The Best of 2010 on WRM

Recently, I saw someone post "The Best of 2010" from her blog ─ what she thought were the best or most interesting posts that she wrote during 2010.  I thought, what a great idea.........I need to steal it! 

So here are some of my favorite or what I think were the most important posts of 2010 from my Well-Rounded Mama blog, just in case you missed some along the way. 

Enjoy, and I look forward to seeing what comes out in 2011!

January 

Second Annual Turkey Awards: Scare-mongering and Shaming Tactics - A condemnation of an opinion piece blasting women of size for the crime of Being Pregnant While Fat, and an examination of the scare tactics and shaming being used in the media to distort the risks around "obesity" and pregnancy.

Healthy Birth Practices: Avoid Unnecessary Interventions - 4th in a series on the Lamaze Healthy Birth Practices.  This one discusses the risks of common routine interventions in labor, why women of size experience these interventions at higher rates, and suggestions for avoiding them.

February

Not much this month because I was in Hawaii for my 25th wedding anniversary!

Eat, Drink, and Be Merry, For Tomorrow We Diet - Research abstract summarizing what we in the fat-acceptance community have known for years ─ that restrained eating (a.k.a. dieting) tends to lead to or exacerbate overeating behaviors.

March

Choosing a Birth Care Provider: Which Type? - Between 80-90% of women in the U.S. choose an OB to attend their births, yet outcomes are just as good (and often better) with family docs and midwives.  This article by guest authors outlines the different type of birth providers available and the pros and cons of each.

You Have The Right To Decline To Be Weighed - Rehash of the debate over whether it's necessary to weigh people at every doctor appointment, when it might be important and useful, and when it's not. 

Why VBAC Bans Are A Violation Of Human Rights - Discussion of the epic fail of ethics in doctors and hospitals that "ban" VBAC, either officially or de facto. 

April

Variability of Uterine Efficiency - One of my favorites of the year, this post for Cesarean Awareness Month challenges the common perception that virtually all cesareans are "necessary" and shouldn't be questioned.  It shows the variation of cesarean rates from state to state, year to year, hospital to hospital, even doctor to doctor, and points out that oftentimes, factors unrelated to the characteristics of the mother herself are the strongest drivers of cesarean rates.

Healthy Birth Practices: Get Upright and Follow Urges to Push - 5th in a series on the Lamaze Healthy Birth Practice, this entry discusses the reasons not to use the "stranded beetle" pushing position so many hospitals use, gives illustrations and examples of alternative birth positions, and discusses the benefits of these positions (especially for women of size). 

May

You're Killing Your Baby - Another in a sadly long series of posts documenting the abusive treatment of women of size in pregnancy.  This was the case of a woman, just over 200 lbs., whose doctor told her that she was "killing her baby" because she "couldn't control" her appetite.  (Her baby was fine and is now almost grown.)

June

Ultrasounds in Women of Size, Part 1 - Doing an ultrasound during pregnancy in a woman of size can be more difficult, but there are techniques to help improve imaging and accuracy, and techniques (like pressing too hard) that can actually result in data distortion.  (Part 2 of this series is in the "to-do" queue and will get done eventually!)

Distoring the Risks Again - Once more addressing the way that the risks of "obesity" and pregnancy are distorted in mainstream media (like this particular article in the New York Times) by using risk ratios instead of real-life numbers, promoting simplistic views of fat people and their habits, ignoring the fact that correlation does not equal causation and that extreme intervention also introduces risks, and by citing worst-case scenario stories of specific fat women.

Healthy Birth Practices: Keep Baby With You - Examines the influence of post-delivery practices in hospitals on breastfeeding and bonding, and discusses how common interventions particularly impact women of size and their breastfeeding rates.

July

Will I Feel My Baby Move If I'm Fat? - One of the most-viewed blog posts on this site ever, this discusses the common myth that fat women won't feel their babies move "because of all that fat in the way."  Poppycock!

About Damn Time: Good News For Vaginal Birth After Multiple Cesarean - A review of ACOG's change of guidelines about VBACs, and in particular "allowing" VBAC after 2 cesareans again.  A celebration of the changes but also a condemnation of the (non evidence-based) decision to disallow VBA2C in 2004 and the chilling effect that has had on women and birth worldwide. 

Limiting Fertility Treatment Access For Fat Women - Excellent article abstract and brief discussion of the current British policy denying access to fertility treatment for "morbidly obese" women across the pond. 

You Will Probably Just Die Anyway - Another in the series of posts, documenting mistreatment of women of size in pregnancy.  This woman was told that she would no doubt get GD, high BP, and probably just die during pregnancy.  The story sparked a number of people to share their stories of mistreatment and scare tactics too.

August

Breastfeeding in Women of Size: Sensationalism Vs. Meaningful Research - Another common theme in articles on "obesity" and pregnancy is that breastfeeding rates are lower in "obese" women.  This article examines the research, notes its shortcomings (particularly the lack of consideration of the impact of PCOS on milk supply), and discusses other possible influences (hypothyroidism, anemia, interventions in labor and postpartum) and how these might also impact women of size disproportionately.  A call to arms for better and more meaningful research on breastfeeding in women of size.

Is Weighing Necessary During Pregnancy? - Part 2 of the series on whether "obese" people need to be weighed at doctor appointments, this installment examines the arguments (and research) for and against weighing during pregnancy. 

Please Document Your Stories of Mistreatment - Notes the importance of documenting examples of size/weight bias, tells some of women's stories, and gives resources for documenting these stories.

Antibiotic Underdosing in "Obesity" - One of the most important entries this year (in my opinion) even though it has nothing to do with pregnancy.  This entry discussed the fact that many "obese" people are underdosed with antibiotics, i.e., are given  ineffective, subtherapeutic levels, and this may cause a lot of our poorer outcomes after surgery etc.  A lot depends on the type of antibiotics (some need weight-based dosing, some do not, depending on the mechanism of action) but research clearly shows that more study is needed into the best dosages for "obese" people ─ yet little of this research is being done. 

