Monday, March 30, 2009
Sharing Your Fears and Questions
However, first let me get some feedback from you. And please, I'd like to hear from as many of you as possible, regardless of your kid status. I want to hear from you whether you've already had kids or not, and whether or not you even plan to have kids.
When you think about the possibility of having a baby (or parenting) at your size, what are your biggest worries, your deepest concerns? What would you most like to see me address here on this blog? What information do you most need?
Let Me Hear From You, Regardless of Child Status
Obviously, readers on my site tend to fall into several categories.
Some haven't had kids yet and are reading here to get more information about "obesity" and pregnancy and parenting. These folks are the primary ones this series would be aimed at, but I don't want to limit it to just them.
I also want to hear from those of you who have had kids, to share what you were most afraid of beforehand, what you think is most important to pass on to those who haven't had kids yet, and to share your continuing struggles with parenting and childbearing and all that entails.
And I want to hear from those who are undecided about having kids, and even those who are sure they are not going to have kids. Your perceptions about pregnancy and parenting are valuable too. Even if you never put this information into practice for yourself, it's still important to hear your own assumptions and concerns so I know what to write about, and to make sure you get accurate information too, even if you personally don't use it.
I also have readers of average size who are involved in the birth world in some way, as birth workers (midwives, doctors, doulas, lactation consultants, childbirth educators, birth advocates) or as parents. Part of the mission of this site is to address the concerns of these folks too.
So here's what I'd ask each one of these groups.
If you haven't had a baby yet:
What worries you most about the thought of pregnancy, birth, parenting? Medical complications, social complications, raising a child in a fat-phobic world, what?
Where does the concern come from....media hyperbole about the risks of "obesity," scare tactics from your doctors, internalized fat hatred, worry and guilt-mongering from your family, knowledge of someone who did have complications.....what are the sources for your concerns? What has you the most concerned and why do you think that is?
What could we do here to most alleviate your fears? What do you most want me to address on this blog?
If you already have children:
What were your biggest concerns, looking back? Were your concerns about pregnancy, about birth, about parenting? Why did you have those concerns?
How realistic were those concerns in the end? What concerns turned out to be no big deal? What blindsided you that you really didn't have on your radar? What are your continuing concerns as you parent your children now?
What would you most like to tell the women thinking about having kids but who haven't yet? What's your top parenting tip having to do with size/weight issues? What do you most want to see me cover on this blog?
If you aren't sure you're going to have children (or even if you're totally sure you're not):
What do you know (and what don't you know) about pregnancy and birth? What would be your fears if you were to go through this as a person of size? What would you most want to know to tell a beloved fat friend or relative about pregnancy, birth, adoption, or parenting?
Remember, you never know for sure whether you're going to have to deal with these issues. About half of all pregnancies are not planned. Surprises happen. Or there's a death in the family and you suddenly need to take in your sister's kids. Or you fall in love with someone who has kids and suddenly you are a step-parent. Or you have the opportunity to do some size-positive mentoring of someone else's kids....nieces, cousins, god-children, friends of the family, whatever.
Life happens, and plans change sometimes. It's important to have this information even if you don't really know if you personally are going to need it.
And even if you are positive you won't/can't/aren't going to have children, discussing the fears and concerns that you would have had is helpful to me to know what sort of things people worry about the most, the kinds of things that most need to be addressed on this blog.
Also, discrimination against women of size in pregnancy, birth, and parenting is an important issue for everyone, regardless of their own plans. Even if this discrimination doesn't personally affect you, you should still care about it, be informed about it, and work against it.
If you are a person of average size and involved in the birth world:
What concerns would you have for a woman of size in pregnancy, birth, or breastfeeding? What worries or concerns do you have for them in parenting? What would you most like your co-workers in the birth field to understand about women of size?
What would you most like to see addressed about "obesity" issues in this blog to benefit other birth workers and advocates?
What I Am Looking For
I particularly want to hear about fears and worries that are particular to people of size.
Everyone out there worries about the usual concerns.....will the baby be healthy, will I be a good parent, how do I combine a career and children, how will this impact my marriage, how will I afford children, etc. etc. Those are definitely important worries too, but certainly not unique to people of size.
What I particularly want to hear about are the specific concerns you might have about pregnancy and parenting as a person of size.
These might include fertility concerns, worries about birth defects, worries about complications in pregnancy, worries about birthing in a larger body, worries about size bias from healthcare workers, worries about parenting children in a fat-phobic world, worries about keeping up with your kids, worries about your kids being embarrassed by your size, worries about your kids being fat too, worries about finding the right balance between promoting health for your kids but not pushing eating-disordered behavior, worries about dealing with "obesity" bias from other parents, teachers or doctors......things like that.
Of all those things (and any others that occur to you), what is most on your mind as you consider the possibility of having kids, whether or not you actually end up having them? What kind of information on addressing fears and questions about pregnancy, adoption, and parenting would you most like to see on this blog?
Hearing from you will help guide me in knowing what is most on people's minds, on what I most need to address, and perhaps in what order I should consider writing this stuff.
Before I start this series, I do have to add a few caveats.
Remember, I'm a busy mom of four who wears a number of other hats besides parenting. I have a lot of demands on my time and can't always devote the hours I'd like to my writing. Also, I prefer to cite research whenever possible to back up what I'm saying, and that kind of writing takes quite a bit of prep time.
Therefore, this will be a periodic series, not a sequential one. I'll do a couple of posts on some common concerns, then take a break and talk about other things. Then in a while, I'll do another one on common worries, then take another break, etc. I'll get to all your needs, sooner or later, as best I can.....but sometimes it may be later than sooner. Don't expect all the answers tomorrow, okay?
Also, obviously I can't promise to have all the answers either. I'm not a medical professional or a parenting guru, and I'm still learning and formulating my own answers. Frankly, I still struggle with some of these worries and questions too, especially the parenting ones.
But I think it's important to open up a dialogue and talk about these issues more, and not just with people who already have parenting down to a science. Maybe we can figure out some of this stuff together.
One thing I've learned in my own journeys is that the first step to working through fears and worries is to name them, talk about them, and share them with others.
Doing so takes away some of the power of the fear or worry, some of the stigma around it, makes it more approachable. Name it and why it worries you and you can develop a proactive plan to deal with it.
Examine your pre-conceptions and assumptions and see what they have to teach you and where you can still do some learning.
Then reach out for new information, review where you were right and wrong, and develop a proactive plan to deal with your concerns. Continue to question everything as you move along your journey. Stay flexible so you can meet each new challenge with grace and creativity.
Share your learning and your process with others, to help them on their journeys too.
Remember, sometimes there may not be easy answers to every question. Sometimes we just have to figure things out as we go.
But let's start a dialogue as a first step in that process.
I look forward to hearing from you.
*Please feel free to comment anonymously if you prefer, or even privately by email. Sometimes it's easier to name your darkest or "silliest" fears if you do it anonymously. All your fears deserve hearing; feel free to do it anonymously if that helps.
Saturday, March 28, 2009
ICAN Conference in Atlanta in April
You can find a description of many of the sessions here, and a schedule of your choices here. You can register for the conference here. (If you register before April 3rd, you avoid the late registration fee!)
- Dr. Sarah Buckley (Australian doctor and author of Gentle Birth, Gentle Mothering)
- Pam England (midwife and author of Birthing From Within)
- Joni Nichols (midwife living in Mexico and helping to run a progressive birth center there)
- Eugene Declercq (professor of maternal and child health and Assistant Dean for Doctoral Education at Boston University School of Public Health)
- Dr. Stacey Kerr (doctor and author of Homebirth in the Hospital)
- Steve Buonaugurio (father and filmmaker of Pregnant in America)
- Susan Jenkins (Legal Counsel for The Big Push for Midwives Campaign)
- Ruth Ancheta (author of The VBAC Sourcebook and The Labor Progress Handbook)
- Susan Hodges (founder and president of Citizens for Midwifery)
Maternal Mortality and Morbidity in the US (Eugene Declercq)
Eugene Declercq, one of the most impassioned and forthright advocates for improving mother baby health in the USA, breaks down the numbers and gets to the heart of why and how the United States is failing mothers and babies so miserably. Declercq makes it easy to understand the numbers and energizes birth activists towards our goal of providing evidence-based care to all.
Undisturbed Birth: Mother Nature's recipe for safety, ease, and ecstasy (Sarah Buckley)
Australian family physician and homebirth mother of four Sarah J Buckley MD brings her celebrated blend of science and wisdom, explaining in this lecture how the "ecstatic hormones of undisturbed birth" (oxytocin, beta-endorphin, epinephrine and norepinephrine and prolactin) are designed to enhance ease, pleasure and safety for mother and baby through labor, birth and beyond. She also explores how common obstetric interventions -- epidurals, Pitocin, cesareans and even close observation of mother and baby -- interfere with this delicate hormonal orchestration, and can compromise ease and pleasure, and sometimes safety, for mother and baby.
