 5 unit increase, maternal age 1.37 (1.17-1.61) per 5 year increase, height 1.09 (1.06-1.12) per 1cm reduction), induction of labour 1.94 (1.38-2.73) and prolonged pregnancy ≥41 weeks 1.64 (1.14-2.35). CONCLUSIONS: Elevated maternal cholesterol in early pregnancy is not a risk factor for first stage caesarean for failure to progress in overweight/obese women. Other clinically relevant risk factors identified are: increasing maternal BMI, increasing maternal age, induction of labour and prolonged pregnancy ≥41 weeks' of gestation.
Theories on Cholesterol, Leptin, and Myometrial Contractility

Med Hypotheses. 2011 May;76(5):755-60. doi: 10.1016/j.mehy.2011.02.018. Epub 2011 Mar 5. Proposed biological linkages between obesity, stress, and inefficient uterine contractility during labor in humans. Lowe NK, Corwin EJ. PMID: 21382668
Cesarean delivery has reached epidemic proportions in contemporary western healthcare. For otherwise healthy first-time (nulliparous) women at term gestation with a single fetus in a head down position, the most common clinical diagnosis prompting cesarean delivery is dystocia, including clinical terms such as uterine dysfunction, failure to progress, arrest of dilation and/or arrest of descent of the fetal head. In 2006, the cesarean rate for this lowest risk population of childbearing women was 26% in the United States despite the goal of Healthy People 2010 to reduce this rate to 15% from a baseline of 18% in 1998. While multiple lines of evidence suggest that the nulliparous uterus is particularly vulnerable to a diagnosis of uterine dysfunction during labor, pathophysiologic explanations for this dysfunction have not been well described. The acute stress response has been implicated as one factor in this dysfunction for many years, while more recently the growing epidemic of adiposity among women of childbearing age has been suggested as an additional pathway by which myometrial cell function may be disrupted. Using both clinical and in vitro evidence, we hypothesize a combined model in which pathways of acute stress and changes associated with maternal adiposity, particularly exaggerated levels of cholesterol and leptin, may independently and synergistically impair the contractile apparatus of the myocyte leading to the clinical diagnosis of uterine dystocia and subsequent cesarean delivery.
Am J Obstet Gynecol. 2006 Aug;195(2):504-9. Epub 2006 May 2. Inhibitory effect of leptin on human uterine contractility in vitro. Moynihan AT, Hehir MP, Glavey SV, Smith TJ, Morrison JJ. PMID: 16647683
OBJECTIVE: The purpose of this study was to investigate the effects of leptin on human uterine contractility in vitro. STUDY DESIGN: Biopsies of human myometrium were obtained at elective cesarean section (n = 18). Dissected myometrial strips suspended under isometric conditions, undergoing spontaneous and oxytocin-induced contractions, were exposed to cumulative additions of leptin in the concentration range of 1 nmol/L to 1 micromol/L. Control strips were run simultaneously...RESULTS: Leptin exerted a potent and cumulative inhibitory effect on spontaneous and oxytocin-induced contractions compared to control strips...There was an apparent reduction in both frequency and amplitude of contractions. CONCLUSION: This physiologic inhibitory effect of leptin on uterine contractility may play a role in the dysfunctional labor process associated with maternal obesity, and the resultant high cesarean section rates.
Reprod Sci. 2007 Jul;14(5):456-66. Contractility and calcium signaling of human myometrium are profoundly affected by cholesterol manipulation: implications for labor? Jie Zhang, Kendrick A, Quenby S, Wray S. PMID: 17913965
The authors elucidate cholesterol's effect on human uterine contractility and calcium signaling to test the hypotheses that elevation of cholesterol decreases uterine activity and that oxytocin cannot augment contraction when cholesterol is elevated...Elevated cholesterol is deleterious to contractility and Ca2+ signaling in human myometrium. Cholesterol may contribute to uterine quiescence but could cause difficulties in labor in obese/dyslipidemic women, consistent with their increased cesarean delivery rates.
Obesity and Contractility

BJOG. 2007 Mar;114(3):343-8. Epub 2007 Jan 22. Poor uterine contractility in obese women.
Zhang J, Bricker L, Wray S, Quenby S. PMID: 17261121
OBJECTIVE: The aim of the study was to elucidate the reason for the high rate of caesarean section in obese women. We examined the following hypotheses: (1) obese women have a high incidence of complications related to poor uterine contractility--caesarean section for dysfunctional labour and postpartum haemorrhage. 2) The myometrium from obese women has less ability to contract in vitro. DESIGN: First, a clinical retrospective analysis of data from 3913 completed singleton pregnancies was performed. Secondly, in a prospective study the force, frequency and intracellular [Ca(2+)] flux of spontaneously contracting myometrium were related to the maternal body mass index. SETTING: Liverpool Women's Hospital and University of Liverpool. POPULATION: The clinical study involved all women who delivered in one hospital in 2002. The in vitro study myometrial biopsies were obtained from 73 women who had elective caesarean section at term. RESULTS: Maternal obesity carried significant risk of caesarean section in labour that was highest for delay in the first stage of labour (OR 3.54). The increased risk of caesarean section in obese women largely occurred in women with normal- and not with high-birthweight infants. Obese women delivering vaginally had increased risk of prolonged first stage of labour and excessive blood loss. Myometrium from obese women contracted with less force and frequency and had less [Ca(2+)] flux than that from normal-weight women. CONCLUSIONS: We suggest that these findings indicate that obesity may impair the ability of the uterus to contract in labour.