September

Delaying Routine GYN Care - Research review of 23 studies documenting the fact that "severely obese" women often delay or avoid routine gynecological tests like Pap Smears and Mammograms because of issues like weight stigma, lack of appropriately-sized equipment, and communication issues with providers.

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider - Sparked by a blog entry from a midwifery blog, discussion of important questions to ask when choosing a birth attendant for your birth.  Some discussion of special issues for women of size too.

Prenatal Weight Gain: When the Conclusion is Made Ahead of the Results - First in a series of posts about prenatal weight gain politics and how they are impacting women of size.  Discusses a new Kaiser study which promotes ZERO weight gain for "obese" women in pregnancy.

October

Prenatal Weight Gain: Ignoring Possible Harms - Second in the series on prenatal weight gain politics for women of size.  Discusses the possible risks associated with very low weight gains (and even weight loss) in "obese" women and the possible implications for the baby's future health. 

Prenatal Weight Gain: The Importance of Study Design - Third in the series on weight gain in women of size.  Discusses how the studies on restricted weight gain in "obese" women often are poorly designed, with critical concerns about sample size, controlling for iatrogenic factors, lack of long-term follow-up, and confusion of correlation vs. causation.

Gaining Weight In Pregnancy Means a Cesarean? - Documents a concrete example of one of the ramifications of restricted weight gain for women of size, which is penalizing women who "gain too much" by requiring them to have an "elective" cesarean.   

Too Out Of Shape for Birth? - Documents another example of size bias, the perception that fat women are "too out of shape" to push out a baby. 

November

Breastfeeding Lowers the Risk for Diabetes and Other Maternal Disease Later in Life - Review of new and old research that shows that extended breastfeeding significantly lowers the risk for diabetes, heart disease, and other issues later in life. 

Failure to Wait Cesareans - Discussion of a new study which shows that many cesareans for "failure to progress" are actually cesareans for "failure to wait."  This particularly impacts first-time moms, women who are being induced, and women of size. 

Third Annual Turkey Awards: Jumping To Conclusions - Documents incidences of science-challenged doctors who ramp up the risk perception around "obesity" and pregnancy to conclude that if a fat woman is somewhat at risk for complication, then she WILL get it, and she or her baby will probably DIE as a result.  (See also, "You Will Probably Just Die Anyway" above.)

December

Contemporary Cesarean Patterns in the USA - Discusses recent study on cesarean patterns in 19 hospitals across the country and its implications.  Nearly half of the women were induced, many had "failure to wait" cesareans, primary cesareans were up sharply (which bodes ill for the future), and VBAC access is limited.  Calls for changes, but is anyone listening?

VBAC After 2 Cesareans - Distorted Risk Perception - Distorted risk perception is especially egregious in "obesity" and pregnancy, but many doctors also have distorted risk perceptions with breeches, VBAC, and especially about VBAC after more than 1 cesarean.  Documents a study in which French OBs underestimate the risks associated with multiple repeat cesareans and overestimated the risk for rupture in VBA2C as 7-15x what it really was.

The Fat Vagina Theory: "Soft Tissue Dystocia" - Documents the commonly-taught but completely unproven theory of "soft tissue dystocia" ─ that extra adipose tissue in the pelvis and vaginas of "obese" women obstruct the baby's path out and is a big part of the high cesarean rate in women of size.  Documents the lack of research supporting this theory and discusses the research and anecdotal evidence which seem to contradict it. 

Year-End Summary

All in all, a productive year, I think!  Which of my 2010 entries were your favorites, dear readers?

Yeah, there were a lot of research-heavy entries, but then I'm a bit of a numbers geek.  Plus I just think it's important to document the research that challenges common perceptions about "obesity" and highlight further research that's needed.  There's plenty of research on "obesity" out there; the problem is that much of it is CRAP or is not very insightful.  The bottom line is that we need better and more meaningful research. 

Next year, we start a periodic series addressing the risks of pregnancy in women of size, discussed in realistic terms but without scare tactics or hyperbole, and ways in which women of size can be proactive about lessening these risks.  Stay tuned!

Happy New Year to all my readers. Have a wonderful 2011!

*If you have specific requests for topics for the next year, feel free to leave them in the comments.  I may not get to them immediately, but I do like idea suggestions.

Contemporary Cesarean Patterns in the USA

This is an interesting new study out on cesarean patterns in the United States. 

Examining this study will be particularly compelling given that the cesarean rate has risen again (for the 13th straight year) to a new all-time high of 32.9%.  (Notice how this information was conveniently released just before Christmas, thereby not making the news cycle in most publications?)

The data in this new study was taken from 19 hospitals all over the USA, so it's a reasonably robust representation of common practice in the States. 

What struck me in the study immediately was the extremely high induction rate....44%!  Nearly half? That is just outrageous.  But at least it's a more accurate reporting of induction rates than some previous studies.  And I bet that at some hospitals, the induction rate is even higher than that.  No wonder the cesarean rate is so high!

They also noted in a companion study that many of the inductions were converted to cesareans before active labor had even really begun, what we call a "failure to wait" cesarean.  They recommended that care providers wait until active labor has been well-established before jumping to a cesarean, especially in first-time moms and in women who are being induced. 

Another thing that struck me was that the cesarean rate for first-time mothers (primary cesareans) was so high.  Nearly 1 in 3 first-time moms had a cesarean.  Usually, first-time moms should have a LOWER cesarean rate than the overall c-section rate.....but not in this study.  I think that's a reflection of how many were induced...and such a high primary cesarean rate is an ominous sign.

It was great that the authors seem to call for reducing primary cesareans, and I was especially pleased that they seem to be calling for more widespread access to VBAC. 

Such a call for change was quite refreshing.  And it's wonderful that such a call for change was published in the American Journal of Obstetrics and Gynecology, one of the main OB-GYN research journals. 

The $64,000 question is ─ will the publication of this study make any difference?  Will hospitals change their policies and induce less women?  Will doctors wait longer before resorting to cesareans?  Will doctors and hospital administrators reverse their formal and informal VBAC bans?  Will everyone involved make a concerted effort to reduce the cesarean rate ─ or will it just continue to be business as usual?