Birth as a Hero's Journey (Pam England)
The hero’s (or heroine’s) journey is so deeply engrained in human psyche, every one resonates with it. Many women spend years, sometimes a life-time, feeling victimized and judged by what they experienced in childbirth. These wounded women seek to make sense of what happened and to find their way home, the final phase of the hero’s journey. When mothers, both expectant and postpartum, identify with the hero’s journey, their birth story and their lives change.
Healing the Wounds of Birth (Sandy Jones)
Giving birth can be deeply fulfilling, but it can also be profoundly wounding -- especially when a mother feels robbed of her birth experiences by an unexpected intervention or distressing outcome. This session sheds light on the emotional pain and loss experience of an unanticipated birth event, its effects on mother-baby and couple bonds, and it explores potential avenues for healing.
Respectful Cesarean (Joni Nichols)
When a cesarean becomes necessary, this sacred moment must still be considered a family-centered celebration. The physical wound is hard enough...we don’t need to leave emotionally wounded women in their wake! How can we achieve this? We need a calm and tranquil atmosphere in the operating room, a mother-to-be with the person (or people!) she wishes at her side, immediate physical contact between mother and baby, continued contact during the remainder of the surgery, and a desire and attitude on the part of the professionals present to be of service to the new family. Think this is impossible? Come and see where these ideas have become realities.
Pregnant Fathers In America (Steve Buonaugurio )
Buonagario will discuss the role of fathers during the birth of their child, how men impact their wives' birth experiences, and how men can be active in creating birth experiences for their wives that empower them.
The Role of the Father in Preventing Cesarean (Rose St. John )
Fathers, once banned from birthing, now thrust into the role of “coach”, are so often put into a situation that inevitably leads to feelings of frustration or failure. Rose St. John uses her experience assisting couples to find their way to a better birth, and addresses the other half of the birthing team and his unique needs. Fathers, partners, mothers and anyone else involved with birthing couples will gain helpful tools to use at births.
Homebirth in the Hospital (Stacey Kerr, MD)
As a physician with strong roots in midwifery, Dr. Kerr is a passionate advocate for childbirth practices that are not only safe but also empowering. Although homebirth is a viable option for many, there are women who do not want to deliver their babies in their own homes. But why should these women be given the message that their bodies are not to be trusted? Can't they birth a baby without unnecessary medical technology and interventions?
Empowering Girls and Women to Love Themselves Promotes Healthy Birth Practices (Pam Chubbuck)
Due to medical, societal, and psychological forces, women are losing their natural ability to give birth joyfully. Women’s self-confidence is eroding as fast and as much as they are told that all childbirth is dangerous enough that it must be regulated by medical procedures all the time. This discussion will cover what happens psychologically/physically during the formative years to stunt girls’ energy to be themselves, what happens to literally change their bodies – so they do not have the energy to do what nature intended - to grow to be women powerful beyond measure, healthy, self confident and wise. Preparing girls to be strong healthy women is foremost in preventing disempowering experiences later on in life. We will also discuss how to heal after negative experiences, and inspire women to start teaching their daughters to be healthy NOW.
There are many other great sessions too; in the interests of space we won't list them all here, but there are many other choices as well. In particular, there are a number of sessions on recovering emotionally after a difficult or traumatic birth, as well as on the politics of birth and birth choices. This conference has something for everyone, whether you are a mom, dad, doctor, midwife, childbirth educator, or doula.
If you are in the Atlanta area, this would be a conference well worth checking out. Even if you are not in the Atlanta area, this is a very worthwhile experience. People come from all over North America (including Canada and Mexico) to ICAN conferences, and sometimes from all over the world. It can be a very powerful experience for attendees, whatever walk of life they come from.
*ICAN is a nonprofit organization whose mission is to improve maternal-child health by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting vaginal birth after cesarean.
ICAN recently published the VBAC Ban Survey, which found that nearly 50% of American hospitals do not allow access to Vaginal Birth After Cesarean (VBAC), and is working hard to change this.
Friday, March 27, 2009
While we were there, it was extremely crowded so I didn't have much chance for any meaningful swimming, alas. When things started to thin out a little, I struck out across the little kids' warm pool (it does have a semi-deep end where you can actually swim a bit) and just stretched my legs a bit.
On the way back from one of those "laps," I saw the life-guard, definitely a plus-sized girl, looking intently at a kid in the water just ahead. I looked closer, but wasn't sure what I was seeing. No one was underwater and drowning, but it looked to me like there was a kid there having trouble staying afloat in water too deep for him to touch bottom. He was trying to tread water but was working awfully hard and looking very stressed.
I was debating whether to grab him, just in case he was in trouble, but since he wasn't facing me straight on, I wasn't sure if he really was in trouble or not. I didn't want to just grab a kid I didn't know out of the blue for no reason, you know? Might freak him out. So I hadn't grabbed him yet, but I was going to ask him if he was okay.
Before I could, though, the lifeguard jumps in the pool and comes for the boy, gets him out of the pool and into the back area, out of sight. From the reaction of her co-workers afterwards, it does look like the boy was in real trouble and she just got to him before it got to the true emergency stage.
I was sorry I had hesitated in grabbing him; shouldn't have second-guessed my instincts. But really, I don't know if I realistically could have gotten to him first anyhow. Maybe, maybe not. Either way, the good news is that the kid was fine. Whew.
I saw the lifeguard in the staff's glass-walled supervision room after the crisis was over, sobbing her heart out. I think she was having the classic post-adrenaline reaction after a life-threatening crisis....you handle everything fine in the moment (while your mind is thinking ohmygodohmygodohmygodohmygod....) and then later, when the crisis is over, your body does the ohmygodohmygodohmygod thing too.
The supervising lifeguard, an older woman, spent quite a bit of time helping her through this. From another friend of mine (whose lifeguard daughter actually saved a drowning, under-the-water-about-to-die child), I gather this is a really common, normal reaction, especially the first time you save someone.
At the end of the "free swim" time, the lifeguard was back to clean-up duties etc. I made a point to go over to her and tell her what a good job she did and give her lots of kudos. She blushed but I think she was glad to have someone acknowledge her. She confirmed it was her first save and I told her that her reaction was very normal. She thanked me, we commiserated, and then we both went about our business.
But all night I was thinking about how proud I was of her, not only as a guard but also as a woman of size. You don't see a lot of plus-sized lifeguards....I've seen a few, but never any as plus-sized as she was (only mid-sized, but still bigger than your average guard by quite a bit). Obviously she was very fit ("despite" her size, I'm sure in some people's minds) and had passed all the qualifying stuff with flying colors because that swim center has its pick of guards who train there.
I was proud of her for not listening to the usual nonsense about fatness and fitness and letting it keep her from this line of work and from saving a life. And I was proud of her boss, for seeing beyond stereotypes and hiring whomever was most qualified without regard to size.
I'm sure most people, looking at her on the street, would not think she was fit enough to be an athlete, let alone save a life, but she was, and she did a great job. Brava to her!
And bravo to all the fathletes everywhere who don't let the naysayers keep them down.
Wednesday, March 25, 2009
Consumer Reports Quiz on Childbirth Interventions
Despite growing evidence of harm, many obstetricians and maternity hospitals still overuse high-tech procedures that can mean poorer outcomes for baby and Mom.Most hospital birth these days come with all kinds of high-tech interventions. The vast majority of women giving birth in the hospital now have the following interventions (and the rate for fat women is even higher):
- chemical induction of labor (or augmentation of contractions after labor begins)
- continuous electronic monitoring
- breaking the mother's waters artificially
- an epidural and/or IV pain meds
- forceps or vacuum extraction
- an episiotomy (cutting the vaginal opening wider)
- a cesarean section
The quiz really debunks their routine use and points out possible risks and side effects women may not be aware of.
Some Sample Questions
Here are a couple of my favorite questions from the quiz. They really speak to the two biggest steps towards cesareans that women make when pregnant......they see an OB instead of a midwife for their care, and they get talked into (or ask for!) induction of labor.
[If you want to lower your chances for a cesarean, that's two places to start right there....first, hire a midwife for your care instead of an OB, and second, don't induce labor unless there is a truly compelling medical reason, well-supported by research.]
True or False? An obstetrician will deliver better maternity care, overall, than a midwife or family doctor.[My note: That doesn't mean fat women; it means women with serious concerns like heart conditions, pre-existing diabetes, some autoimmune conditions, certain pregnancy complications, etc.]
False. Studies show that the 8 percent to 9 percent of U.S. women who use midwives and the 6 to 7 percent who choose family physicians generally experienced just-as-good results as those who go to obstetricians.
Those who used midwives also ended up with fewer technological interventions. For example, women who received midwifery care were less likely to experience induced labor, have their water broken for them, episiotomies, pain medications, intravenous fluids, and electronic fetal monitoring, and were more likely to give birth vaginally with no vacuum extraction or forceps, than similar women receiving medical care.
Note that an obstetric specialist is best for the small proportion of women with serious health concerns.
True or False? Induced labor increases the likelihood of Caesarean section in first-time mothers.I was also happy to see a question in there about VBACs! Yay!
