Sunday, October 25, 2009

Healthy Birth Practices: Walk, Move, and Change Position

We're talking about the Six Lamaze Healthy Birth Practices, taking each one in order, discussing why it's helpful and important, and then discussing why these practices are often discouraged with women of size and how that impacts their birthing and cesarean rates.

The second Healthy Birth Practice is:

2. Walk, move, and change position

Walking around, moving, and changing positions make labor and birth easier and more comfortable.

But far too often, women are stuck in bed during labor and birth with a fetal monitor and tubes all over the place and are no longer really able to move.

This needs to change---and nowhere moreso than for women of size.

Why It's Important To Stay Mobile in Labor

Watch a typical birth on TV reality shows and you'll see that most women who labor and birth in the hospital are stuck in bed. Although hospitals now allow more movement in early labor than they used to, by the time labor has progressed very far, most women are still flat on their back, semi-sitting on their behinds, or propped a little to one side. Very few are up and moving about. And even fewer push the baby out in any position other than semi-sitting with the knees pulled back or their feet in stirrups.

This reflects our modern medical culture's expectation that women should labor and birth reclining in bed, and this positioning is strongly encouraged by doctors because it is more convenient and comfortable for them to attend.

However, if you look at labor behavior in non-Western cultures, women tend to move around in labor a lot. They may labor standing, sitting, walking, dancing, leaning over, in water, or on all fours.

Some choose to give birth lying down in bed, it's true, but more often they birth upright in a standing, squatting or in a "supported squat" position (someone holding them in a semi-squat from above and behind).

Some women give birth leaning on a table or bed, or sitting on a special "birth stool" that keeps them semi-upright. Many homebirth midwives today have special birth stools that women can choose to use. Others create a birth stool-like position by having the dad sit on a chair, knees apart, and having the mother hook her legs over his knees.

Some women have a strong instinct to pull or push against something during labor, especially when pushing out the baby. They may give birth hanging onto a bar or dangling from a rope or a person's hands. This is not unlike the "supported squat" position mentioned above, only now the woman is supporting her own weight.

Some women find themselves pulled towards laboring or giving birth in asymmetric positions, such as walking up stairs, or standing/kneeling with one foot up and one foot down. Others "do the hula" and circle their hips a lot.

This lifts up one side of the pelvis and creates extra space for poorly-positioned babies to reposition and rotate more easily. If the baby has trouble negotiating its shoulders past the mother's pubic bone, some midwives think a kneeling lunge or the all-fours position is particularly helpful for resolving things.

Because it too helps create more space in the pelvis, many women are pulled towards laboring and birthing on all fours.

This is often helps lessen back labor, and may help turn a "sunnyside up" (posterior) baby to an easier position for birth. If the baby is large or its shoulders are a tight fit, this position may help them slip out more easily.

All of these positions are much more commonly seen in non-Western cultures, and also in non-technological approaches to birth here in the West.

Why do women birth in all these different positions? Cultural expectations play a part of course---but research shows that when Western women are given access to a room in which the bed is not the central feature and are encouraged to labor and birth as they feel most comfortable, most do not choose to birth lying down in bed either.

The reason that most women prefer to move around a lot in labor and birth is because it's physiologically sensible and logical. It helps them give birth more easily and more comfortably.

Their bodies intuitively tell them they need to move and so they do it. Even in high-tech medical model births where women are stuck in bed, many still try to move as much as they can, shifting in bed, rocking their bodies, turning to their sides, trying to arch their backs. In fact, women with an epidural may have better results pushing in a side-lying position than in stirrups because there is more mobility of the pelvis in this position. Yet it is often not even tried.

This is not to say that women should never give birth lying down or in the semi-sitting position. Actually there are times when lying down can help a baby get past the mother's pubic symphysis more easily, and of course, many women in the hospital do manage to give birth vaginally in the semi-sitting position despite its challenges.

It can be done--but most women, when given true freedom of movement, do not choose these positions for birth, and there are times when other positions probably facilitate birth much better than these. The point is that women should have the choice.

What Research Says and Why

Research shows that being more upright in labor shortens the first stage of labor (dilation of the cervix) and lessens the need for epidurals. Alternative positions may also help increase the pelvic space available for the baby

Gravity helps move the baby further down into the pelvis, putting more pressure directly on the cervix, which helps it dilate more quickly and evenly. Mobility also helps change the internal dimensions of the pelvis, creating a little extra room for a baby when needed. (This is a little like how, if your boot or your jeans are a bit tight, you wiggle back and forth to get into it anyhow.)

Lying on the back or in a semi-sitting position means that the tailbone basically gets pushed into the pelvic outlet, making the space available for the baby a little smaller. Because the woman is sitting on the bed, the bed prevents the tailbone from moving out of the way as the baby is coming out, and it compresses the pelvic outlet. When women give birth in more upright positions or on all fours, they often arch their back at the last moment, moving that tailbone out of the way and creating more space at the pelvic outlet instead of less.