It's positive that the questions are being asked and dialogue is being opened ─ but I am not holding my breath.  Perhaps this is the beginning of a reversal of the pendulum, but the momentum is so strong towards inductions and cesareans right now that it's going to take a mighty counterforce indeed to really reverse things. 

It's up to us to be part of that counterforce for change.


Abstract

Zhang J, et al.; Consortium on Safe Labor.  Contemporary cesarean delivery practice in the United States.  Am J Obstet Gynecol. 2010 Oct;203(4):326.e1-326.e10. Epub 2010 Aug 12. PMID: 20708166

Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA.

OBJECTIVE: To describe contemporary cesarean delivery practice in the United States.

STUDY DESIGN: Consortium on Safe Labor collected detailed labor and delivery information from 228,668 electronic medical records from 19 hospitals across the United States, 2002-2008.

RESULTS: The overall cesarean delivery rate was 30.5%. The 31.2% of nulliparous women were delivered by cesarean section. Prelabor repeat cesarean delivery due to a previous uterine scar contributed 30.9% of all cesarean sections. The 28.8% of women with a uterine scar had a trial of labor and the success rate was 57.1%. The 43.8% women attempting vaginal delivery had induction. Half of cesarean for dystocia in induced labor were performed before 6 cm of cervical dilation.

CONCLUSION: To decrease cesarean delivery rate in the United States, reducing primary cesarean delivery is the key. Increasing vaginal birth after previous cesarean rate is urgently needed.

Cesarean section for dystocia should be avoided before the active phase is established, particularly in nulliparous women and in induced labor.

Happy Holidays

May you have a wonderful holiday season. May you enjoy family time, whether that's with family of origin or family of choice.  And may you have a wonderful new year. 

Peace and blessings to us all!

*Painting by Renoir; image from Wikimedia.

Waterbirth Video of Plus-Sized Mom

A (plus-sized) reader of my blog sent me the link to the video of her recent waterbirth.  This seems like the perfect complement to last week's post about a new waterbirth study, plus it's a lovely, cheery story for Christmas week. 

Not only is this awesome because it's waterbirth─ the coolest thing ever! ─ but it's waterbirth in a woman of size, something some care providers and some facilities do not "permit."  (Actually, women of size are the perfect candidates for waterbirth, since it can help us be more mobile in labor and pushing.)

But this mom didn't let rules against waterbirth in women of size stop her ─ she found a place and a provider that was amenable to waterbirth for her, regardless of size. 

This was her fifth child.  She had had vaginal births with all her prior children in the hospital, but with some significant interventions (forceps, big episiotomy, a near c-section with the fourth one because she wasn't progressing fast enough for them...even after 3 prior vaginal births!).  She was determined to change things for the next baby. 

She had a boy, 9 lbs. 12 ozs., 22.5 inches long, a size many doctors would freak out over (and some would mandate a c-section for) ─ but she had him naturally and easily with the mobility that the water offered. 

Here are her words about her story (slightly edited):

I avoided seeking out a midwife for my previous births because of size issues, but I went for it and called tons of midwives, wearing my heart on my sleeve as I brought up the issue of weight. I found a wonderful midwife, had a healthy pregnancy and had my baby at home in the water.

I am still on cloud nine. It was one of the most amazing accomplishments of my life. 

I want to help as many moms as possible develop the courage for the birth they want. Waterbirth, long sigh, was so wonderful. Compared to straps around my tummy that didn't fit, cutting into my skin (literally) at the hospital on a bed I could barely move in....

I want to help any mom of any size to achieve the birth she wants - I didn't have that courage for my other births and its a big regret. This was my fifth birth and first home/waterbirth.

My first son was a hospital birth with a very 'old school' obstetrician. I was induced. He only saw me in labor to break my water and he barely darkened the doorway when I started pushing. He mostly waited in the hallway. The nurse finally called him over because she felt my pushes were inadequate - he almost immediately said we needed forceps. My son was born via forceps with a very intense episiotomy.

The next three births followed, with some changes - new doctors, new hospitals, more interventions that I felt weren't needed. My fourth birth they 'threatened' a c-section because I was not progressing to their liking. I didn't get said c-section but I was left very frightened by the threats. I told my husband before I was even home that if we were blessed with another baby I was not going to any hospital. 

I had to face my fears of finding a midwife who would accept me even though I am a plus size mom. I called many midwives before I even knew if I wanted to get pregnant again. I felt so strongly about a homebirth that if it was not an option, it would have affected my choice to even get pregnant again. I found a wonderful Midwife...and I achieved the birth I knew I wanted. My homebirth healed many disappointments from the past. And I was so much more comfortable than I was with any pain-relieving techniques offered at the hospital.

Even though my body may not be [what] want many women would want, I LOVE my body. It brings me so much joy. With my body I shared love with my husband, grew a healthy baby and birthed him naturally in the safety of my home. That is indescribable joy.

Here is the video of her birth:



*Reposted with permission from http://rubyslippersx3.blogspot.com/

Italian Waterbirth Study

Giving birth in the water is one of the most wonderful things EVER.

I can't tell you how much I loved it, how much it helped with labor pain, and how it made it easier to be really mobile during labor. 

It's a terrible shame that it is not offered as an option more widely in the United States.  Certainly, more hospitals in Europe seem to be incorporating it before we do. 

One of the objections you hear voiced on occasion by the doctors who resist waterbirth is the idea that it's  not sterile enough and babies would be put at risk for infection. 

This study contradicts that idea.  Yes, there were microorganisms in the water, but the babies seemed largely unaffected by them, and in fact had a lower rate of infection/antibiotic use than babies born after "land delivery."

Alas, the study is in Italian so the only information I have is in the abstract, but note that the episiotomy rate in the water was less than 1%, a rate rarely seen in most hospitals.  There's a tremendous benefit right there.

Also note that only 13% of women needed drugs for the pain. This is the "aquadural" effect; many women find that pain is greatly lessened (or at least more manageable) when in the water. 

It's not that it totally relieves pain ─ I can attest that it doesn't.  I still felt labor pains intensely during my waterbirth.  However, they were manageable.  The warm water felt WONDERFUL, it helped lessen the pain enough to get by, and I was able to be quite mobile in the birth tub in a way that helped me respond proactively to the pain. 