True. The cervix may not be ready for labor. Other effects of induced labor include an increased likelihood of an epidural, an assisted delivery with vacuum extraction or forceps, and extreme bleeding postpartum.
True or False? Once you’ve had a C-section, it’s best to do it again.Click on the link to read their entire report, called "Back to basics for safer childbirth: Too many doctors and hospitals are overusing high-tech procedures." It's short but very good. I'll just end with a couple of pithy quotes:
False. Studies show that, as the number of a woman’s previous C-sections increased, so did the likelihood of harmful conditions, including: trouble getting pregnant again, problems delivering the placenta (placenta accreta), longer hospital stays, intensive-care (ICU) admission, hysterectomy, and blood transfusion.
The current style of maternity care is so procedure-intensive that 6 of the 15 most common hospital procedures used in the entire U.S. are related to childbirth.Can I hear an AMEN!!??!! So refreshing to hear this from a mainstream media resource!!
Although most childbearing women in this country are healthy and at low risk for childbirth complications, national surveys reveal that essentially all women who give birth in U.S. hospitals have high rates of use of complex interventions, with risks of adverse effects.
...When it's time to bring a new baby into the world, there's a lot to be said for letting nature take the lead.
Tuesday, March 24, 2009
Dealing With Blood Pressure Miscuffing Proactively
We've discussed measuring your own arm and using that measurement to know which cuff size you should use, and how to buy your own cuff if needed. We've shared some of our own miscuffing stories, and discussed how miscuffing seems to be particularly common in pregnancy and can lead to many unnecessary interventions if not caught.
Today, in the last of the series, we're going to talk about overcoming resistance from healthcare workers about miscuffing, and being proactive healthcare consumers if miscuffing occurs.
Miscuffing General Guidelines
Using the wrong blood pressure cuff size is actually pretty common. That's why it's so important to measure your arm size and know which cuff you should use. Basically, the guidelines are:
- if your arm is over about 13.4 inches (34 cm), you should be using a "large" adult cuff
- if your arm is over about 17.7 inches (45 cm) or so, you should be using a "thigh" cuff (although the cuff range in this size is less standardized and you should read the range on the side of the cuff each time)
- if your arm is over about 20.5 inches (52 cm), you need a special-order cuff size, which you can get from http://www.amplestuff.com/.
Research is VERY clear that fit is NOT the critical issue; length and width of bladder is.
Chances are that if you are significantly "overweight" or "obese" or if your arms tend to be larger/heavy, you probably need the large cuff. Supersized people often need the thigh cuff. So generally speaking, you can probably guess at your cuff size. But really, it's best to know your own arm size (in centimeters!) so you can be sure which cuff size you need.
Resistance from Healthcare Workers
Research from the latest NHANES survey of the American population showed that 42% of all men and 26% of all women aged 40-59 years (which is when hypertension often starts to show up) required large BP cuffs.
You would think that this would mean that doctor's offices and hospitals would routinely carry large cuffs and that healthcare workers would automatically get the larger cuff when needed, wouldn't you?
But no, miscuffing seems to be a pretty common experience among people of size. Anecdotally, many have more than one miscuffing story to share. It is probably more common than most medical authorities realize.
Unfortunately, it can be difficult to convince some healthcare workers to use the appropriate cuff, despite years of research on the topic. Sometimes this is just simple ignorance or improper training about the difference cuff size can make. Sometimes, though, the resistance goes deeper than mere misinformation or ignorance.
Some doctor practices don't own a large cuff in order to save money or because they haven't really thought the matter through. It's not that they are trying to discriminate; it's more a matter of cutting corners on a tight budget or simply not even thinking about cuff sizes.
[But frankly, if this is true of your doctor's practice, you should be questioning whether you should even be going there. A large cuff (and a thigh cuff!) should be standard equipment for every practice; if it's not, it shows the practice is not very aware of important issues for people of size. If you have a choice, find another, more size-friendly practice.]
Some healthcare workers will tell you that the large cuff is "broken" or "out for repair" or "can't be found." Sometimes this might even be true.....but often, it's an evasion to hide the fact that the practice hasn't bothered to buy a larger cuff, or to hide the fact that they are too lazy/busy to go find the larger cuff.
Mind, staff members are often overworked and very busy; hospitals in particular tend to understaff their wards these days. You can understand why an overworked nurse or medtech might not want to take the time to go find the large cuff or the thigh cuff hidden in some obscure cupboard somewhere.
But it doesn't matter. That's their job. They NEED to get the most accurate measurements possible because all your treatment decisions will be based on these numbers. Even if it is inconvenient, it is critical that they use the correct equipment for the job.
Sometimes medical workers will say things like, "cuff size doesn't make that much difference at your size," or "as long as the cuff goes around your arm it'll be fine," or "a forearm reading is just as good"----but none of these stand up under closer investigation.
Cuff size really does matter and often makes quite a bit more than a "couple of points" of difference.....sometimes it can make 50 points or more difference. And it's not whether the cuff goes around your arm, it's whether the bladder inside the cuff is the right proportion to your arm. Furthermore, while a forearm reading can do in a pinch, it tends to overestimate blood pressure and should not be relied on unless there truly is no other choice (and then only on an occasional basis).
All of these are merely excuses.....unacceptable excuses.....for trying to get away with using the wrong equipment. Don't let them con you into acquiescing; insist on the correct equipment for the job every time.
What If Miscuffing Happens To You?
If the wrong blood pressure cuff is brought out for you, the best thing to do is to politely refuse to have your blood pressure measured at all. You don't need to be confrontational about it since it's helpful to maintain a good relationship with the staff, but you do need to be politely firm about it.
Remember, invalid data on your permanent record is worse than no data at all. Insurance workers may determine your eligibility for life insurance or health insurance or other programs based on reviews of your medical files; a spuriously high reading may impact your ability to get insurance (or cause you to have to pay more). Better not to have a reading on there at all than to have a spuriously high one.
Taking a blood pressure is a medical test like any other, and you ALWAYS have the right to refuse a test. You don't give up your rights when you walk through that clinic door; you always have the option to decline testing.
Of course, no one is advocating that you avoid blood pressure readings, just that you make sure that the data is accurate.
If they do not have the equipment needed, you are completely within your rights to refuse such a test. Just tell them politely but firmly that you would be happy to have your BP taken....once the correct-sized cuff is located. Until the correct cuff is available, tell them you choose to exercise your right of informed refusal.
Documenting and Protesting Miscuffing Issues
What if a healthcare worker refuses to let the issue go? What do you do?
First of all, try to educate them. Most healthcare personnel are genuinely in the profession to help people and are open to learning how to better serve special populations. Educate them about the need for the proper-sized cuff and how much miscuffing can affect BP readings. It may simply be a matter of not realizing how much difference cuff size can make.
Most of the time, a little polite education and persistence will be enough to eventually bring about the right cuff for the job. However, sadly, occasionally personnel refuse to listen or even indulge in bullying or manipulative tactics.
Medical bullying is real, and occasionally healthcare personnel can get very unpleasant. Just remember that you cannot be compelled to take a medical test against your will. Keep telling them calmly but firmly that use of an incorrectly-sized cuff gives invalid data and you will be happy to have your blood pressure taken when they use the correct cuff.
Use the phrase, "I do not consent," because this phrase has a stronger impact with medical personnel. Also remind workers that patients always have the right to informed refusal of any medical procedure or test. Make it clear that you do not object to taking the blood pressure itself, but that you refuse to have it taken with incorrect equipment because it will result in invalid data. Offer to sign an "informed refusal" form if needed.
If this is not enough, you can ask to see the healthcare worker's supervisor and share your concern. Request that another worker be assigned to you; this kind of request is actually not that unusual and supervisors are often able to accommodate such a request.
Ask a friend or a loved one to act as spokesperson for you if you are feeling poorly or find it difficult to communicate effectively or assertively. Having another voice there can make all the difference in the world when you are ill or find it difficult to speak up for whatever reason.
If you still find that medical personnel are unresponsive, ask to see a Patient Advocate. Most hospitals have one. Tell them that you have concerns about your needs being met as a person of size. Share with them the importance of using a large blood pressure cuff, and about resistance you have met.
The job of the Patient Advocate is to help represent your needs and to advocate for them. Because they have a recognized voice and role within the institution, they often have a great deal of influence and may be able to get needs met that might otherwise get ignored.
Registering a Patient Complaint
Being firm and assertive sounds all well and good in principle, but realistically, it's not always easy to be assertive in these situations, especially when you are feeling sick and vulnerable. Many people (including me) have been bullied into taking the BP with the wrong cuff, despite our protests. What then?
Don't be a silent victim. Even if you have been "convinced," manipulated, or downright bullied into taking a BP with the wrong cuff, it's not too late to try and change that behavior for yourself and for others in the future.