Another concern with lying flat on your back or in a semi-sitting position is that it can compress the blood flow to the uterus, compromising baby's oxygen supply. In fact, doctors often warn women during pregnancy not to sleep or lie on their backs for too long---yet once the mother is in labor, suddenly this advice is no longer followed and women are left for hours in this position. Moving around freely keeps the weight of the baby and the uterus off of the blood supply to the uterus, and helps ensure a better continuous oxygen supply to the baby.

Movement is also the body's natural response to discomfort. Think about how people respond to pain in daily life. Animals in pain are often restless and move around a room. If you stub your toe, you hop about for a while until the throbbing subsides a bit. If you are too sick to move around a lot, you may rock back and forth to deal with the discomfort you are feeling, or shift position frequently.

Many women handle labor pain in the same way. Some relax deeply and become more motionless to handle labor pain, but many respond to labor pain by moving. They may shift position frequently, walk around the room, rotate their hips, push actively against the doorframe or wall, dangle from a squat bar or pull against someone's hands, or rock back and forth as they deal with the surges of labor contractions.

Being stuck in bed on your back makes it more difficult for your body to move in response to the pain and makes you more likely to need drugs for pain relief. Pain meds are not "bad" (and we can be glad they are an option when needed), but they do come with risks to the baby and the mother. It's much simpler and safer to reduce the need for pain medications by allowing the mother to move freely in response to her pain and her body's instincts, reserving the meds for when they are truly needed.

Furthermore, many women find that their bodies intuitively tell them how they "need" to move during labor and birth in order to best facilitate the descent and rotation of the baby through the pelvis. Many women feel the need to get up and move about, to go onto hands and knees, to lift one leg, or to arch their backs during labor. Often, well-meaning nurses discourage this kind of movement near the end of labor, seeing it as counter-productive to getting the baby out, when in fact it may be exactly what is needed to get the baby out. We simply need to respect women's instincts more.

This is not to say that mobility is absolutely forbidden in hospitals these days. There is progress from the past when many hospitals required women to lie flat for labor, using drugs and physical restraints in order to keep them immobilized. Many hospitals today recognize that movement in labor is beneficial and "allow" the mother to change positions, walk, use a birth ball, or even labor in water.

Many doctors will tell women that they can labor in whatever position they'd like---and the nurses will absolutely support that---BUT when it comes time to actually catch the baby, most doctors insist the woman be back in bed, semi-sitting, with her knees pulled back and her body curved into a "C" position.

Alas, this is only the best position for birth if you are the attending doctor. It allows the doctor to sit on a stool and catch the baby without discomfort. But it makes the mom essentially push the baby out "uphill," makes pushing both more painful and harder to deal with, and diminishes the pelvic space. How sad that the priority in hospitals today is on the comfort and convenience of the doctor, not the comfort, convenience, and health of the mother and baby.

The research on mobility during labor is summarized in the Healthy Birth Practice Paper: Walk, Move Around, and Change Positions Throughout Labor and its accompanying video:

When you walk or move around in labor, your uterus, a muscle, works more efficiently. Changing position frequently moves the bones of the pelvis to help the baby find the best fit, while upright positions use gravity to help bring the baby down the birth canal. The diameter of the pelvic inlet and outlet can increase as a woman moves around in labor....

Researchers who examined all of the published studies on movement in labor found that, when compared with policies restricting movement, policies that encourage women to walk, move around, or change position in labor may result in the following outcomes:
  • less severe pain,
  • less need for pain medications such as epidurals and narcotics,
  • shorter labors,
  • less continuous monitoring, and
  • fewer cesarean surgeries
In fact, no woman who participated in any of the research studies said that she was more comfortable on her back than in other positions. No study has ever shown that walking in labor is harmful in healthy women with normal labors....

Walking, moving around, and changing positions make labor easier and safer...Lamaze International encourages you to plan to be active throughout labor, to practice labor and birth positions during pregnancy, and to choose a care provider and birth setting that provide many different options for using movement.
Ah, and that is the key.

You must choose a birth setting and a care provider that not only "allows" but believes in the importance of mobility in labor and will do everything possible to help promote that.

Yes, "even" in women of size.

And therein lies the problem.

Mobility Restrictions Affect Women of Size Disproportionately

Even in hospitals that pay lip service to mobility in labor for other women, oftentimes "obese" women are not allowed the same freedoms.

In many hospitals, fat women are restricted to their beds--or if not outright restricted, strongly discouraged from moving about during labor. This is because of several erroneous beliefs or concerns about "obesity" and pregnancy.

Fear of Stroking Out

First, some care providers have the erroneous belief that all fat people have high blood pressure and are about to stroke out or have a heart attack at any moment. Even when a fat person's blood pressure is perfectly normal, care providers often believe that their high BP has simply yet to be unmasked and may well spike during the work of labor.

Because women with high blood pressure are typically kept relatively immobile in bed during labor, many doctors and nurses assume that fat women should be kept immobile in bed too, "just in case." But if the woman's blood pressure has been normal throughout pregnancy and is normal in early labor, chances are it will remain so, and keeping a woman of size immobile "just in case" is unnecessary and overkill.