Friday, May 30, 2014

Midwives Can Safely Care for Obese Women

Image Credit: Andy Ellison
In many places, midwives are no longer permitted to care for obese women, or at least obese women over a certain BMI (often 35 or 40). 

Many women of size these days are "risked out" of midwifery carehomebirthbirth centers, waterbirth, and even some hospitals. Some OBs are even refusing to see obese patients at all. A fat woman's only choice for care may become a high-risk specialist, even if she is healthy and has no complications.

I've written about this before. I call it Ghettoizing Women of Size.

It is done based on hyperbole around the risks of obesity and does not reflect the fact that many obese women are healthy, do not develop complications, and do just fine with midwifery or other "alternative" care. 

In the following recent Dutch study, although more obese women had their care transferred to OBs (some of which could simply represent bias or exceeding BMI cutoffs rather than actual complications), the obese women who were cared for by midwives had no more adverse outcomes than other women.

This shows that, providing there are no major complications, obese women (and even "morbidly obese" women) can be safely cared for by midwives.

There is no need for automatic transference of care, and definitely no need for routinely ghettoizing obese women into high-risk, high-intervention care.

*Midwives, let's see some more formal studies of midwifery care of obese women. Personally, I'd love to see a study comparing outcomes of healthy obese women routinely assigned to OB care and those routinely assigned to midwifery care. 



Reference

BJOG. 2014 Mar 12. doi: 10.1111/1471-0528.12684. [Epub ahead of print] The impact of obesity on outcomes of midwife-led pregnancy and childbirth in a primary care population: a prospective cohort study. Daemers D1, Wijnen H, van Limbeek E, Budé L, Nieuwenhuijze M, Spaanderman M, de Vries R. PMID: 24618305
OBJECTIVE: To assess the impact of obesity on the likelihood of remaining in midwife-led care throughout pregnancy and childbirth. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. POPULATION: A cohort of 1369 women eligible for midwife-led care after their first antenatal visit. METHODS: First-trimester body mass index (BMI) was calculated as weight measured at booking divided by height squared. Obstetric data were retrieved from medical records. Multiple logistic regressions were performed to examine the effects of BMI classification on midwife-led pregnancies and childbirths. MAIN OUTCOME MEASURES: Percentages of women remaining in midwife-led care throughout pregnancy and throughout childbirth. RESULTS: Of women in obesity classes II and III, 55% remained in midwife-led care throughout pregnancy and 30% remained in midwife-led care throughout birth. Compared with women of normal weight, women in obesity classes II and III had fewer midwife-led pregnancies (OR 0.38, 95% CI 0.21-0.69), and women who were overweight or in obesity class I had fewer midwife-led childbirths (OR 0.63, 95% CI 0.44-0.90; OR 0.49, 95% CI 0.29-0.84, respectively). Compared with women of normal weight, women who were obese had higher referral rates for hypertensive disorders (4 versus 14%), prolonged labour (4.6 versus 10.4%), and intrapartum pain relief (4 versus 10.4%). The women who were eligible for midwife-led birth and who were overweight or obese, had no more urgent referrals than women of normal weight. Women who were obese and who completed a midwife-led birth had no more adverse outcomes than women of normal weight, with the exception of higher rates of large for gestational age (LGA) babies (>97.7 centile; 12.1%, versus 1.9% in normal weight and versus 3.3% in overweight women). CONCLUSIONS: Although fewer women who were obese remain in midwife-led care during pregnancy and childbirth, there was no increased risk of unfavourable birth outcomes for women who were obese and eligible for a midwife-led birth when compared with women of normal weight. This indicates that when primary care midwives use a risk assessment tool throughout pregnancy and childbirth they are able to safely assign women who are obese to either midwife-led or obstetrician-led care.

Sunday, March 30, 2014

Wait for Spontaneous Labor If the Cervix Isn't Ripe


Here is a new study that suggests that it may be better to await spontaneous labor in first-time obese mothers with an unripe cervix, rather than trying to force labor to start regardless of the Bishop's Score.