Document the experience and write a letter of complaint to the healthcare worker's supervisor. Be polite, no matter how upset you are; calmly recount what happened and cite research that shows how undercuffing can inflate blood pressure. Close by giving them a clear way to meet your concern; ask them to make sure a large cuff and thigh cuff are available at all times, ask them to re-train their workers on the importance of correct cuff size, etc.
Often, medical supervisors will be very responsive to this type of letter. The trick is to be polite, document your concerns with corroborating research, and to give them a concrete course of action to remedy the problem. You can also encourage responsiveness by forwarding a copy of the complaint to insurance or supervisors further up the management chain of command.
I wrote a letter of complaint like this several years ago after the urgent-care experience I wrote about previously, where the nurse conned me into a "science experiment" to see "if the large cuff really made any difference or not" (it did; 50 points of difference, but the erroneously high reading was still recorded in my chart).
I wrote a letter documenting the experience and sent it to the supervisors of the facility and my insurance. The supervisors immediately apologized to me, promised that a large cuff would be purchased for the facility, and promised that the staff trained on the importance of its use. I've been back to that facility since then, and they indeed did have the correct cuff (and used it).
Because of that experience, I developed a handout that can be sent along with a letter of complaint, documenting blood pressure cuff size guidelines and citing research on obesity and cuff size. It is available on my website, here, and I have given permission for it to be used for this purpose. Feel free to make use of it if you need it.
Some fat people (especially women) may feel guilty about being assertive like this. After all, women are often raised with the idea that "good girls" are always polite, always please others, and never complain. Also, as fat people, we are often taught that we don't deserve good treatment, that our needs and desires don't matter, and that it's not our place to question medical authorities. Some have been taught to be too embarrassed by the size of their arms to draw attention to them by demanding the right cuff.
But think about it. They are asking you to take a test with improper equipment, the inaccurate results of which could ultimately result in harm to you. You are completely within your rights to refuse testing under these circumstances, to advocate for the proper equipment, and to complain if medical personnel are not responsive to your concerns.
Don't feel that improper blood pressure technique is too trivial to complain about; if personnel are using incorrect technique or equipment to take blood pressure, sooner or later someone is going to be harmed by that. The mistake needs to be pointed out and corrected.
You are doing yourself a favor by insisting on correct equipment, but not only that, you are doing a favor for every fat person who comes after you.
Step up to the plate and be ready to advocate if needed.
Friday, March 20, 2009
Blood Pressure Cuff Size and Pregnancy
When a too-small cuff is used, blood pressure readings are falsely elevated, sometimes by really sizable amounts. This can lead to medications and interventions that are unnecessary and which can carry significant side effects.
Blood Pressure Cuff Size And Pregnancy
In pregnancy, being vigilant about blood pressure cuff size is even more important, yet using the wrong cuff size (miscuffing) seems even more common in pregnancy.
Anecdotally, fat women report that obstetrics providers often don't carry the full range of cuff sizes and tend to be very cavalier about using the correct size, even more so than non-pregnancy healthcare providers. Even hospital labor wards don't always use the correct size consistently.
Yet it is particularly critical to have an accurate reading of blood pressure in pregnancy due to concerns about hypertensive disorders of pregnancy (like pre-eclampsia), which can be very serious indeed.
Unfortunately, many "obese" women are incorrectly diagnosed with BP issues and subjected to interventions like medications, inductions, and sometimes even unnecessary cesareans because of use of the wrong BP cuff size.
Hypertensive Disorders of Pregnancy/Pre-Eclampsia
Hypertensive Disorders of Pregnancy is one of the most common (and potentially serious) complications of pregnancy.
The term "hypertensive disorders of pregnancy" is an umbrella term used to cover a multitude of blood pressure issues that happen in pregnancy. The terminology for it varies a lot (toxemia, pregnancy-induced hypertension, gestational hypertension, etc.), but that's a discussion for another day. The main issue here is what is commonly known as "pre-eclampsia."
Pre-eclampsia is a rise in blood pressure after 20 weeks gestation in a previously normotensive woman, accompanied by protein in the urine. If it is accompanied by altered lab results (like elevated liver enzymes, uric acid, or low platelets), it becomes really serious.
Severe pre-eclampsia can become truly life-threatening to both mother and baby, sometimes very quickly, and is one of the leading causes of maternal mortality in the world. Thus, doctors take BP issues in pregnancy very seriously indeed, and with good reason.
Outside of pregnancy, a borderline BP number is not pursued that vigorously, but in pregnancy many OBs get nervous about even borderline blood pressures and often will start very aggressive interventions very quickly.
Furthermore, because "obese" women do tend to have higher rates of pre-eclampsia, doctors tend to be even more interventive with women of size at the first suggestion that there might be BP issues.
Therefore, it is extremely important for pregnant women of size to have accurate BP data....yet miscuffing seems to be particularly common in obstetrics.
As a result, pregnant "obese" women need to be particularly vigilant about checking cuff size.
My Anecdotal Stories
Sadly, in 3 out of my 4 pregnancies, miscuffing was an issue at some point or other. That's how common it is, especially in pregnancies of women of size.
Normally I am quite vigilant about cuff size, and during prenatals I always asked about whether they were using a large cuff.
However, during labor my mind was busy concentrating on coping with contractions and I didn't always ask about cuff size. As a result, at one point the nurse took my BP, became quite alarmed, and was about to initiate several big interventions as a result.
Luckily, I surfaced enough to ask if she had used the large cuff; she said she couldn't find it and it wouldn't make much difference anyhow. We fought about it for quite a while; she was really resistant to getting the larger cuff, and stated strongly that it didn't matter that much and we really needed to start these interventions sooner than later.
I became quite assertive and insisted she go get the large cuff. She huffed out (she was quite mad!) and finally managed to "find" one and re-took my BP.
It was totally normal, as my blood pressure had been throughout all my pregnancy.
During that entire hospital stay, very few staff members understood the importance of a large cuff, and many resisted the idea of getting one. Even when they were willing to get one, they often had trouble finding one, despite being in a hospital setting where they should be plentiful. The resistance to using the correct-sized cuff was considerable, both on an individual and institutional basis.
I managed to stave off the risky interventions that are standard with high blood pressure, but only because I knew about the importance of cuff sizes and was ready to be quite assertive about it.
In my second pregnancy and labor, I was extremely vigilant about checking on BP cuff size. Because I always asked and because my labor support people asked for me as well when I was preoccupied in labor, I did not have any cuff size issues in this pregnancy......until after the baby was born.
It was only postpartum that the cuff size issue arose....because I was doped out on drugs, post-cesarean, and my support people had gone home to get some sleep.
A nurse came in in the middle of the night to check on me and take my vitals. I was so wiped out and groggy from drugs I didn't bother to ask about cuff size. She took my BP and commented that it was really up.
[It is unusual....but possible....to have normal BP throughout pregnancy and all of labor, and yet still develop pre-eclampsia after the baby is born. That's why they are careful to monitor BP throughout the postpartum period too.]
Fortunately, I surfaced enough to ask whether or not she had used the large cuff. She said no, it was broken, and it didn't really matter that much anyhow. It's a little blurry now but I think she told me I wasn't fat enough for it to be that important anyhow, that the regular cuff fit around my arm just fine.
I think I pointed out that it's not whether the cuff fits or not, it's the size of the cuff/bladder in proportion to your arm size that makes the difference, and that she needed to get the larger cuff.
At that point, she got really snotty. She asked me where I had gotten my medical degree from, implying that she was the medical professional and I was just a lowly ignorant patient, and what did I really know about it anyhow.
[This is typical of medical bullying; when you don't do what they want you to do, they bring out the old "*I* am the medical professional and know more than you," and try to intimidate you into submission.]
I still insisted. She rolled her eyes and snapped that she had so many patients to check on, she couldn't take the time to go get the other cuff, yadda yadda. I still insisted. She was pissed.
Eventually, she did come back with a larger cuff she somehow "managed" to find....and of course, my blood pressure was just fine.
In this pregnancy, I wanted to avoid the hospital and OBs from the get-go. I chose a homebirth midwife, but she did not own a large BP cuff.
She had not attended many women of my size before so she was not fully familiar with the importance of a large cuff, but she was very open to learning about it from me. We both agreed we needed to have accurate readings to make sure I stayed low-risk enough for a homebirth. I was nearing 40 at that point and the risk for blood pressure issues goes up with age, so even though I'd never had an issue with blood pressure before, we still needed to watch carefully in this pregnancy. After listening to the evidence, she agreed that a larger cuff would be important.
It's been quite a while so I'm a bit hazy on the details of how we got one, but she either bought one or we managed to borrow one. Either way, we managed to find a way to get a large BP cuff so we could have accurate readings.
Fortunately, my BP stayed normal throughout the pregnancy, despite my age. But if I had not been so familiar with cuff size issues, she would not have known that it was so important for someone of my size and I probably would have gotten risked out for no good reason. Luckily, she was open to learning about it.
I did transfer to the hospital during that labor and had my VBAC in the hospital after all. Fortunately, I never had an issue that time with cuff size at the hospital. I always asked, and they either always had the right cuff already, or were willing to go get it without arguing about it. That was a refreshing change!