Fetal Monitoring Issues

Another reason fat women tend to be kept immobilized is fetal monitoring issues. The baby of an "obese" woman is viewed as being at ultra-high risk for problems, so continuous electronic fetal monitoring (EFM) is often seen as obligatory in them, even in spontaneous labor with no drugs or pain meds (when EFM is usually not mandatory). This fear of problems for the baby is largely exaggerated, as the vast majority of babies of fat women do just fine--but in this litigious society, doctors tend to err on the side of interventions, even though continuous fetal monitoring has not been shown to improve outcomes.

Although theoretically, EFM should permit the woman to move around somewhat during labor, in practice it often means that the woman must lie still in bed in order to get an uninterrupted reading. Because women of size have extra adipose tissue that makes getting reliable EFM more difficult, they often have to keep extra still to get a reading.

Although telemetry (wireless) monitoring is available, it is usually not offered to women of size. Furthermore, because external EFM can be more difficult in women of size, an internal fetal monitor is often encouraged or even made mandatory for "obese" women in many hospitals. An internal monitor requires that the mother's waters be broken and a small electrode screwed into the baby's scalp. These wires go up into the mother's vagina, further restricting her ability to move around, and many women are told that once their water is broken, they are no longer allowed out of bed.

So external and internal fetal monitoring often are a big part of why women of size tend to have less access to full mobility during labor.

Fears of Falls and Worker's Comp Claims

Other reasons for restricting movement in women of size are fears about them falling, the strain on healthcare workers who might have to move them or help support their weight, and the financial burden of workers comp claims that might be filed as a result.

Although falls like this are quite uncommon in labor, the concern that a healthcare worker might injure themselves having to help a fat person is a common concern and has often been used to justify denying a woman of size access to waterbirth, to birth centers, and to movement during labor.

Barbara Harper, director of Waterbirth International, addresses the issue of denying fat women access to waterbirth based soley on BMI and fears of worker's comp claims. She says:

When I teach the professional Waterbirth Credentialing workshop, I do address waterbirth BMI restriction policies and insist that hospitals treat each woman individually...I implore them to look at pre-pregnancy activity levels.

I have been successful in having the BMI policies removed from some hospital protocols, but not in others.

There is no available scientific evidence one way or the other, with the exception that we did a search in both the US and the UK to find workers compensation cases for back injuries in labor and delivery settings. There were some, but none related to water.

Holding the leg of a 300 pound woman while she is pushing is much harder than helping her in and out of the bath.

Stereotypes about Strength and Mobility Levels

Many birth attendants also don't believe that fat women are strong enough or flexible enough to be mobile in labor. They don't encourage mobility because they've been programmed to believe that all fat people are unfit, weak, and sedentary, so why bother trying?

Unfortunately, these unconscious stereotypes about fatness also discourage medical staff from suggesting mobility and change of position options to their fat patients, most of whom could handle them just fine. Many fat women are far more flexible and fit than is commonly believed.


All of these factors combine to keep fat women in bed, on their back or semi-sitting, and strongly discouraged from moving around at all. Yet this may be the group that can most benefit from mobility in labor in many ways.

Why Mobility in Labor May Be Even More Important in Women of Size

No one has ever really studied mobility in labor in an "obese" population, so it's difficult to conclusively prove that mobility is important in this group. However, if it is helpful in women of average size, there is no reason to believe it wouldn't also be helpful in women of size.

Anecdotally, "obese" women who have had access to full freedom of movement during labor and birth usually report having fewer cesareans and fewer other problems compared to their previous births in which movement was restricted. (This was certainly true for me and a number of women of size I know from ICAN.)

Now, that's only anecdata at this point, but many women of size and their birth attendants find they achieve better results when they move freely and use non-traditional birthing positions. Waterbirth in particular seems to be VERY helpful to many women of size because the water buoyancy makes it easier for them to shift positions and maintain them with less stress.

One thing that many doctors worry about in fat women is the dubious concept of "soft tissue dystocia." Basically, this means that they worry that extra adipose tissue "down there" will make it harder for a baby to fit through easily. Many (in all seriousness) blame the higher cesarean rate in "obese" women on soft tissue dystocia (or "fat vaginas" as some doctors call it).

Ironically, almost no research has been done on "soft tissue dystocia" to see if it really is a valid concern or not, but doctors everywhere have been trained to believe it with every ounce of their being. A minor detail like lack of proof makes no difference. (I seriously doubt its validity as a real factor for fat women, but that's a whole 'nuther post.)

But let's pretend for a moment that soft tissue dystocia might be real, and that a fat vagina might reduce the pelvic space available to push the baby out. IF that were true (and that's a big IF), then mobility in labor would be even more important for "obese" women because it could open up the pelvic dimensions and give their babies a little more room to get out. It might make the difference between a cesarean and a vaginal birth, or a shoulder dystocia and a normal spontaneous vaginal birth. Every centimeter counts and mobility in labor can help add a little extra room that might make a difference.

And yet, fat women are the ones least likely to be given access to full mobility in labor. Ironic how the logic is so inconsistently applied, isn't it?