Reference

Am J Obstet Gynecol. 2014 Jan 31. pii: S0002-9378(14)00063-5. doi: 10.1016/j.ajog.2014.01.034. [Epub ahead of print] Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m2 or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks. Outcomes were analyzed using χ2, Student t, or Wilcoxon rank sum tests as appropriate with a significance set at P < .05. RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.

Monday, March 17, 2014

A Woman Your Size Has No Business Being Pregnant

Although this past year's Turkey Awards went to ignorance around PCOS, we have to give a Dishonorable Mention Turkey Award to a recent entry at My OB Said What?!?:
“Why are you crying? It’s not like you lost anything. A woman your size has no business being pregnant anyway.” -ER nurse to an overweight woman suffering the miscarriage of her third child
Really? REALLY?!?!

It's hard to believe a healthcare worker would say say something this insensitive and unprofessional to any woman in the middle of losing her baby, but sometimes they do. Healthcare professionals are human like anyone else, of course, and have rough days where they find it hard to be empathetic....but even in the middle of a bad day, they need to remember the wisdom of silence when you can't quite muster up empathy.

There is nothing quite so tender as a miscarriage or stillbirth. Medical professionals need to remember that just because a miscarriage is early doesn't mean it's not still a loss. Even if an early miscarriage doesn't seem like a loss to them, they need to honor the fact that it feels like a loss to THAT patient.

And telling someone not to cry when they are in the middle of losing someone precious to them shows a tremendous lack of empathy. Most likely it comes from the fact that the person's grief is making the medical professional uncomfortable and they don't know how to deal with it, so they belittle the person's pain and tell them to just get over it.

But it's not supposed to be about caregiver's comfort level, it's about the PATIENT'S comfort level and needs, and they need to remember that in their dealings with patients. You don't have to feel things the same as your patients, but you need to be respectful of the patient's feelings, even if you don't agree with them, aren't what you personally would feel, or make you uncomfortable.

But the thing that bothers me the most about this entry is the idea that women of size "have no business being pregnant."

That's absolute nonsense, yet it's a very common feeling among many medical professionals, due to the hyperbole around risks in women of size. Some have been taught that fat women are at SUCH a high risk that they have come to believe that fat women can't possibly have a healthy pregnancy or a healthy baby, and that's simply not true.

Many of us DO have healthy pregnancies and healthy babies, and it is NOT an irresponsible act to have a baby at a larger size.

Yes, women of size are at increased risk for some complications, but being at increased risk does not mean that complications will happen, nor does facing potential risk disqualify you from motherhood.

All kinds of women are at increased risk for complications due to various factors (age, family history, racial or ethnic status, various health conditions) but usually are not told that they have "no business being pregnant." Their risk status is acknowledged and counseling toward risk mitigation is given. The same can be done for women of size.

In dealing with women with risk factors, the focus should be on helping them have the healthiest pregnancy possible, even while acknowledging possible complications. Many caregivers are mature enough to recognize that plenty of women will have perfectly fine pregnancies and healthy babies despite having risk factors.

And in those who do experience complications, mature caregivers realize that the emphasis should be on kind and empathetic care in helping the woman towards the best possible outcome, not on scolding and judgment.

Although I'm sure there are women with various other risk factors who have faced reproductive policing, most of the time these days it's considered wrong to question a woman's basic right to motherhood, even in a mother at risk for complications. Yet reproductive policing and shaming seems to be considered acceptable behavior in the medical community towards "obese" women.

Sorry, but NO ONE has the right to forbid reproduction. The government, medical authorities......history has shown time and again that these people should NOT be the gatekeepers of reproduction. Whether to have a baby is a decision for the woman and her partner to make and no one else.

Couples should be counseled (with compassion, not scare tactics) about their risk status and possible complications, yes, but if they decide to move ahead anyhow, they should be treated with respect.

The ability to reproduce is one of the basic rights of people in society; the state and/or medical caregivers have NO business trying to govern that. 

Nor should women be subject to shaming or scolding for the simple act of wanting to have a family. 

That applies just as much to women of size as well as to women in any other group.

Tuesday, February 4, 2014

Supraumbilical Incisions Associated with Greater Risk in Obese Women

Here is yet another study showing that vertical incisions (supraumbilical, in this case) results in suboptimal outcomes, even in "morbidly obese" women.

To review, doctors have assumed for many years that vertical (up-down) incisions would lessen the risk of infection and wound complications in very fat women by avoiding an incision in the moist area underneath the belly. This was based more on assumptions than on real evidence, but it was taught as a medical truth for many years.

However, a number of recent studies have shown poorer outcomes with vertical incisions, showing the need to re-evaluate this medical teaching. Yet some doctors still believe and promote that a vertical incision is necessary in high-BMI women.

New Study

This study reaffirms (yet again) that vertical incisions do NOT improve outcome. 

It found that women who had a supraumbilical vertical incision experienced more blood loss, longer operating times, and nearly 25 times the risk of a classical cesarean, which is a far riskier uterine incision with long-lasting implications for future pregnancies.