This was the only pregnancy that I did not have cuffing issues. I selected a homebirth midwife for this pregnancy (a different one than with #3), but because she is a woman of size herself, she knew about the importance of a larger cuff and already owned one.
I can't tell you what a relief it was to just sit back in prenatals and in labor and know that I didn't have to be so constantly vigilant about blood pressure cuff sizes! She not only had the proper cuff size, but she also knew how to take it properly in all the "little" details (which a lot of medical workers don't do correctly either.....things like having you seated with back support, legs uncrossed, raising the arm to the correct height, not talking to you while taking the BP, etc.).
My baseline BP was a little higher in this pregnancy because of my age (early 40s) but with the correct cuff we were able to document that it stayed normal throughout.
I had my home waterbirth after all and it was wonderful.
Other Women's Stories
I have collected stories on my website of pregnant women of size who were almost forced into immediate cesareans because of high blood pressure readings brought on by miscuffing. Here are two. (If you have additional stories, I urge you to submit them to me for documentation on my website.)
I came within an hour of having an emergency c/s at week 33 with my son. They even went as far to have the surgical resident (who would be assisting my regular OB) and the anesthesiologist speak with me. They were just waiting for my regular OB to get to the hospital and see me before they prepped me.
When he did come in and see me, the first thing he did was take my BP. When he reached for the BP cuff, he said, "Is this the cuff they're using to check your pressure with?" I said yes, then he went out and yelled up one side and down the other to the nursing staff about jeopardizing his patient and baby because they didn't use the large cuff. It made a huge difference! The readings went from [about] 180/104 to [about] 114/63. Surgery cancelled!
Usually I'm much more alert than that and demand the large cuff. I had requested it several times in the hospital and the nurses kept saying it didn't matter...[even after delivery] the jerks still wanted to use the small cuff!!!
And these are the stories of the women whose misreadings were discovered.
Having gone through two pregnancies with elevated BP, it became kind of crucial to me to have it done correctly.
When I was pregnant with [my daughter], I would have it done at my OB/GYN office, and have it either normal or slightly elevated. Then I would get to my perinatologist's office and have it skyrocketed.
The first issue was the cuff---until I insisted I get the right sized cuff (my OB didn't even own one, but I made sure the girl ran next door to borrow one from another doctor for each of my visits---the peri didn't have one and was the only doctor in the building).
The second thing was my OB always had me either sit in a chair and not speak while they did it, or they did it with me lying down. The peri always did it...on the exam table, legs dangling, no back support, while they were chatting with me. Finally, upon the recommendation of the peri, I got a unit for home. From that point on, I refused to let the peri's office do it. I would do it myself while I was out in the car, and bring them my reading.
Twice they suggested my OB take [my daughter] by c-section immediately due to high BP. Thank gosh my OB relied more on his own records than on the recommendation of the peri.
Oh, and I had to fight with the insurance company to get a large-sized cuff for my home unit.
How many "obese" women have been pushed into cesareans they didn't need because they were miscuffed and the error was never discovered? How many have had to get magnesium sulfate (good for pre-eclampsia treatment but it makes you feel like total crap) because they were miscuffed and the error never discovered?
Let's be fair; some women of size do truly experience pre-eclampsia and need these interventions as a result. You certainly cannot say that all fat women's experiences with pre-eclampsia in pregnancy have been spurious.
But because miscuffing is such a common mistake in women of size, chances are very high that some fat women have been diagnosed and treated in error. And because all of these interventions carry significant risks, that's a pretty big mistake to make, whether it's from ignorance or from laziness. It really highlights just how important cuff size is, especially in pregnancy.
Over the many years that I have been running my website on plus-sized pregnancy and reading stories from other pregnant women of size, this issue of blood pressure cuff sizes keeps coming up again and again.
Despite all the many years of research and training out there for medical professionals on the importance of the correct BP cuff size, miscuffing is consistently still a problem....both outside of pregnancy and in it. However, I have to say miscuffing seems particularly pervasive in obstetrics.
Because hypertensive disorders of pregnancy are a very serious potential complication of pregnancy and because the threshold for intervention is very low when a baby is involved, accurate blood pressure readings are particularly important during pregnancy.
This is even more critical for "obese" women, because many providers assume fat women are automatically going to develop pre-eclampsia anyhow, and because using the wrong blood pressure cuff is such a common error.
You would think that this would mean that attention to the proper cuff size would be particularly strong in obstetrics, but in reality, many women find that there is even less attention to it in obstetric offices and on labor wards.
Therefore, it's critical that pregnant women of size:
- know their own arm size (in centimeters!) and which cuff size they need
- ask about cuff size EVERY TIME blood pressure is taken in pregnancy, labor, or postpartum (and double-check the range printed on the cuff if they are borderline in size)
- train their partners and labor support personnel to ask about cuff size for them during labor if they are too preoccupied
- learn to be assertive about proper cuff size and not allow themselves to be bullied or dissuaded from the proper cuff
- consider purchasing their own cuff and bringing it to every appointment and to the hospital if they are supersized, borderline in arm size, or if they have very heavyset arms
Wednesday, March 18, 2009
Sharing Our Blood Pressure Miscuffing Stories
Yet many people of size report being miscuffed or having to argue about cuff size with their healthcare workers, even now. Why does this still happen?
For one thing, not all providers carry larger cuffs. Sometimes, clinics try to cut costs by not ordering larger cuffs, or they may not be aware just how strongly miscuffing can affect blood pressure.
Other times, larger cuffs are available but medical personnel simply do not want to go to the trouble of finding them.
This is actually distressingly common; I have had this happen to me numerous times in the last 15 years, and have heard from many other women of size who have experienced similar issues.
I have many stories about this, but let me just share a brief example of one here, and then I'd like to hear your stories.
A few years ago, I had gone to an urgent-care clinic for antibiotics for an ear and bronchial infection that had rapidly deteriorated; I wanted to get some quick antibiotics for it to keep it from getting worse before I could see my regular doctor.
While there, they of course wanted to take my BP. That's fine. As always I asked to make sure it was a large cuff; it was not. Therefore, I refused to have my BP taken.
I made sure they understood that the problem was not taking my blood pressure (which was usually normal); it was taking it with the wrong-sized cuff.
Didn't matter. They treated me like I had high BP and was just trying to avoid documenting that. (After all, I was fat and that means I probably had hypertension, right?) And oh, did the pressure ever start to just give in.
They told me the large cuff was "out for repair" and they had to use the regular one because they "had" to have something to write down in the records. I refused to have it done that way because I didn't want an artificially-inflated reading on my records.
They tried to tell me that the using the large cuff only made a few points' difference in BP and wasn't that important. I told them that it could make a very large difference indeed and continued to refuse.
They tried to tell me that as long as the cuff fit around my arm, it was fine. I pointed out that this was not true, that it was the size of the bladder inside proportionate to my arm size that was the real issue.
They tried to talk me into taking my BP on the forearm instead. I told them that this method was not that accurate and since it wasn't an emergency and my BP didn't have anything to do with why I was there (the ear/bronchial infection), I would not consent to that either.
Finally, in a stroke of genius, they appealed to my sense of science. They said, "Let's do an experiment and see just how much difference it makes. What's your normal BP; we'll compare that with the results we get from this regular cuff. Let's see whether it makes a lot of difference."
Being the foolishly gullible curious person that I am, I fell for it. (That was stupid. They weren't interested in the science at all, just in getting a reading that they could write down in my records.)
Long story short, my blood pressure was 50 points higher with the regular cuff; it was normal with the large cuff I had it taken with at another doctor's office the next day. But that inaccurately high reading is in my permanent record now, forever.
I have had several other experiences where healthcare workers tried to take my BP with the regular cuff. It's happened even in my regular doctor's office, which usually knows to use the large cuff with me. That's why it's so important to ask every time.
In addition, miscuffing was a problem for me in 3 of my 4 pregnancies. More on that soon....just want to point out that if it happened in THREE OF FOUR pregnancies (and fairly recent ones, too), it's a pretty darn common problem.
Research on the errors that miscuffing causes has been around for more than 25 years, and while miscuffing is less common than it used to be, it is still a distressingly frequent problem.
Healthcare workers get training in the importance of cuff size, but it routinely gets disregarded or forgotten over time. It is definitely something that people of size need to be on the alert for.
Do you have any stories of miscuffing? What happened? How did you handle it? If you complained, how did the authorities respond?
*Coming soon......miscuffing in pregnancy and why correct cuff size is even MORE important when you are pregnant.
Monday, March 16, 2009
The Importance of Blood Pressure Cuff Size
I've written about blood pressure cuff sizes on my pregnancy website before, but recent comments suggest to me that perhaps it's time I revisit the importance of blood pressure cuff sizes.
So today, we start a small series about the importance of the proper blood pressure cuff size. This is an important issue for fat people of any gender or situation, but it's particularly vital knowledge for fat pregnant women, as we'll explore in a later post.