If you are pregnant, the most critical issue is to find a care provider and a birth setting that is supportive of you moving around as needed, whatever your size, and which will encourage you to labor spontaneously as much as possible (which will help you retain the ability to move freely).

Major red flags would be facilities that require or strongly encourage"obese" women to have constant EFM (especially mandatory internal monitoring), have BMI limits on access to waterbirth or other "alternative" modalities, or who assume that you will be induced and/or "need" an epidural because of your size. These are not birth settings where you will be encouraged to be as mobile as possible, and you are likely to have a higher risk for a cesarean under these conditions.

However, some hospitals and birth centers (and even homebirth midwives) talk a good game but
it's only lip service. In the end, some don't really support full mobility or spontaneous labor for fat women either. These have to be a little more carefully vetted because they can be wolves in sheep's clothing, pretending to be something they are not.

Tour the hospital and birth center and see just how many woman in labor are out walking the halls, ask how many use the tubs to labor in water, and how many have full mobility not only in labor but to actually push the baby out too. Ask your care provider what the weirdest position is that he/she has ever caught a baby in, and how often women in his/her care give birth in any position other than semi-sitting. Ask to interview former clients and see whether they felt they were encouraged to be truly mobile in labor.

If you observe carefully and ask a few open-ended but pointed questions, you'll be able to find the providers who truly support mobility and spontaneous labor instead of the ones who just give lip service to it. That won't guarantee you a better birth, of course, but it's a good step on the journey towards it.

Graphics from Wikimedia Commons or excerpted from (Many thanks to Janelle Durham for making these latter illustrations and information available freely!)

Monday, October 12, 2009

Oven-Roasted Tomatoes: Food of the Gods

I posted earlier about the over-abundance of produce my garden was making, and how puzzled I was at how some people turned their noses up at getting free fresh organic produce.

(Interestingly, that post got the most comments of anything I've ever written about on this blog. Fat people actually like vegetables....who knew, eh?)

Now, here we are at the end of tomato season, and I'm drowning in tomatoes. I'm giving them away right and left to those who are open to receiving, and I still have more. The weather is about to go bad so I know I'm on the last gasp of sun-ripened loveliness, so I hate to give them all away--yet I have more than I'll ever eat fresh.

Ah, but now I know what to do with them! I found the greatest recipe over the weekend, and OMG, is it good! It's so easy that I decided I have to share it here.

Oven-Roasted Tomatoes

Food of the Gods indeed. You have to try this.

As I posted about previously, I've been wanting to make my own spaghetti sauce with these tomatoes all summer, but I'm not an enthusiastic cook and I can think of a lot of other things I'd rather do with my time than stand around in a hot kitchen, tending 'maters.

My mother-in-law, bless her, tried to help out by stewing a bunch of my extra tomatoes (without asking me! Augh!) but that's not good spaghetti sauce in my book. Too watery, not enough flavor. We'll freeze it and add it to chili later in the winter but meh. I'm just not a cooked-tomato kind of gal.

A friend mentioned oven-roasting the tomatoes and then turning it into spaghetti sauce. The oven dries up a lot of the juices so it's not so watery for the sauce, she says. And it concentrates the flavors, apparently. So I thought I'd try that, once I found a little time.

Well, I'm still looking for that extra time, but the end of the tomato season is upon us so my hand was forced. It's cook 'em or throw 'em onto the compost pile, so I made some time for it over the weekend. And am I glad I did.

Oh. My. God. This was almost a religious experience, it was so good. And really, it was very easy, which is always a key recipe ingredient in my book. And it actually made cooked tomatoes taste good! Amazing. Never thought I'd see the day when I enjoyed cooked tomatoes.

How To Roast Tomatoes

You wash your tomatoes. It doesn't matter what kind you use. I used big red 'maters, golden, orange, Romas, heirlooms, cherry 'maters, you name it. They all work.

Cut 'em up. I quarter the big ones, and halve the small ones. They cook faster that way. Toss 'em with a little olive oil, then place them on an oiled cookie sheet.

Slice up some onions and toss them in with the tomatoes. Put in some unpeeled garlic cloves too (not peeling them lets them steam instead of dry out, and tends to make them more flavorful and less bitter). Sprinkle it all with a little sea salt, a little oregano and thyme, and whatever other spices float your boat. There's no exact science to it, just throw in whatever sounds good to you, in whatever proportions you like.

Then roast 'em in an oven on 400 degrees for about an hour or so, till they are semi-dried up but still all bubbly. (You choose how dry you want them to get; still a little bubbly is how I like mine.) If you arrange your oven racks properly, you can roast two pans at once.....and trust me, you're going to want to! I did four pans over the weekend and could've done more if I'd had the time.

When they are done, let 'em cool a tad, then use a spatula and scoop them off into a bowl. Taste, and know you've gone to heaven....even if you're not much for cooked tomatoes. Rinse and repeat till you are out of tomatoes or out of storage space.

You can roast 'em slow or you can roast 'em fast. Some recipes online recommend 150-200 degrees for nine hours. Others recommend 400-450 degrees for an hour or two. Or this recipe recommended 325 degrees for 2.5-3 hours.