In addition, the study showed that doing a vertical incision did NOT reduce the risk for infection or other wound complication. In fact, although the difference did not rise to statistical significance (probably because of the small sample size), there was a clear trend towards more wound complications in the group with the vertical incision (19% vs. 8% in the horizontal incision group, a 2.7x risk after adjusting for confounders).

Discussion of Cesarean Incision Research

Many providers are catching on that vertical incisions generally result in poorer outcomes, even in the most obese women. I'm happy to report that there seem to be fewer women of size being pushed into classical cesareans purely because of weight, and that more educational institutions are teaching that low transverse (side-to-side) incisions are preferable in most cases, regardless of the woman's BMI.

Sadly, though, there are still some stubborn hold outs who insist that very obese women "need" a vertical incision, and some educational institutions and materials are still promoting this approach.

And it's important to note that even though fewer providers are using vertical incisions in obese women now, about 1 in 10 to 1 in 15 obese women having a cesarean are still being subjected to a vertical incision.

This flies in the face of the fact that the vast majority of research clearly indicates that vertical incisions carry more complications and often result in the risky classical uterine incision that has tremendous short- and long-term health implications for the mother. 

Furthermore, research on vertical versus horizontal incisions in non-maternity abdominal incisions confirms the general superiority of horizontal incisions.

Some recent researchers are resisting the move towards low transverse incisions in women of size. They have claimed that the evidence is not yet conclusive on whether vertical or low-transverse incisions are better. They point out that most study samples are not randomized and do not rise to the "gold standard" research that is most desirable, and that some studies have not found a statistical difference in wound complications between incision types.

While the call for gold standard research is a legitimate concern, there have been enough studies that have found worse outcomes with vertical incisions that they should be curtailed while we wait for the results of a randomized controlled study. (There is a randomized study currently being conducted but it won't be finished for several years yet; if we wait until this study is finished and published before changing policy, many more high-BMI women will likely suffer major wound complications and associated morbidity by being subjected to vertical incisions in the interim.)

It's true that a few studies (like the one discussed today) have not found a statistical difference in wound complications between vertical and low-transverse incisions. However, if you read the full studies more closely, all found a strong trend towards worse outcomes in the vertical group. These differences simply did not rise to statistical significance because of the small sample sizes involved, not because results were truly equivalent.

It's also important to point out that not a single study has found improved outcomes with vertical incisions. If vertical incisions really resulted in superior outcomes, that trend would be clear, and it most definitely has not been. Instead, the trend is markedly in the other direction and only fails to be clear because of the small sample sizes in some studies.

Clearly, more research needs to be done. But in the meantime, considering the strong trend in the existing research, vertical incisions should be reserved only for times when it is truly medically indicated (certain placental presentations, certain fetal positions, extremely emergent situations, etc.).

Bottom line, vertical incisions should NOT be done routinely simply because a woman has a high BMI.

It's time for all the educational institutions and clinicians to acknowledge this and adjust their teaching and practices accordingly.


Reference

J Pregnancy. 2013;2013:890296. doi: 10.1155/2013/890296. Epub 2013 Nov 20. The effect of cesarean delivery skin incision approach in morbidly obese women on the rate of classical hysterotomy. Brocato BE1, Thorpe EM Jr1, Gomez LM1, Wan JY2, Mari G1. PMID: 24349784 (Free full text can be found here.)
OBJECTIVE: To assess the risk of classical hysterotomy and surgical morbidity among women with a body mass index (BMI) greater than 40 kg/m(2) who underwent a supraumbilical incision at the time of cesarean delivery. METHODS: We conducted a retrospective cohort study in women having a BMI greater than 40 kg/m(2) who underwent a cesarean delivery of a live, singleton pregnancy from 2007 to 2011 at a single tertiary care institution. Intraoperative and postoperative outcomes were compared between patients undergoing supraumbilical vertical (cohort, n = 45) or Pfannenstiel (controls, n = 90) skin incisions. RESULTS: Women undergoing supraumbilical incisions had a higher risk of classical hysterotomy (OR, 24.6; 95% CI, 9.0-66.8), surgical drain placement (OR, 6.5; 95% CI, 2.6-16.2), estimated blood loss greater than 1 liter (OR, 3.4; 95% CI, 1.4-8.4), and longer operative time (97 ± 38 minutes versus 68 ± 30 minutes; P < .001) when compared to subjects with Pfannenstiel incisions (controls). There was no difference in the risk of wound complication between women undergoing supraumbilical or Pfannenstiel incisions (OR, 2.7; 95% CI, 0.9-8.0). CONCLUSION: In women with a BMI above 40 kg/m(2), supraumbilical incision at the time of cesarean delivery is associated with a greater risk of classical hysterotomy and operative morbidity.