Why Blood Pressure Cuff Size Is Crucial
The size of your blood pressure cuff is of critical importance in getting proper medical care. If you have your BP taken with the incorrect cuff, the result will be inaccurate and you may get inappropriate treatment.
- If you use a cuff that is too small, the resulting blood pressure reading will be too high.
- If you use a cuff that is too large, the resulting blood pressure reading will be too low.
Being off in either direction can have significant health implications.
For example, if they use a too-small cuff (undercuffing) and you are incorrectly diagnosed with high blood pressure as a result, you will be given strong drugs which may have significant negative side effects, yet without any benefits to offset these risks.
On the other hand, if your blood pressure is truly high and goes undiagnosed because they are using a too-large cuff (overcuffing), it can lead to damage to your blood vessels, stroke, and heart attack.
Either way, what is most important is to have ACCURATE data on which to make medical decisions.
Using the wrong cuff size (miscuffing) means that any readings you get are meaningless. Always insist on the correct cuff size before permitting a blood pressure reading.
Miscuffing is Very Common
Research demonstrating the importance of proper cuffing has been around for more than 25 years, yet it remains one of the most common medical mistakes made with people of size.
One classic study on the importance of correct cuffing was Maxwell (Lancet, 1982). This study examined "obese" people already diagnosed with high blood pressure, then re-took their blood pressure with the correct cuff for their arm size. They found that 37%----more than ONE THIRD!----of obese hypertensives were incorrectly diagnosed and actually had normal blood pressure.
Linfors (1984) found twice the level of high blood pressure in "obese" subjects with the standard BP cuff compared to the large adult cuff. Numerous other studies since then have confirmed that using a too-small cuff significantly overestimates blood pressure in "obese" people (sometimes called "Spurious Hypertension").
Of course, cuff size is not just an issue for fat people. A recent study showed that a "standard" cuff often underestimates blood pressure in very lean people; about 80% of the "lean" pregnant women in this study had their blood pressure underestimated with a standard cuff. Thus, many skinny folks may be told that they have normal blood pressure when in fact they have hypertension and are being untreated.
Correct cuff size is an important issue for people of all sizes, but experts agree it is particularly paramount for the "obese."
Typical Cuff Sizes
Do you know what your arm measurement is? You should. Go get a tape measure right now and see what it is. Measure at the mid-point of your arm with a flexible cloth measuring tape.
Once you have measured, memorize that number so you will have it at the tip of your tongue if a cuffing question comes up at an appointment.
If you can, measure it in centimeters because that's how BP cuffs are labeled. However, if you can only measure in inches, click here to help you convert your measurement. (Or do it yourself; multiply by 2.54 to convert inches to cm; divide to go the other way.)
BP cuffs typically come in three sizes--adult, adult large, and "thigh" cuffs.
The adult size is meant for an average-sized adult. The large cuff is meant for people with larger-sized arms (like men with very muscular arms, or "overweight" and "obese" people). The so-called "thigh" cuff is an even larger cuff which is used for supersized people or people who carry a lot of extra weight in their arms.
- Regular Adult Cuff: 27-34 cm, up to 13.4 inches
- Adult Large Cuff: 35-44 cm, 13.8 inches to 17.3 inches
- "Thigh" Cuff: 45-52 cm, 17.7 inches to 20.5 inches
Research differs on exactly when the larger-sized cuff becomes necessary, but the American Academy of Family Physicians states that if the arm circumference is greater than 34 cm (13+ inches or so), a larger cuff size is definitely needed.
Although most fat people will be served by an "Adult Large" cuff, some will need an even bigger cuff. This is the unfortunately-named "thigh" cuff. It's generally used on folks with arms larger than about 17.5 inches or so. Thigh cuff ranges vary a lot, but generally they top out at about 20.5 inches.
What if your arm is larger than that? Never fear, there are cuffs available for you, but they are a special purchase and not likely to be carried by a doctor's office. See below for more information on buying your own specialty cuff or on using forearm measurements instead.
Typical Cuffing Errors
The most common errors in blood pressure cuffing are:
- Using a regular cuff when a large cuff is needed. This error is extremely common; healthcare workers should know about the importance of this but often ignore it because they don't want to go to the trouble of getting a large cuff or because they don't believe it makes that much difference
- Using a large cuff for all obese people, even when a thigh cuff is really needed. Unfortunately, many healthcare workers do not know when a thigh cuff is needed
- Using a thigh cuff for "super-obese" people, even when the upper limits of the thigh cuff are surpassed. Unfortunately, many healthcare workers are not aware of the upper limits of the larger cuffs
If you arm is even remotely borderline, it's very important that you always look at the cuff size range printed on the side of the cuff. If you are not within the range listed or are very close to its upper limits, request a different size and don't let them talk you out of it.
Common Cuffing Questions
What if my arm is close in size to the cutoffs? Which do I use?
One of the most difficult cuffing questions is what to do if your arm measurement is on the borderline between two cuff sizes. In this situation, it is difficult to know which way to err. You don't want to use the larger cuff and miss some hypertension that truly needed treating; on the other hand, you don't want to be treated for something you don't really have either.
Research shows that the error rate begins to increase as you get close to the cuff size cutoffs. Sprafka found that blood pressure cuff sizes made a significant difference in the prevalence of hypertension, even among people who were marginally large and whose arm circumferences were right around the cuff cutoff of about 13 inches. They stated:
Using a cuff one size smaller than appropriate resulted in...[an overestimation of the prevalence of hypertension of] approximately 36%.
Generally sources suggest that you should err on the side of the larger cuff if you are truly borderline because the degree of error is significantly greater when a too-small cuff is used than when a too-large cuff is used.
Do I really need to check the cuff size every time I have my BP checked?
If you need a larger cuff, you need to check that they are using the correct cuff every time you have your BP taken. Never take it for granted, even if they've always done it correctly before.
However, you don't necessarily have to check the range printed on the side of the cuff every single time unless you are near the upper limits of the cuff size. If you are in the middle of the large cuff range, just about all the large cuffs will probably work for you. Just make sure they are using a large cuff.
But if you are borderline it all, it really behooves you to check the range on the cuff. This is because BP cuff sizes are not standardized. Each maker uses its own cutoffs; the numbers listed above are merely general guidelines. Although it's unusual, it is possible to go to one office and need a large cuff, yet need a thigh cuff with the same arm size at another office.
The bottom end of cutoffs for large cuffs (just over 13") tends to be pretty standardized, but the upper end is not. It can vary by quite a bit. Therefore, if you are closer to the upper cutoff between large and thigh cuffs (or at the upper end of the thigh cuff range), you will need to check the cuff sizes printed on the cuff.
Cuff sizes are usually printed right on the side of the cuff (in centimeters, of course). If you know your arm size in cm, you can easily see if you are within the range printed on the cuff. That's why it's so important to memorize your arm size.
What about forearm readings?
In a pinch or in an emergency situation, a regular cuff can be used on your forearm; this will give a general "ballpark" picture of your BP but has not been found to be accurate to the degree really needed for most non-emergent treatment decisions.
Graves (2001) notes that while forearm blood pressure readings are possible, "These readings are not usually performed as falsely higher diastolic blood pressure readings may be obtained."
A Brazilian study (2004) found that forearm blood pressure readings with a standard cuff tended to overestimate BP readings compared to upper arm measurements with an appropriately-sized cuff. Another recent Missouri study (2008) found a similar result.
Singer (1999) found that forearm readings were within 20 mm Hg of upper arm readings in the majority of people, which is not that significant in an emergency situation with non-pregnant people. However, a difference of 20 points can make a lot of difference in treatment decisions in pregnancy, or if a healthcare provider is trying to decide whether or not to put you on high blood pressure medicine when you are borderline.
Therefore, forearm BP readings should be reserved mainly for emergencies in which a BP is needed now, or for supersized folks whose arm size is over 50 cm but who do not have quick access to a specialized cuff.
Generally speaking, forearm readings should not be relied on for regular routine readings or for making non-emergent treatment decisions, nor should they be relied on for decision-making or interventions in pregnancy unless there is a critical emergency.
Buying Consistency: If In Doubt, Get Your Own
Even if you are in the mid-range of the large cuff (which should be routinely available in every medical office or facility), you cannot always count on the doctor's office or even the hospital to have the correct size blood pressure cuff, for it to be in working order, or for medical personnel to be willing to use it. Therefore, you might want to consider purchasing your own blood pressure cuff and taking it with you to each appointment and to the hospital.
"Supersized" people or those with heavy arms may particularly want to invest in their own blood pressure cuffs. While many offices carry large cuffs, not all carry a thigh cuff. If your arm is over 17-18 inches in circumference or you weigh significantly over 300 lbs., you might especially want to consider buying an appropriately-sized cuff of your own.
Undercuffing is chronic in these groups, as few healthcare workers realize when a thigh cuff is required. Sadly, even when they know a thigh cuff is needed, many don't bother to use it, even in very large people.
If your blood pressure is borderline, if your arm is very heavy, or if you are supersized, investing in your own cuff is probably a good idea.