Sorry, I have other things to do than stand around for hours watching tomatoes roast, so I went with the fast-roast method and it was GREAT. However, if you really want truly dried tomatoes, the slow-roast option may be better. Or try a solar oven for a really long-roasted option that doesn't use up a ton of electricity. I hear that works pretty well.

There's no real big science to all this; experiment to see which way you like it the best. It's okay if you make your oven hotter or cooler than mine, or if you cook it longer or slower or add other ingredients or whatever. That's what I like about this's so adaptable. And it's really easy, which is good for lazy people like me.

Did I mention yet it is easy?

What Then?

Now, once you have the oven-roasted tomato/onion/garlic mix, you have many options. You can eat them as is.....and OH, they are great that way! Or you can freeze them in a Ziplock bag for later use in chili or stirred into pasta or whatever. Or you can chop them up fine with some olives and things for a savory topping for fresh bread. All that's quite tasty too.

Or you can make spaghetti sauce from it like I did.

Hunt down all the unpeeled garlic cloves in the roasted mixture and then squeeeeeze them from one end. The roasted garlic will ooze out the other side, into your roasted tomatoes. Whir your onion, garlic, and tomato mixture in the Cuisinart or blender and voila, spaghetti sauce to die for. Easy peasy.

Add your choice of meat if you'd like, or eat it vegetarian...whatever floats your boat. Add some red wine if you like a little "bite" in your spaghetti sauce. Or sneak a few extra veggies into your Cuisinart if you want to up the vegetable count in the sauce without any ankle-biters knowing it. There are sooo many different ways to enjoy this; have fun experimenting with it. Freeze any extra and enjoy it in the middle of winter. YUMMMMM.

My fresh-made spaghetti sauce turned out lighter in color than bottled spaghetti sauce (probably from all the yellow and orange tomatoes I used) so it doesn't look quite the same, but it tastes amazing. Even my tomato-hating kids liked it and ate it enthusiastically. I'm making more this week with the last-gasp remnants of tomato season.

I'll still buy bottled spaghetti sauce and enjoy it too, but this that's the really good stuff. It's like comparing wine in a box to a really good fine wine--they're both pretty good, and they both do the job, but ooooooh, only one is truly a tastebud extravaganza of delight.

Now I actually have a reason to hope for an abundance of tomatoes next year. I have a hunch there will be a lot less tomatoes being given away from my household next year!

Comments section is now open for other end-of-season tomato ideas.........

Monday, October 5, 2009

Healthy Birth Practices: Let Labor Begin On Its Own

In the next few weeks, we will be looking at the Six Lamaze Healthy Birth Practices and why they are important for promoting healthy births.

We will also see how many of these optimal birth practices are actively discouraged for "obese" women during labor and how this impacts their cesarean rate, birth experiences, and breastfeeding.

The first Healthy Birth Practice is probably the most important one of all:

1. Let labor begin on its own

Ironically, this is one of the most often ignored in current obstetric practice with women of size.

General Risks of Induced Labor

Today, more and more women of every size are having their labors induced. This is risky because when labor is started artificially, it means that the baby and mother are not truly ready for birth yet, and complications can ensue. (Study references beyond those already linked to can be found in the Healthy Birth Practice Paper, here.)

Inducing labor, especially in first-time mothers, tends to increase the risk for cesareans. The mother's body may not be ready to dilate fully and she may therefore end up with a cesarean for "Failure To Progress" (FTP). Or the baby may not yet be in the easiest position for birth and the mother may end up with a cesarean for "Cephalo-Pelvic Disproportion" (CPD, or baby didn't fit right).

Inducing labor also increases the risks for vacuum- and forceps-assisted births. This is often because the baby had not yet moved into an optimal position for birth, or because the mother has an epidural and the baby cannot rotate easily through the pelvis. Help may be needed to get the baby out, but this help often also comes with the price of an episiotomy (cutting to widen the vaginal opening).

Inducing labor early can also result in a "near-term" preemie which may experience problems with jaundice, low blood sugar, and difficulty breastfeeding. Even close to term, the baby's lungs may not be completely ready to breathe yet on the outside, and as a result, the baby may experience respiratory distress after the birth and end up in the Neonatal Intensive Care Unit (NICU).

Induction also carries direct risks to both mother and baby in other ways as well. For example, the induced mother's uterus may experience "tachysystole" (hyperstimulation) and labor may need to be stopped before it results in uterine rupture (a tear in the uterus) or placental abruption (the placenta pulling away from the uterus prematurely). Induction is also associated with amniotic fluid embolism, and while rare, this can result in death to the mother.

Furthermore, although synthetic oxytocin (a.k.a. "pitocin" or "syntocinon") is chemically the same as the mother's own oxytocin, it does not act exactly the same in the body during labor. As Dr. Sarah Buckley notes:

Synthetic oxytocin administered in labor does not act like the body’s own oxytocin. First, syntocinon-induced contractions are different from natural contractions, and these differences can cause a reduced blood flow to the baby. For example, waves can occur almost on top of each other when too high a dose of synthetic oxytocin is given, and it also causes the resting tone of the uterus to increase.