So we shouldn't over-exaggerate the pain-relieving effects of water in labor. For some people it really does take the pain away.  But for many of us it merely takes a significant edge off and helps you cope more proactively with it. (And if it helps shorten labor, I'm okay with that!)

But the point is, waterbirth is helpful and not harmful.  Infection is not really an issue. 

Time for more U.S. hospitals to get a clue and start incorporating more waterbirths.



Thöni A, Mussner K, Ploner F. [Water birthing: retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection]. Minerva Ginecol. 2010 Jun;62(3):203-11.  [Article in Italian]

Reparto di Ginecologia e Ostetricia, Ospedale di Vipiteno, Bolzano, Italy.
Abstract

The aim of this study was to document the practice of 2625 water births at Vipiteno over the period 1997-2009 and compare outcome and safety with normal vaginal delivery. The microbial load of the birth pool water was analyzed, and neonatal infection rates after water birth and after land delivery were compared.

METHODS: The variables analyzed in the 1152 primiparae were: length of labor; incidence of episiotomies and tears; arterial cord blood pH and base excess values; percentage of pH<7.10 and base excess values >/=12 mmol/L. In all 2625 water births, the variables were: analgesic requirements; shoulder dystocia/ neonatal complications; and deliveries after a previous caesarean section. Bacterial cultures of water samples obtained from the bath after filling (sample A) and after delivery (sample B) were analyzed in 300 cases. The pediatricians recorded signs of suspected neonatal infection after water birth and after conventional vaginal delivery.

RESULTS: There was a marked reduction in labor duration in the primiparae who birthed in water; the episiotomy rate was 0.46%. Owing to the pain relieving effect of the warm birth pool water, pain relievers (opiates) were required in only 12.9% of water births.

Arterial cord blood pH and base excess values were comparable in both groups. Shoulder dystocia/neonatal complications were managed in 4 water births; 105 women with a previous caesarean section had a water birth.

In sample A, the isolated micro-organisms were Legionella spp. and Pseudomonas aeruginosa; in sample B, there was elevated colonization of birth pool water by total coliform bacilli and Escherichia coli. Despite microbial contamination of birth pool water during delivery, antibiotic prophylaxis, as indicated by clinical and laboratory suspicion of infection, was administered to only 0.98% of babies after water birth versus 1.64% of those after land delivery.

CONCLUSIONS: Results suggest clear medical advantages of water birthing: significantly shorter labor duration among the primiparae; a net reduction in episiotomy rates; and a marked drop in requests for pain relievers.

During expulsion of the fetus at delivery, fecal matter is released into the birth pool water, contaminating it with micro-organisms. Despite this, water birthing was found to be safe for the neonate and did not carry a higher risk of neonatal infection when compared with conventional vaginal delivery.

PMID: 20595945

VBAC After 2 Cesareans - Distorted Risk Perception

I recently wrote about ACOG's change in guidelines (August 2010), now "allowing" a trial of labor (TOL) again in women with 2 prior cesareans, whether or not they have had a prior vaginal birth.  This was a welcome change of policy and a breath of fresh air after many years of campaigning to get VBA2C back.

However, in the same post, I discussed the chilling effect that the earlier 2004 guidelines (which disallowed TOLs after 2 prior cesareans unless the woman had already had a prior vaginal birth) had had on the choices of women, and decried the reality that many women were forced into unnecessary repeat cesareans by these old guidelines.

The fact of the matter is that when ACOG makes these sweeping policy decisions (like all breeches should be born by cesarean, or VBAMC is not appopriate), it has MAJOR effects on the birthing climate in the world, effects that are not easily changed even if ACOG later recognizes its decisions were based on questionable research and changes its mind.

The net effect of disallowing VBAMC has been that only a few doctors in the world now "allow" women to choose a trial of labor after 2 prior cesareans, even though the risks associated with this have been shown to be reasonable. 

And although ACOG now "allows" a trial of labor after 2 cesareans, few OBs are rushing to change their policies.  The barn door is open, that horse is gone, and it's not coming back anytime soon.  I have hopes for change still, but I'm not holding my breath while waiting. The simple truth is that women are still being harmed by those old rules, even now.  ACOG has much to answer for.

This is similar to what has happened with breech births in the United States.  A flawed study came out that suggested that all breech babies were safer being born by cesarean, and BOOM, vaginal breech birth all but disappeared from the country, almost overnight.  Medical schools even quit teaching how to attend vaginal breech births, so many doctors now have no idea how to safely attend a surprise breech that shows up at the hospital. 

Research since the flawed breech study has questioned its conclusions and other recent studies have shown that vaginal breech birth is a reasonable option for most breech babies (and safer for the mother) ─ but it's close to too late to bring back the option because the art has been lost among so many providers.  Canada has been leading the way to try and get vaginal breeches re-established, but there's a long way to go.

As with breech, many doctors have developed an extremely distorted picture about risk with VBAC after two cesareans. 

And as with breech, all it took was one flawed study (Caughey 1999) that showed an abnormally high rate of rupture in VBA2C mothers, and ACOG rushed to virtually ban access to VBA2C. 

The problem is, that study had only 134 women in it, a sample size far too small to reliably determine risk (much less base sweeping policy decisions on); coincidence could easily have distorted the results.  No study before or since has shown such rates ─ but that didn't matter to ACOG.  It changed the rules, VBAMC was basically disallowed, and despite later research that showed the risk was not nearly as high as the Caughey study, VBAMC is still viewed by many as "far too risky" to even consider.  All on the basis of one very small, very flawed study.

Of course, some doctors have been overestimating the risk for uterine rupture in any VBAC  for years, but the degree of risk overestimation is especially egregious with VBA2C. 

Look at the following study, which surveyed doctors in France about their perceptions of the risks for uterine rupture with VBA1C and VBA2C.  The doctors overestimated the risk for rupture with both, but the overestimation was HUGE in the VBA2C group. 

In addition, they underestimated the risks associated with multiple repeat cesareans and counseled the women insufficiently about these.

