Fetal Over-testing in the Last Trimester Because of Fat?

This is a comment that was left on my blog recently, in the "Will I Feel My Baby Move If I'm Fat?" post. It's a new twist on the old wives' tale (more like old OB's tale) that fat women supposedly have too much abdominal fat to feel their babies move in pregnancy.

"I am 29 weeks today and a nurse practitioner I saw last week told me I have to have nonstress tests 2X week because of my weight. She claims I won't feel the baby's movements so they need to monitor them. Has anyone else been told this? I'm a very busy woman and incredibly stressed about having to go to the hospital 2X week, plus she says I have to do an ultrasound monthly, plus do my weekly doctors appts. Advice would be great because I don't want to do this but I feel I have to so the baby will be monitored appropriately."

Seriously?  A non-stress test 2x per week from 29 weeks on because a fat woman supposedly won't feel her baby's movements? 

This is pure and unadulterated bullsh*t.  Women of size feel their babies move perfectly well, thank you. There's no fat between the baby and the inside of the uterus; we feel every roll and punch and kick.

Nearly every woman of size I've ever spoken to has said that yes, they feel their babies move just fine; I certainly did. Yet this myth about fat "preventing" women from feeling their babies still persists. That it persists among the public is disappointing but attributable to ignorance; that it persists among some healthcare providers is nothing short of appalling.

But the second question here is whether fat women are so incredibly high-risk from "obesity" alone that we have to be monitored 2x/week from the middle of the second trimester on?  Yet other women only start monitoring around week 41? Oh puleeeze.

Even most diabetics aren't monitored this aggressively. Insulin-dependent diabetics usually start fetal surveillance around 32 weeks. For gestational diabetics not on insulin, the need for fetal surveillance is widely debated; if used at all, it is usually introduced around the end of pregnancy.  Only diabetics with severe comorbid complications like vascular issues or kidney disease usually benefit from this kind of aggressive monitoring starting in the late second trimester. Are the providers in the above scenario seriously comparing the risk of an uncomplicated pregnancy in an obese woman to that of a brittle type 1 insulin-dependent diabetic with pre-existing kidney damage?

The only time I can see this kind of over-the-top monitoring being truly needed in a woman of size would be in someone who has experienced serious major poor outcomes in a previous pregnancy, or who is experiencing major complications in a current pregnancy (HELLP syndrome, hypertensive disorders, prior stillbirth, brittle or uncontrolled diabetes, diabetes with comorbidities, IUGR, or various other serious complications). The commenter didn't mention any such comorbidities.

Now, the argument some docs make for increased fetal surveillance in "obese" women is that some studies have shown an increase in the risk for stillbirth in these women.  However, not all studies have shown an increase in the risk of stillbirth in obese women. Moreover, there is no data to prove that aggressive monitoring in obese women lowers the risk for stillbirth.  

It is questionable whether obesity itself, without concurrent complications like HELLP or uncontrolled diabetes, necessitates this kind of frequent monitoring.  It is telling that most care providers do not require it. The American College of Obstetricians and Gynecologists (ACOG) does not currently recommend increased antepartum surveillance in the last trimester for obese women.  Nor does the Society of Obstetricians and Gynaecologists of Canada (SOGC).  And research suggests that obese women don't have more poor results on non-stress tests.

Although there may be a somewhat higher risk for stillbirth in women of size, and although non-stress tests and biophysical profiles can sometimes help identify babies at high risk for stillbirth, these tests don't always help and come with downsides too. The rate of  false-positives is quite high, and often results in unnecessary interventions like early induction of labor or cesareans, and these also carry risks.

So while I can understand some providers wanting to offer this as an option to women of size (especially those who experience comorbid complications like hypertension disorders or restricted growth), I strongly question the value of its routine use in women of size with uncomplicated pregnancies. Furthermore, the testing schedule this woman has been put on is quite excessive (barring some complication we are not aware of).

Awareness of the possibility of complications in women of size is one thing, but clinicians must remember that over-testing brings its own risks and often becomes a self-fulfilling prophecy.

I've been through four pregnancies as a "morbidly obese" woman and I was never required to do this kind of monitoring. Nor do I know many other fat women who have been required to do this extreme amount of monitoring. And I can assure you that I most definitely felt my baby well enough to do kick counts by the end of pregnancy.  The idea that non-stress tests or biophysical profiles are required because fat women are too fat to adequately keep track of their baby's movements is ludicrous.

Commenter, unless you have some major complication we don't know about, you might want to think about running far and fast from this practice so you can find one that doesn't see you as such a ticking time bomb.  Pick a practice that knows that fetal surveillance testing has both pros and cons, that knows there is a high risk of false positives and over-intervention with these tests, and that is willing to discuss these pros and cons with you and let you make the final decision on their use instead of compelling you to follow an arbitrary schedule of testing virtually designed to find problems and intervene.

*How about you?  If you are a woman of size, have you been required to have such aggressive fetal surveillance from so early on?  What kind of fetal testing was recommended for you as a woman of size by your providers?