Second, oxytocin, synthetic or not, cannot cross from the body to the brain through the blood-brain barrier. This means that syntocinon, introduced into the body by injection or drip, does not act as the hormone of love. However, it does provide the hormonal system with negative feedback—that is, oxytocin receptors in the laboring woman’s body detect high levels of oxytocin and signal the brain to reduce production. We know that women with syntocinon infusions are at higher risk of bleeding after the birth, because their own oxytocin production has been shut down.
Induction also carries risks to the baby. Induction often involves breaking the mother's amniotic sac manually at some point during labor, which carries the risk of umbilical cord prolapse. Although rare, this can cause brain damage or even death to the baby and necessitates an immediate emergency cesarean.

The use of labor induction drugs often causes contractions that are harder and closer together than in spontaneous labor, and as a result, baby is not given as much time to recover its oxygenation between contractions. This lack of recovery time can cause fetal distress. This is why babies must be continuously monitored during an induced or augmented labor.

These harder, longer, and more intense contractions often also result in a higher use of pain medications by the mother. There is nothing wrong with choosing to receive pain medications if you need them (and it's great that women have the choice available if needed), but it's important to remember that these are strong medications and they do carry real risks to both mother and baby.

While many women go into labor intending to "go natural" (without pain medications), this becomes very difficult if the mother is induced. Although not impossible, it's a rare woman who is able to complete a whole induced labor and birth without at least some pain medications.

Furthermore, induction increases the risks of further interventions becoming "needed," all of which have their own risks. And induction decreases the mother's ability to utilize the other Health Birth Practices such as move freely, be upright for pushing, etc. From the Let Labor Begin On Its Own practice paper:

In addition to an increased risk for mild prematurity and cesarean surgery, induced labor often creates the need for more medical interventions.

In most cases, if you are induced, you will need an IV and continuous electronic fetal heart rate monitoring. In many settings, you must stay in bed or very close to the bed. As a result, you may be unable to walk freely or change positions in response to your labor contractions, possibly slowing the progress of your labor. You may be unable to take advantage of a soothing tub bath or a warm shower to ease the pain of your labor contractions. Artificially induced contractions often peak sooner and remain intense longer than natural contractions, increasing your need for pain medications.

Labor induction leads to a cascade of interventions, which often result in cesarean surgery.
Induction of labor is far from the benign and minimally risky option that many doctors portray it to be. It has real risks, and in many cases these risks are underplayed.

Sometimes induction of labor is truly needed, and as with cesareans, we can be glad that it is available when needed. However, also as with cesareans, its casual overuse without sufficient consideration about possible risks may result in significant harm.

The Epidemic of Induction in "Obese" Women

Research (insert major-league sanity watchers points if you read these studies!) consistently shows that fat women have higher rates of induction than their average-sized or underweight peers. Yet few studies connect the dots between an elevated rate of induction and a higher cesarean rate in this group.

Michlin 2000 found an induction rate of 20.4% in "obese" mothers, vs. an induction rate of 10.2% in "normal weight" mothers.

Graves 2006 found an induction rate of 33.7% in "obese" women (BMI greater than 29), versus 19.2% in "normal" weight women (BMI 19.8-26 in this study), or 12.6% in underweight women (BMI less than 19.8).

Numerous other studies have also found an increased rate of induction among "obese" women.

Sometimes the higher rate of induction in "obese" women is because they have higher rate of medical complications like pre-eclampsia (blood pressure issues), where getting the baby out sooner may be important. In these cases, a higher rate of induction could be justified.

However, research also shows that even when there are no medical complications, "obese" women are induced at a higher rate than average-sized women.

For example, Usha Kiran 2005 studied 677 "obese" (BMI greater than 30) women in Wales with no complications. They still found a higher induction rate of 36% in "obese" women, compared to a 25.5% induction rate in the control group (BMI 20-30).

So the story of high induction rates goes well beyond complication rates. This raises the question: Why are "obese" women induced at such high rates?

The answer is that there are many factors in this trend.

Some of it is fear. The hyperbole about risk in obesity and pregnancy has created such a state of anxiety that many practitioners assume that inducing labor earlier is better, ostensibly before complications can occur. Alas, there is little recognition that they may actually introduce more risks than they alleviate by inducing early, and little work has been done to challenge or affirm whether inducing early helps or harms women of size.

Another factor may be biological differences. For example, fat women tend to have longer gestations and more "postdates" pregnancies. This may be tied to the fact that many women of size have longer menstrual cycles (which, unless greatly divergent, is rarely adjusted for in pregnancy dating). In addition, the definition of "postdates" has shortened in many studies, making even more fat women fall outside the narrowing definition of normal. This may have the net affect of raising the induction rates in women of size even higher.

In fact, in two of the studies above with high "obese" induction rates (Graves 2006 and Usha Kiran 2005), postdates pregnancies were listed as a major cause of the high induction rates.