As a result, less than a quarter of doctors surveyed would even consider "letting" a woman try a VBA2C trial of labor. 

The amazing thing is that this survey was published five years after major research showing far lower rupture rates in VBA2C mothers than these doctors estimated.

So what is the risk for rupture in VBA2C?  Studies vary, but the largest and most statistically powerful studies have shown rupture rates generally between 0.9% - 2.0% (Leung 1993, Miller 1994, Asakura 1995, Lin and Raynor 2004, Macones 2005, Landon 2006).

Tahseen and Griffiths (2010) did a meta-analysis of studies on VBA2C.  They found the average rupture rate was 1.36% and that the maternal morbidity between VBA2C and repeat cesarean was similar.

Note that all these studies include VBA2Cs with lots of induction and augmentation.  (Indeed, in Macones 2005, 16 of 19 ruptures in the VBA2C group were associated with induction or augmentation.)  With spontaneous labors only, the rupture risk for VBA2C would likely be even less.  (Never zero, alas, but less.)

What did the French doctors estimate the rupture risk to be with VBA2C?  14%!!!  Seven to fifteen times than the real risk.   

Distorted risk perception among doctors is one of the biggest things we battle on so many topics, from VBAC after multiple cesareans, to breech births, to pregnancy among women of size. 

AUGH.



Abstract

Vaginal birth after two previous c-sections: obstetricians-gynaecologists opinions and practice patterns. Doret M, Touzet S, Bourdy S, Gaucherand P.  J Matern Fetal Neonatal Med. 2010 Mar 17.

Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, Service d'obstétrique, F-69677 Bron, Lyon, France.

Objectives. To evaluate obstetricians' practice patterns, opinions and factors influencing decision-making about mode of delivery in women with two previous c-sections.

Methods. A questionnaire was mailed to the 160 obstetricians from the Rhone-Alpes perinatal network. Questionnaires included demographic, organisational information and questions about physicians' opinion, practice patterns and patient counseling concerning vaginal birth after c-section (VBAC) after one and two caesarean sections.

Results. Response rate was 65.6%; 100% and 23.8% would offer VBAC to women with respectively one and two previous c-sections.

Uterine rupture rate was largely overestimated in both women with one (2.8%) and two prior c-sections (14.2%).

Factors positively influencing obstetricians were cerebral palsy estimated rate less than 20%, a minimal decision to birth delay less than 20 min when emergency c-section would be required. Neonatal severe outcomes consecutive to trial of labour as well as placenta praevia or accreta risk and morbidity associated with multiple c-sections would be insufficiently discussed.

Conclusion. Obstetricians largely prefer a third planned c-section in women with two previous c-sections.

This decision is partly based on a large overestimation of immediate maternal and neonatal serious outcomes consecutive to trial of labour as well documented serious long term outcomes of multiple c-sections are insufficiently considered.  [sic]

PMID: 20233132

The Fat Vagina Theory: "Soft Tissue Dystocia"

One common misconception that many birth attendants have about labor in women of size is the "fat vagina" theory.

In this theory, birth attendants believe that women of size have a lot of extra fat tissue internally, crowding the maternal pelvis and birth canal.  Extra fat tissue then supposedly gets in the way and obstructs the passage of the baby through the bony pelvis and/or vagina.

In medical research they call this "soft tissue dystocia," but sometimes doctors will patronizingly explain it to patients as the "fat vagina" theory.

[Note: "Fat Vagina" is an actual term used by an OB to tell a friend of mine from ICAN why she had a cesarean ─ she was told her morbid obesity made her vagina "too fat" to let the baby out during labor ─ and she's not the only one who has been told that.  So although my sarcasm meter is certainly on when I use it, that's really a term that has been used with some women of size.]

Alas, it's not just doctors who buy into the "fat vagina" theory.  One TV birth show featuring a midwifery practice even promoted this same theory, encouraging a fat woman who wanted a Vaginal Birth After Cesarean (VBAC) at their birthing center to lose weight during pregnancy in order to "decrease the fat deposits in the vagina" and "make it possible" for the woman to have a VBAC. (As if no fat woman has ever had a VBAC without losing weight!  Sorry, they have. And so have I.)

Or there's the story one of my blog's readers emailed to me:

[The midwife] said I will have a large fat buildup around my birth canal and uterus so baby will get stuck in a natural birth. 

Alas, this "fat vagina" belief is a theory near and dear to many birth attendants' hearts.  They have been taught in medical or midwifery school that "soft tissue dystocia" is the cause of many cesareans in fat women, and they believe it with all of their hearts.  It's very difficult to get them to question its existence. 

But what does the evidence say? 

The Research, Such As It Is

One of the most frustrating aspects of the whole "fat vagina" theory is how little actual evidence there is on it, yet it is taught as if it is clearly established science. 

One study (Crane 1997) describes it as a possible reason for a higher primary cesarean rate in "obese" women:

Perhaps dystocia due to an increased deposition of soft tissues in the maternal pelvis may lead to the observed increase in the cesarean delivery rate.

One review (Vahratian 2005) noted that many studies attribute the increased rate of cesareans in "obese" women to soft tissue dystocia but that few prove it.

Several authors have speculated that this association [between obesity and cesarean rates] may be due to the added soft-tissue deposits in the pelvis of obese women, which coupled with a larger fetus might necessitate more time and stronger contractions to progress through labor.  However, direct evidence of fat deposition in the pelvis is needed to support this assertion.

The study noted that as yet, the authors promoting this theory have failed to provide this evidence.

Most studies discuss increased maternal fat deposits as if it is a proven concept, but no one has actually done much study showing a real difference in maternal fat compartments, let alone proven that it affects labor.

Barau et al., 2006, also favors the concept of soft tissue dystocia but acknowledges that:

There is no direct support of this concept by medical imagery studies.

So why are healthcare providers so devoted to this theory when there is very little actual proof of it? 

Most of the time, practitioners believe in the concept of soft tissue dystocia because they know that visceral fat can build up around internal abdominal organs, so they speculate that a similar thing must be happening in the maternal pelvis.