Nowadays, a number of internet companies offer blood pressure cuffs for sale; be sure you only buy one with the correct size cuff for you. Don't just accept that the cuff size is "large;" you need to get the exact range because of the lack of standardized cuff sizing.
In addition, if possible, choose a cuff whose accuracy has been tested and validated. Many monitors out there on the market have not had their accuracy verified. Remember, you want accurate data on which to make your treatment decisions.
The internet company, Amplestuff, sells blood pressure cuffs in varying sizes (including sizes for arms over 20 inches). It is one of the only good sources for the very largest of cuffs. These cuffs attach easily to the blood pressure devices in most offices, and then accuracy is always at your fingertips.
Blood pressure cuff size is a critical issue in healthcare for people of size, yet despite years of research on the issue, miscuffing is quite common. Some sources suggest that up to 1 in 3 BP readings are miscuffed, and that the "obese" are particularly at risk for miscuffing issues.
If your arm is over about 13 inches, you need to ask about cuff size EVERY time you get your blood pressure taken. Even if the office routinely uses the larger cuff with you, you still need to verify cuff size; don't ever take it for granted that they are using the correct cuff size.
Blood pressure is a very important health issue. If you truly have hypertension, it really does need to be treated. However, these decisions need to be made on the basis of accurate data, and research is very clear that miscuffing is still a significant issue for fat folk.
Coming soon: Your chance to share your BP miscuffing stories, the heightened importance of BP cuff issues during pregnancy, and how to deal proactively with resistance from healthcare workers.
Thursday, March 12, 2009
Fat Women can VBAC
Nice to get some good news in the midst of all the doom and gloom stuff on how hard VBAC is to get anymore!
Because VBAC is so hard to get in the hospital these days (and particularly so for women of size) a lot of women are birthing outside the hospital in order to get a real shot at a VBAC. Of course, like anything else, this has its pros and cons, risks and benefits.....but so does birthing inside the hospital.
This mom chose to birth at home with a midwife in attendance. She gave birth in the water. Her other children were nearby, and her husband helped catch the baby. (Those are his hands you see in the picture.)
She wanted me to be sure to pass on that by many doctors' estimates, she'd "never" be able to VBAC....and yet she did.
She is a woman of size (about 250 lbs. pre-pregnancy), and some doctors won't let women of that size even have a trial of labor. Others will "let" you, but will try to convince you that your chances of success are very small because of your size, so best to just sign up for that repeat cesarean. Yet somehow, she managed to VBAC.
She is short and she had a big baby this time. She specifically wanted me to mention that, because the combination of short and fat and a big baby often will make doctors risk you out of a VBAC. And yet, somehow she managed to VBAC anyhow. (So did I, another short fat woman with big babies!)
She was told her pelvis was too small with her first baby (who was only 6 lbs., 14 oz), but both her VBAC babies were bigger than her cesarean baby. Somehow she managed to VBAC an 8 lbs., 3 oz. baby out of that "too small" pelvis, and this baby was even bigger at 9 lbs. 8 oz. So much for her small "deformed" pelvis.
Obviously, there are things that are more important than maternal size or baby size; fetal position is a critical part of the whole story. If the baby is in a poor position, even a small baby can have trouble getting through. If the baby is in great position, even big babies usually get through just fine. More on that in a future post!
For now, let's just savor the fact that despite a VBAC ban in half the US hospitals, despite the tremendous bias against fat women even trying for a VBAC, despite all the factors "working against" her in many docs' eyes.....she managed to VBAC.......and not once but TWICE.
FAT WOMEN CAN VBAC.
You can read her complete story on her blog,
Her cesarean story can be found here.
Her first VBAC story (a hospital transfer to a hospital......which banned VBACs no less!) can be found here.
Pictures of her second VBAC can be found here.
Monday, March 9, 2009
A History of VBACs and Cesareans in the USA
Several blog visitors have brought up questions about why the cesarean rate is so high now and why attitudes towards VBACs have changed over time.
So let's take a moment to discuss a simplified bit of the history of cesareans and VBACs (Vaginal Birth After Cesarean, pronounced "vee-back") in the USA.
The Days of Low Cesarean Rates
For most of the 20th century, cesareans were a rarely-used procedure, used only in truly life-threatening situations after all other options had been exhausted. The risks from the operation were so significant that doctors were very reluctant to use it without true need.
Doctors in the USA also followed Dr. Edwin Cragin's 1916 dictate of "once a cesarean, always a cesarean." They were very reluctant to do a cesarean on a woman because that usually meant that all her future children would also be born by a similarly risky operation.
They recognized that the decision for cesarean affected a woman's entire reproductive life, and also had other potential life-long consequences (scar tissue, bowel obstructions, damage to other organs, etc.).
For this reason, the cesarean rate hovered between 1 - 5% until about the 1970s.
Cesareans Become Safer
Over time, changes in technique and technology came about that made cesareans safer and easier. This was a good thing.
Antibiotics became common, cutting the risk of infection. Blood transfusions became available. Anesthesia improved greatly, and eventually, the development of regional anesthesia (via epidurals and spinals) decreased the risk of complications over general anesthesia (where the mother is unconscious).
Surgical techniques also improved. Instead of doing "classical" vertical incisions (up-down incisions, from belly button to pubic bone), doctors began using a low-transverse incision (side to side, just above the pubic bone). Low transverse incisions caused less bleeding, were less prone to wound complications, and were less likely to rupture (come apart) in a future pregnancy.
This conversion from vertical to mostly low transverse incisions also made VBAC a safer choice to consider.
The Cesarean Rate Begins To Climb Rapidly
As technology improved and cesareans became safer, doctors started doing more and more of them. As you can see below, the cesarean rate rapidly increases between 1970 and 1988, until it reaches an all-time high (for that time period) of 24.7% in 1988.
- 1970 - about 5%
- 1975 - about 10%
- 1980 - about 16%
- 1985 - 22.7%
- 1988 - 24.7%
Of course, sometimes doing more cesareans was a good thing. For example, instead of risky high forceps deliveries (which often caused injuries to both mother and baby), cesareans became the delivery of choice. Birth injuries related to forceps declined. In that situation, cesareans probably were safer.
However, this also soon meant that even judicious low forceps use (which can help turn a poorly positioned baby and make vaginal birth possible) came into disuse. Vacuum extraction is now used instead of forceps most of the time, but it has its risks too, so many doctors prefer to go straight to surgery instead.
Generally it's a good thing that instrumental delivery has gone down, but along with the loss of this has come a loss of knowledge that mild positional issues can be resolved by any method other than cutting the baby out. For example, studies show that manually repositioning a baby can cut the cesarean rate dramatically, without the risks of instrumental delivery.....but few doctors and hospitals are being taught these skills anymore.
New technology such as External Fetal Monitoring (EFM) also increased the cesarean rate, but without improving fetal outcome in most cases. Despite this, EFM has become "standard of care" and continues to crank up the cesarean rate even today.
In time, more and more doctors saw the cesarean as the "go-to" choice for births they perceived as more risky, either medically or legally. More and more breeches began to be delivered by cesarean, and many babies suspected to be "big" were sectioned out. Mothers with any sort of complication became automatic candidates for a cesarean, even when other choices existed.
Even more influential in the meteoric rise in cesarean rates was the increased use of labor inductions (which strongly increases the risk for cesarean, especially in first-time mothers). Induction of labor allowed doctors to practice "daylight obstetrics" and have more reasonable hours, but the price was more surgery for the mothers and often, more intensive care visits for the babies.
As a result, there was an unprecedented explosion in the cesarean rate. This was quite controversial; many public health officials (including many doctors) decried the strong rise in cesareans and actively looked for ways to reduce the rate.
Others, however, began to be seduced by how convenient cesareans were for scheduling their time and also saw scheduled cesareans as a way out of the increasing risk of malpractice suits.
The debate over the "best" and "most optimal" cesarean rate began to rage and still continues today.
VBAC Becomes More Common
When the cesarean rate was only around 5%, the "once a cesarean, always a cesarean" dictum wasn't a pressing public health issue. But as the cesarean rate went up, that dictum became more of an issue.
If more and more women had primary (first-time) cesareans and all of them had to have repeats for every child, then the cesarean rate had the potential to expand at an unheard-of rate.
VBAC was seen by public health officials as one way to keep the cesarean rate from rising even higher. In addition, more women started questioning whether they had to have a cesarean for every single child. Although still controversial, VBAC became more and more acceptable as an alternative.
In the late 70s and the 80s, concurrent with the rise in the cesarean rate, US doctors finally began really researching VBAC, showing that it was a safe and reasonable choice. Still, there was quite a bit of resistance to VBAC at first, and women had to struggle to find caregivers who would "let" them VBAC.
Many women were told that they would "kill their babies" if they tried to VBAC, yet they heard through the grapevine that VBACs were more common in Europe, and that some U.S. practices were beginning to attend VBACs also. Women began pushing back, trying to make sure VBAC was available universally.