In Usha Kiran 2005, 41% of the "obese" women had "post-dates" pregnancies, which this study defined as greater than 41 weeks. This poses the question....if nearly half of the "obese" women have "postdates" pregnancies, doesn't this suggest that something about the definition of postdates or the dating of these women is wrong?

And in fact, the Usha Kiran study also shows how strongly induction negatively influenced outcomes in the "obese" group. Tellingly, the cesarean rate in the "obese" group with spontaneous labor was 19%, whereas it was 41% in the induced group. Nearly half the "obese" women who were induced ended up with a cesarean, but only one-fifth of the ones with spontaneous labor had a cesarean.

The study further 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.

The high rate of induction in women of size is one of the strongest factors in the high rate of cesareans in women of size, and may factor into other negative outcomes in this group....yet there is very little recognition of this fact among medical professionals.

Induction for Macrosomia

The strongest factor by far in the high induction rate of "obese" women is the fear of a big baby. I can't stress this strongly enough. In my opinion, fear of big babies is what's really driving the high cesarean rate in women of size.

Doctors and many midwives have been trained to think that most big mamas produce big, "overly fat" babies, and therefore are strongly at risk for shoulder dystocia (where the baby's shoulders get stuck and baby may be injured).

Because shoulder dystocia injury is one of the main causes of practitioners being sued, many practice defensive medicine. With macrosomia (big baby), this means many induce labor early for women suspected of having a big baby. They reason that bringing labor on a bit early, while the baby is smaller, may make it easier for the baby to be born without shoulder dystocia.

Now, this sounds logical--induce early while the baby is small to increase the chances of it coming out vaginallyand safely--but unfortunately, research shows exactly the opposite effect. Studies actually show that inducing for a big baby often worsens outcome.

The Healthy Birth Practices handout on "Let Labor Begin on Its Own" makes a point of debunking the common idea that it's important to induce early when a big baby is suspected.
It is also important to know that suspecting a large or very large baby is not a medical reason for induction. Studies have shown that inducing labor for macrosomia (large baby) almost doubles the risk of having cesarean surgery without improving the outcome for the baby (Horrigan, 2001; Leaphart, Meyer, & Capeless, 1997; Sadeh-Mestechkin et al., 2008; Sanchez-Ramos, Bernstein, & Kaunitz, 2002).

Furthermore, it is very difficult to know how big your baby is until he is born. Ultrasound is not good at predicting macrosomic (very large) babies. According to ACOG (2009), an ultrasound estimate of the baby’s weight is imprecise, with a variability of 16% to 20%.
Simhayoff 2004 found inducing labor in women with macrosomic babies increased the cesarean rate, not decreased it. The c-section rate in the induced group was 17.8%, vs. 11.9% in the group with spontaneous labor.

Leaphart 1997 found that inducing for macrosomia more than doubled the cesarean rates, from 17% to 36%, while not significantly reducing shoulder dystocia rates.

Combs 1993 found that inducing for macrosomia increased the cesarean rate from 31% to 57%, and there was twice as much shoulder dystocia in the induced group.

Navti 2007 studied the management of women with macrosomic babies at their institution in the U.K. They concluded that "induction for fetal macrosomia alone did not improve outcome but was associated with a significantly higher emergency caesarean section rate and should therefore be discouraged."

Another troubling aspect of induction for suspected macrosomia is the inaccuracy of estimating fetal size. Research shows that ultrasounds for fetal size are particularly poor at predicting macrosomic babies accurately. Furthermore, it also shows that the mere suspicion of macrosomia often raises the cesarean rate significantly.

Weiner 2002 found that merely estimating the baby to be big--even when it wasn't big at all--doubled the cesarean rate.

When the baby is suspected to be large, there may be a lower threshold for diagnosing labor troubles and proceeding to a cesarean. Blackwell 2009 found a higher cesarean rate for labor arrest (34.8%) in those mothers in whom fetal weight was overestimated, vs. those for whom fetal weight was not overestimated (13.3%), despite similar actual labor lengths. This shows that when a big baby is suspected, practitioners expect labor to be abnormal and are quicker to order a cesarean.

Sadeh-Mestechkin et al., 2008, found that when macrosomia was suspected and the baby really was big, the induction rate was much higher (42.1%) than when the baby really was macrosomic but nobody suspected that (13.6%). As a result, the c-section rate was much higher in the suspected macrosomia group (57.1%!) than in the non-suspected macrosomia group (16.7%), even though babies in both groups were actually big.

Let me repeat that. Both sets of babies were big, but the suspicion of macrosomia raised the c-section rate from 16.7% to a whopping 57.1%. In other words, the size of the baby itself had much less impact on the cesarean rate than the perception that the baby might be big and the resulting management of labor.

A higher cesarean rate might be acceptable if induction of labor for macrosomia actually prevented shoulder dystocia and related birth injuries, but research shows that it does not. In fact, one extremely large study (Christoffersson 2003) shows that induction of labor (especially when associated with epidurals and vacuum/forceps delivery, as induction of labor often is) actually increases the risk for shoulder dystocia.