Furthermore, they often observe more tissue during pap smears in "morbidly obese" women, sometimes needing to use a larger speculum in order to hold open the vaginal vault and do the exam.  Therefore, they jump to the conclusion that there is more fat "crowding" the pelvis of women of size, and that therefore, this must be obstructing the passage of the baby through the mother's pelvis.

But just because a fat woman's vagina tends to have more tissue to hold back with a speculum does not necessarily mean that there is enough fat way up inside the pelvis (pelvic inlet) or at the pelvic outlet to be clinically significant.  

Remember, because the considerable weight of a fat woman's abdomen presses down with the weight of gravity, it may tend to make the vaginal walls more prone to collapse and look overly crowded, but it may not actually be so, or not enough to make much difference. And even if there was somewhat more tissue in a fat woman's vaginal area, remember......fat squishes.  It's unlikely that there would be enough tissue there to actually impede a baby's exit, even in very fat women. 

The one study we do have that actually did medical imagery to discover whether there are extra maternal fat deposits in the pelvis does not support the idea that there is enough extra soft tissue to be relevant to birth.

Wischnik (1992) did a study on the "fatty pelvis" to see whether fat compartments within the pelvis actually resulted in "functional reduction of the birth channel diameters."  They found slightly more fat compartments, but did not find it to be clinically relevant.  They concluded:

The common assumption can no longer be maintained, that adiposity necessarily causes soft tissue dystokia  [sic] due to larger fat compartments within the small pelvis.

So from a strictly evidence-based point of view, there is no substantiated medical evidence of enough increased deposits to be medically significant. 

All we have is the observation that there is slightly more tissue pushing in and thus more need for a stronger speculum during the pap smears of women of size. 

I think most medical providers then take a leap of logic and conclude that if fat women's babies don't come out as easily as skinny women's babies, it must be due to fat blocking the way....and the need for a bigger speculum during a GYN exam in some women of size just seems to confirm that bias. 

But I think they need to look more closely at this assumption.

Alternative Explanations

Unfortunately, despite a glaring lack of evidence, soft tissue dystocia is a concept that continues to be taught and widely believed. 

Barau 2006 argued that although there is no hard proof of soft tissue dystocia, it must exist because there is an increase in cesareans due to prolonged labor in obese women compared to average-sized women with similarly-sized babies. 

However, I will point out again that a higher rate of malpositioned babies among women of size could also explain their longer labors and increased rate of cesareans due to labor dystocia.

Babies who face their mothers' tummies (occiput posterior) don't fit as easily through the pelvis, present with a larger head diameter, and often experience long, slow, hard labors.  Research clearly shows that posterior babies have longer and slower labors and have a much higher cesarean rate than anterior babies. 

Although the subject needs further study, some research has found a higher rate of malpositioned babies in "obese" women, and very old obstetric research also often notes in passing a higher rate of occiput posterior and other malpositions in women of size as well.

And anecdotally, women of size often do seem to have more malpositions, especially occiput posterior, many of which result in cesareans.

Many of these fat women have been told they had cesareans because of their "fat vagina" or "too small" pelvis.  Yet if you read their stories carefully, they had all the signs and symptoms of a malpositioned baby instead. 

Furthermore, many women who had cesareans for "fat vaginas" went on to have subsequent vaginal births with babies that were even larger than their cesarean babies....without losing weight first. This would be impossible if the problem really were a "fat vagina." 

The key was having a well-positioned baby, not losing weight or reducing maternal pelvic fat deposits. 

Another problem with the concept of the "fat vagina" is the inconsistency with which this diagnosis is applied. If a ~275 lb. woman (like my friend from ICAN) is told that her vagina is "too fat" and prevented her baby from getting out, then it follows that a 350 lb. woman should not be able to birth a similarly-sized baby vaginally. Yet we know that women of that size can and do have vaginal births. I have birth stories on my website of vaginal births to women at 300, 350, and 400 lbs.  Yes, women of this size have a high cesarean rate because they are almost never given a real chance to actually have a vaginal birth.....but it can happen when they are given a realistic chance.

If fat vaginas truly prevented vaginal birth as much as some providers think they do, there would be NO vaginal birthers above a certain size. Sure, vaginal birth is always a combo of factors, including pelvic size/shape, the baby's size and position, (passenger, powers, position, etc.), so some variability in who gives birth vaginally is logical, but if soft tissue dystocia were a really significant factor, really supersized women would never birth vaginally.  Yet many can and do, if they have a well-positioned baby and are given a realistic chance.

In my opinion, the real issue behind a higher rate of "dystocia" cesareans in women of size is probably fetal position, not fat vaginas. 

However, because doctors are trained to blame obesity as the go-to diagnosis when they don't have another explanation, soft tissue dystocia gets blamed for "blocking" the baby's way out. 

But that's just lazy thinking, not actual proof of soft tissue dystocia.

What About Shoulder Dystocia?

Another fear that many doctors and midwives have is that extra soft tissue in a fat woman's vagina might cause such a tight fit for the baby that the baby's shoulders will get stuck ("shoulder dystocia"), which can be a true obstetric emergency.

This fear seems borne out by studies which have shown higher rates of shoulder dystocia in "obese" women. Yet many of these studies did not control for other factors, like macrosomia, diabetes, forceps/vacuum extractor, or induction, all of which increase the risk for shoulder dystocia, and most of which occur at higher rates in women of size. 

It's important to note that other studies have found that obesity is not a risk factor for shoulder dystocia when these other factors are controlled for. 

Furthermore, it is not extra fat crowding the vaginal walls that causes shoulder dystocia. Rather, shoulder dystocia is caused by obstruction by the bony pelvis, not soft tissues. A complex interplay of factors results in shoulder dystocia, including fetal position, maternal position and mobility, pelvic shape, induction, operative delivery, diabetes, and macrosomia. 

But justified or not, fear that "extra" soft tissue will cause shoulder dystocia is a big contributor to the high planned cesarean rate and early induction rate in women of size. 

But What If Soft Tissue Dystocia is Real?

Frankly, soft tissue dystocia as a concept has not been proven at all, but some care providers believe in it with all their heart and refuse to be dissuaded from the possibility, pointing out that it hasn't been disproven conclusively either.  That's a fair point.