Out of this struggle, a grass-roots women's health movement began, pushing for more choices in childbirth. Women like Nancy Wainer Cohen, Esther Zorn, and Lois Estner pushed to make VBAC a choice for all women, while other pioneers like Suzanne Arms, Penny Simkin, Robbie Davis-Floyd, Sheila Kitzinger and many others pushed for reform of outdated childbirth practices like universal episiotomy, pubic hair shaving, mandatory drugging of the mother, prolonged separation of mother and baby, promotion of formula feeding over breastfeeding, etc.
The International Cesarean Awareness Network (ICAN) was born in 1982 (under a different name at first) and consumers finally had an organized voice demanding the right to choose VBAC. In 1983, Nancy Wainer Cohen and Lois Estner published Silent Knife, a book about VBACs that still remains a classic even now, more than 25 years later.
The power of the consumer to demand change began having an impact, and by the early 90s, VBAC was available in the vast majority of U.S. hospitals.
VBAC Management Began To Change
By the early-to-mid 90s, VBAC became the norm in many places, reaching its peak in 1996.
Research in the 80s had shown that VBAC was an eminently reasonable choice, so more and more hospitals and doctors began offering it. However, they knew from research that in rare cases, the uterine scar could separate in a subsequent pregnancy (uterine rupture), so they were very cautious in how they managed VBAC labors.
VBACs in the 80s were rarely induced, and pitocin augmentation of labor was done very conservatively and with great care.
This began to change in the 90s. As induction of labor became the norm in other labors, so it began to be applied liberally to VBAC moms.
Inducing VBACs became commonplace; many doctors believed that inducing early increased VBAC success (despite studies showing the opposite effect).
In addition, a new induction drug came along called Cytotec (generic name: misoprostol), which was cheaper and more convenient to use than other induction drugs. It was only after a number of years of use and some pretty horrible outcomes that it was "discovered" that Cytotec actually strongly increased the risk for uterine rupture in VBAC moms.
Although researchers still argue about it today, it's become apparent that inducing labor by any means also increases the risk of uterine rupture. Some induction methods increase the risk much more strongly than others, but all methods show some increase of risk over spontaneous labor. This is particularly true if the mother has never had a vaginal birth before, or if multiple induction agents are used. Cytotec in particular raises the risk of rupture strongly.
This routine induction of VBAC was the beginning of a crisis for VBACs.
Because VBAC in the early 90s was so mismanaged, by the late 90s a movement against VBAC was starting to take hold. There were several factors in this VBAC-lash.
Because vaginal birth is cheaper than major surgery, promoting VBAC was seen as a way to cut costs for insurance companies. Unfortunately, this meant that VBAC became required in some places, and some women were not given a choice about whether or not to VBAC.
This was the first step on the road to VBAC-lash, because not all women want to VBAC, nor are all women suitable candidates for it.
Some women were required to labor who had contra-indications for labor. Others were forced to labor in crowded hospitals with very inadequate supervision. Conditions in some places were so poor that even when signs of a rupture were obvious, the woman did not receive timely intervention. Other women were induced with dangerous drugs like Cytotec that had a very high rate of rupture.
As a result, some babies were lost, some babies were damaged, and some mothers lost their uteri. This was a tremendous tragedy, and those families were justifiably upset and well within their rights to sue.
Because more and more VBACs were induced, more and more cases of uterine rupture began appearing, more babies died or were harmed, and doctors and hospitals faced some spectacularly big lawsuits. This played a huge role in the VBAC-lash.
But instead of blaming the overuse of induction, mandatory VBACs regardless of suitability, and mismanagement of labor, doctors began saying that it was actually VBAC that was unsafe.
Now mind, research does NOT support this; if you examine the research carefully, the rate of rupture in spontaneous labor VBAC does not change over time. It remains around one-half of one percent on average; some studies show rates as low as 0.2% or even less.
The risk of serious, permanent harm to the baby or mother is even lower. Babies are at far more risk of dying from amniocentesis, a procedure that doctors do not hesitate to recommend.
Yet suddenly, VBAC was considered "too dangerous" because doctors were lumping all VBACs (induced and not, carefully chosen and not) together.
Right or wrong, doctors' perception of VBAC began to change, and they began to see it as tremendously risky.....both in absolute risk to the mother and baby, and in medico-legal risk to themselves. Many doctors decreased the number of VBACs they attended, and some doctors stopped offering VBACs at all.
By the very end of the 90s, there was a distinct downfall in the rate of VBACs, and after 2000 the rate really began dropping off.
The reason for this dropoff is that in 1999, ACOG issued new guidelines for attending VBACs, requiring doctors and anesthesiologists to be "immediately available" during a VBAC labor. This means the OB and the anesthesiologist had to be IN the hospital during a VBAC mother's whole labor. This was financially and logistically impractical, so more doctors quit attending VBACs.
A lot of smaller hospitals instituted official VBAC bans because they could not meet the "immediately available" guidelines. This has had a particularly significant impact on states with lots of rural or small-city hospitals.
Because there had been a few spectacularly high lawsuit awards, many malpractice companies raised rates for or refused to cover doctors who attended VBACs. Therefore, even some doctors who still believed in VBACs and wanted to attend them often felt like they could not afford to continue, or that their hands were tied by hospital and malpractice insurance policy.
Because of malpractice insurance issues, even some large hospitals with 24/7 surgical and anesthesia coverage also began to not "do" VBACs, or began to strongly discourage them.
Now the rate of VBACs in this country has dropped significantly, with many women essentially being forced into repeat cesareans, as documented in the recent TIME magazine article.
Currently, about 92% of women who have a prior cesarean undergo cesareans with all their subsequent children. This is about the same low level of VBACs as in 1986, just as the VBAC movement really started to take off.
We are not quite back to the days of "once a cesarean, always a cesarean" because about 8% of women with prior cesareans still do somehow manage to have VBACs in this country despite all the bans......but basically, we are almost there.
Yet a few voices of sanity still prevail. The authors of an 2006 Irish study on VBAC state:
The North American studies have highlighted correctly the risks of [rupture] in women who labour with a previous caesarean section. We are concerned, however, that obstetricians individually and collectively may have overreacted to their publication and that some have been too quick to revert back to a policy of ‘once a caesarean, always a caesarean’. This simplistic mantra may have been appropriate at the start of the 20th century, but our experience suggests that such a ‘one policy fits all’ approach may not be in the interests of both mother and baby at the start of the 21st century.Cesarean Rates Soar Again
Combine the anti-VBAC climate in the country with the fact that cesareans make more money for hospitals, more money (hour for hour) for doctors, and make the lives of doctors and hospitals incredibly more convenient, and cesareans in this country have truly become epidemic.
Doctors like to claim that the steep rise in cesarean rates in the USA is because maternal demographics are changing.....mothers are older, fatter, have more multiples, etc. However, careful examination of the research shows that cesarean rates are increasing for ALL women, regardless of risk profiles.
Another argument is that women are requesting all these cesareans and the poor doctors' hands are tied. But there is no convincing research that cesarean on maternal request plays a large part in cesarean rates.
Blaming the explosion of cesarean rates on the mothers just doesn't wash....the truth is it is physician practice patterns that are driving the rates.
Because practice patterns differ between doctors and hospitals, you have a much higher risk for cesarean in some hospitals than in others. For example, in New Jersey, some hospitals still have cesarean rates in the 20-36% range, but many hospitals now have about a 40% cesarean rate. This is becoming more and more common.
Some hospitals in New Jersey, California, and Florida have about a 50% cesarean rate, and there are more and more of these starting to appear. A few even have c-section rates as high as almost 60%......and the high cesarean trend shows no signs of abating.
Remember when public health officials got all up in arms in the late 80s because the cesarean rate had spiked to around 25%? Well, they did reduce it for a while (it dropped down to 20.8% by 1995), but now it has spiked again, even higher than it was then.
Only this time, almost no one cares.
Now the cesarean rate has soared up to over 30% nationally (the rate was 31.1% in 2006) and is still going up.
(The 2007 figures are due out from the CDC very soon....watch for them. Also watch to see whether the cesarean rate receives much attention in the media afterwards.)
Many consumer groups like ICAN are fighting this spike in cesareans, yet hardly a medical voice is raised against this out-of-control trend.
In some states (like New Jersey and Florida) the c-section rate is almost 40% already.
Now, at the end of the first decade of 2000, about one out of every three women in the USA has her baby surgically extracted, and in some hospitals that becomes ONE OUT OF EVERY TWO....or more.
And if you have that first cesarean, it has become extremely hard to find a hospital that will give you a realistic chance at a VBAC. We are not quite back to the days of "once a cesarean, always a cesarean" but we are getting darn close.
This is the sad and sorry state of birth in America. It can change, but consumers must take the first step and vote with their feet, away from the doctors and hospitals that practice so unsafely and unjustly.
*Graph is of cesarean rates from 1989-2003 only. Source found at: http://www.childbirthconnection.com/article.asp?ck=10554.