Gherman 2006 reviewed the topic of preventing shoulder dystocia and noted:
There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients.
Sadeh-Mestechkin et al., 2008, also concluded, "Our ability to predict macrosomia is poor. Our management policy of suspected macrosomic pregnancies raises induction of labor and cesarean delivery rates without improving maternal or fetal outcome."

Although research continues to pour in, showing that induction for macrosomia worsens outcomes and that even estimation of fetal weight is harmful, providers continue to resist changing their practice patterns. Ultrasounds to estimate fetal weight remain routine at the end of pregnancy, and induction for suspected macrosomia remains very common.

Induction for Macrosomia: Still Common Practice with Women of Size

Despite all the evidence that estimating fetal weight and inducing early for macrosomia actually worsens outcomes, it is still routine practice to do these things with "obese" women in particular. Very few practitioners question doing it.

Many providers cite shoulder dystocia as the reason for doing so, believing that fat women are at particularly high risk for shoulder dystocia, while others believe that inducing early will increase a fat woman's chance of having a vaginal birth. But does research really bear out these assumptions?

It is true that "obese" women, on average, do have bigger babies than women of average size. However, most fat women do not have macrosomic babies. Michlin 2000, discussed above in the induction section, found that "obese" women had a macrosomia rate of 16.8% (vs. 8.4% in the average-sized women), and this is similar to rates in other studies as well. Although the rate is higher in the "obese" group, it should be noted that 83% of the "obese" group did not have big babies.

The vast majority of "obese" women do not have macrosomic babies, yet the majority are treated as if they will have huge babies, and as if shoulder dystocia is inevitable in this group as well.

In addition, many women who do have macrosomic babies have vaginal births anyhow. The afore-mentioned Navti 2007 study found that 83% of women who had babies around 10 pounds or more were able to have vaginal births. Even very big babies can often be born vaginally, given time, patience, sufficient mobility, and a calm caregiver.

Furthermore, studies that adequately control for other factors such as diabetes status, macrosomia, and induction status have found that obesity itself is NOT an additional risk factor for shoulder dystocia. (Robinson 2003, Neumann 2001, Poggi 2003)

Robinson's study concluded:
Demonstrating a lack of independent association between maternal obesity and shoulder dystocia may encourage clinicians to allow nondiabetic obese patients an adequate trial of labor rather than to choose to proceed to cesarean delivery earlier because of the fear of shoulder dystocia. This may decrease the incidence of cesarean delivery and the morbidity associated with it in the obese patient population.
Unfortunately, most clinicians have not taken this advice to heart. Although the reasons for induction may get coded differently in official documents, many fat women anecdotally report that fear of a big baby or shoulder dystocia is one of the reasons most frequently used to pressure them into induction of labor.

A policy of inducing most fat women because of the fear of a big baby means that most will be induced unnecessarily, as most will not have big babies anyhow. It disproportionately and unnecessarily exposes these women (and their babies) to all the risks of induction listed in the first section. Furthermore, since inducing for macrosomia usually increases the cesarean rate, it disproportionately increases the cesarean rate in women of size, exposing them to those risks as well.

Few studies have directly examined the question of whether inducing for macrosomia in "obese" women improves or worsens outcomes, but it is reasonable to suspect that it worsens outcomes, as it does in other women.

In what studies we do have, Graves 2006 found that the combination of obesity, macrosomia, nulliparity (first-time mom), and induction doubled the risk for cesarean section. And remember, Usha Kiran 2005 found a c-section rate of 19% in spontaneous labor vs. 41% in induced labor. They also found that induction was the beginning of many of the negative outcomes found in women of size.

Unfortunately, the authors did not follow through to the logical conclusion and question whether they should be inducing so liberally. Instead they conveniently just blamed obesity for the cesarean rate.

Conclusion and Video Link

If you want to read further about the risks of inductions and why spontaneous labor is better for mothers and babies in most cases, read the accompanying Healthy Birth Practices handouts that explain and cite research to support their conclusions. See also the video link below.

If you are a woman of size and want to lessen your risk for cesareans, ask your caregivers an open-ended question about what they would do if they suspected you were carrying a big baby. Then just let them talk and see what they say.

If they mention decision-making based on ultrasound for estimated fetal weight, inducing early for a smaller baby, or scheduling a planned cesarean if baby is over 9 lbs., then you know this is not an evidence-based provider.

Rather, it is one who makes decisions out of fear, has many negative assumptions about size, and who is mainly motivated by litigation concerns, rather than what's best for you and your baby. With this kind of provider, you are likely to end up with lots of interventions and a strong possibility of a cesarean. Whether that's acceptable is up to you...just go in with your eyes open and knowing the risks.

Either way, be sure to watch the video below.

*The topic of induction for suspected macrosomia is of particular interest to me, since 3 of my 4 children were "encouraged" to come early because of fears of macrosomia due to my size. 2 of these "encouragements" resulted in cesareans.

If you are a woman who was encouraged to have an early induction or planned cesarean because of suspected fetal macrosomia, be sure to briefly let us in on your story in the Comments section.