To these providers I would argue that IF soft tissue dystocia were indeed real, then it is vital to change how most providers manage the labors of women of size in order to minimize its theoretical impact.

The typical way the labors of many "obese" women is managed often includes inducing early, breaking the bag of waters early, strongly encouraging early placement of an epidural "just in case," strictly limiting mobility, and using semi-sitting or lying back positions for pushing. Yet these measures often limit the amount of pelvic space the baby has to fit through.

If a bunch of extra fat is supposedly crowding things already, these restrictive protocols just make things worse.

IF soft tissue dystocia were real, mobility in labor would be even more important to women of size because it opens up the pelvic dimensions and gives "obese" women the best possible chance to help that baby fit through. Yet "obese" women have the most restrictions on their mobility in labor and are the least encouraged to try alternative positions for birth.

If a provider truly believes that soft tissue dystocia might be real, then the answer is not to pre-emptively induce or section women of size, but to give them every chance at creating more space in the pelvis. 

This means not having her in the usual lying back/semi-sitting position, which puts pressure on the tailbone and presses it into the pelvic cavity, reducing the space available. 

This means not requiring/pressuring her for an early epidural (as many practices encourage with women of size), so that she can move freely during labor and encourage her baby to be in a good position for birth. 

It means not breaking her waters early in labor, so the baby has the watery cushion to help it move into an optimal position. 

It means letting her stay upright as much as possible, so she can use gravity to help bring that baby down and press it through those supposedly fat-crowded walls. 

It means letting her push in whatever position feels comfortable to her, encouraging her to stay mobile, and letting her utilize things that will help her stay mobile more easily (a labor tub, a dangling support or trapeze bar, a squat bar, etc.).

Personally, I don't believe that soft tissue dystocia is clinically relevant, but if you are a provider and you firmly believe in its existence, follow that to its logical conclusion and utilize labor protocols that help that woman maximize her pelvic space, not inhibit it via restrictive protocols. 

Conclusion

Soft tissue dystocia is a belief that is near and dear to many doctors' hearts (and sadly, even to some midwives' hearts). Yet despite no research to support it, it as taught as if it is fact. 

At this point, soft tissue dystocia is NOT fact.  It has not been proven at all, and remains highly speculative as a possible cause of labor issues.

Furthermore, many women of size who have had their cesareans blamed on "fat vaginas" have gone on to have vaginal births in later births----without having lost weight first.  If soft tissue dystocia were really the cause of their cesareans, this would not have been possible. The issue for them was fetal position, not maternal soft tissue. 

The "morbidly obese" friend of mine who was told that her "fat vagina" was the cause of her cesarean?  She has since gone on to have TWO vaginal births.....at the same maternal weight, with similarly-sized babies.  So much for her "fat vagina" preventing the baby from coming out! 

And then there's the commenter on my blog who had a similar experience: 

I was told by my OB, while on the operating table and again at my 6 week check, that 'my vagina was too fat to birth a baby naturally'. Had a VBAC 3 years later though!

[Comment on 10-12-10, on Prenatal Weight Gain: The Importance of Study Design.]

Far too often, "fat vagina" is just a convenient excuse for lazy thinking, a handy scapegoat for the high cesarean rate in women of size, and a convenient excuse for blocking access to VBAC in yet another group.

And unfortunately, it prevents caregivers from examining their own care practices and how iatrogenic influences like weight bias, induction, fear of macrosomia, restrictive protocols, "failure to wait" and fetal position issues are the real factors driving the cesarean rate for women of size.  

Fat Reserves Equal Extra Nutrition On Board?

Reply turned post from My OB Said What?!:

“Well, you had a little extra nutrition on board when you got pregnant so you really don’t need to be gaining much weight.” – OB to mother who inquired about her low weight gain during her pregnancy; 

Comments like this represents another misperception that a lot of people have about nutrition and weight gain in women of size in pregnancy....that fat women are "over-nutritioned" and so have plenty of excess "nutrition" available for themselves or for a baby. 

This is one reason why some doctors champion the idea that fat women don't need to gain weight in pregnancy....they believe that because a fat woman is "over-nutritioned," she has plenty of nutrient and energy stores to draw from and therefore doesn't need the same amount of calories and/or nutrients that other women do.

For example, here's a quote from an article about doctors wanting to lower pregnancy weight gain guidelines:

Dr. Patrick Catalano of Case Western Reserve University in Cleveland said an obese woman has nutrients stored away and doesn’t need to gain weight to provide for the baby.

But does an obese woman really have "extra" nutrition stored away?  And is that really an adequate substitution for nutrients from fresh whole foods eaten during pregnancy?

The Context of the Original Post

The doc in the original post at My OB Said What?!? is probably just trying to reassure the mother that a lower weight gain is very common in women of size and not necessarily something to get very alarmed about. That's true. As long as the mother is not deliberately trying to restrict gain, her nutrition is good, and baby is growing well, things will probably be fine even with a low gain.

(As we've noted before, most women of size gain less in pregnancy than other women, and many gain very little in pregnancy even without restriction.  However, a policy of deliberate restriction to cause weight loss or little or no gain in women who would otherwise naturally gain may very well increase the risk of prematurity and too-small babies.)

The problem I have with his comment is the bit about "extra nutrition on board." He probably just meant it as a polite way to tell the mom she had extra fat reserves before pregnancy, so she didn't need to gain the same amount as women who don't already have those fat reserves. So I'll give this doc the benefit of the doubt and assume this was probably just his awkward way of saying it's not necessarily a problem if she gains less weight naturally.

But when many other doctors make this kind of comment (and I've seen it a number of times), what they really mean is that fat women can (and should) restrict intake significantly and baby will not be affected because of the fat mother's supposed extra reserves.

I strongly question the accuracy and wisdom of this.

Concerns With This Assumption

The doctors who favor strictly-limited caloric intake to restrict weight gains among women of size assume our fat reserves are basically "extra nutrition."  They reason that because we have supposedly have "extra nutrition," the baby will just take what it needs from mom and she therefore has little or no need for extra nutrition or calories.

There are several problems with restricting calories and assuming the baby will "get what it needs" from the reserves of the obese woman:

• It assumes that the mother has extra nutritional reserves just because she's got extra fat stores
• It assumes that getting nutrients from the mother's reserves is the same or at least as good as getting those nutrients directly from fresh food

Do Nutritional Reserves Really Substitute Adequately For Fresh Nutrient Intake?

Yes, the baby can get energy for growth from the mother's fat reserves, but that's NOT the same (or as valuable) as REAL NUTRITION from fresh food intake.

Doctors should be promoting a sensible diet and nutrients for mom and baby from fresh whole foods, not from the baby cannibalizing the mother's reserves.

Furthermore, if the mother's caloric intake is not sufficient for her energy needs, other things are sacrificed.  Anne Frye, midwife and author of Holistic Midwifery states:

If calories are insufficient, the body will burn available protein for energy instead. When protein is burned due to a lack of sufficient calories, less amino acids will be available for fetal growth and development, for albumin production to expand the blood volume, and to help with uterine muscle growth.

Doctors and midwives will often suggest a diet which provides plenty of protein (90-100g) but only 1500-2000 calories. Reasoning that the woman is eating a high protein diet, midwives may dismiss a woman’s diet as a causative factor when she develops toxemia [pre-eclampsia] or premature labor…Women must eat enough calories and protein from nutrient-rich sources to meet their particular requirements.

In a 2005 article,"Eating for two, gaining too much", Jacqueline Stenson quotes Dr. Michael Nageotte, then-president of the Society for Maternal-Fetal Medicine:

Though very low weight gain in some women may cause a baby to be underweight, even babies born to mothers who’ve endured famine have fared well, he says. “The fetus, being a very efficient parasite, if you will, is able to survive and get what it needs from the mother,” Nageotte says.

This is a dangerous assumption.  Although babies born during famine usually survive, they usually do so at a price. "Fetal origins" research clearly shows that many of them are at increased risk for diabetes, hypertension, insulin resistance, obesity, and heart disease later in life.  That is hardly faring "well."  Clearly, undernutrition in utero has serious potential consequences and should not be shrugged off so casually.

Furthermore, it is questionable whether the fetus is truly getting everything it needs from its mother.  Jeremy Appleton, ND, writes:

Evidence clearly contradicts the idea that a fetus can protect itself nutritionally when the mother is fasting or dieting. Although we know that a fetus can draw on maternal stores even when the mother is deficient, the extent to which this can occur is unknown. Data collected during the Dutch famine suggest that a malnourished mother protects her own body stores of nutrients at the expense of the fetus. During the famine, mothers lost proportionately less body weight (2% loss) than their fetuses (10% loss). Optimum fetal growth occurs only when the mother is able to gain a crucial amount of extra body weight during pregnancy. For this reason, pregnant women should not diet.

Naeye did a study that surveyed pregnancy outcome by weight gain over a group of over 50,000 women in 12 hospitals and found:

The fetus is exceptionally dependent on maternal nutritional reserves when mothers have very low weight gains…The quantity and balance of amino acids and other nutrients supplied from such maternal reserves may not be as favorable to the fetus as those largely deprived from dietary intake. Even large stores of depot fat do not seem to ensure an optimal outcome of pregnancy when weight gains are very low or mothers lose weight.

I think the assumption that babies will just take their nutrition from the mother's stores ─ and that this is just as good as getting it from dietary intake ─ has not been proven at all.  An "over-nutritioned" mother still needs fresh foods, adequate calories, adequate protein levels, and a wide variety of nutrients from dietary intake, just like any other mother.

Do Women of Size Really Have Extra Nutritional Reserves?

Furthermore, research shows that many people of size actually have nutritional deficits in things like iron, B-12, folate, and other areas.

For example, Schweiger 2010 recently found the following nutritional deficiencies in "morbidly obese" people just before they underwent weight loss surgery:

The prevalence of pre-operative nutritional deficiencies were: 35% for iron, 24% for folic acid, 24% for ferritin, 3.6% for vitamin B12, 2% for phosphorous, and 0.9% for calcium, Hb and MCV level was low in 19%...Patients with BMI [greater than or equal to] 50 kg/m(2) were at greater risk for low folic acid (OR = 14.57, 95% CI:1.4-151.34). 

Similarly, Aasheim 2008 found a number of nutritional deficiencies in "obese" patients:

Low concentrations of vitamin B-6, vitamin C, 25-hydroxyvitamin D, and vitamin E adjusted for lipids are prevalent in morbidly obese Norwegian patients seeking weight-loss treatment.

One author summed it up when he stated:

Though commonly considered a state of “overnutrition”, obesity has increasingly been recognized as a risk factor for several nutrient deficiencies, including lower levels of antioxidants and certain fat-soluble vitamins.

Doctors should not assume that if you are carrying "extra" weight, you automatically have plenty of extra nutrients available for baby. Many women of size actually do not.

Other Concerns

In addition, there are other concerns with placing mothers on restricted calorie diets during pregnancy:

• If the "obese" mother does not have good nutritional reserves, a restricted calorie diet makes it difficult to get the full range of nutrients needed for both the mother and the baby
• If the mothers' caloric intake is insufficent for her needs, fat stores will be burned and ketones will be spilled as a side effect, which may impair cognitive development of the fetus (as we've discussed before)

Therefore, I believe it is best to err on the side of caution and not assume that a fat mother has plenty of extra nutrients stored and can easily tolerate a restricted calorie diet.  I believe that fat mothers need the same or greater level of nutrients and similar (or only just slightly less, since we do not need to put down maternal fat stores) caloric intakes as other mothers.

Conclusion

While I think THIS doctor in THIS comment was probably just trying to find a polite way to reassure the mom about her lack of gain, many doctors have said something similar but meant it to justify restricting "obese" women's intakes in pregnancy.

Those doctors believe that the baby will draw any needed energy and nutrients from the mother's fat reserves and therefore it's fine to place the mother on highly restricted calorie diets in pregnancy.

THAT I have a problem with.

Although doctors think they are doing fat women a favor when they put them on restricted diets/weight gains, it is more likely that they are doing far more harm than good.