We have been doing a long series about Lipedema, sometimes known as "painful fat," "big leg," "riding breeches," or "two body" syndrome.
In lipedema (also spelled lipoedema), the fat cells in certain parts of the body experience overgrowth and swelling. It results in an abnormal accumulation of fat, particularly in the lower half of the body; often the arms are affected too.
As we have discussed, lipedema is rarely recognized by doctors, despite being discovered 75 years ago. Often it is thought to be simple obesity, or it is confused with "lymphedema," the accumulation of lymph fluid in the interstitial areas.
In Part One of this series, we discussed the typical features of lipedema and how differentiate between lipedema and lymphedema.
In Part Two of the series, we discussed how lipedema progresses, the different stages of progression, and why it's so important to be aware of lipedema
In Part Three of the series, we discussed the different types of fat distribution patterns, looked at some pictures to illustrate type and stage of lipedema, and detailed how lipedema is diagnosed.
In Part Four of this series, we examined possible causes of lipedema, as well as medical conditions often associated with it.
Now, in Part Five, we are discussing possible treatments for lipedema in detail. Because we want to give more detail about each option, we broke the treatments into several sub-posts:
In Part Six, we will discuss practical ways to deal with and live proactively with lipedema. Eventually, I'll tell my lipedema story too, and someday I'll discuss lipedema and pregnancy considerations.
But today, let's summarize what we have learned of the various lipedema treatment options.
Dealing with a New Diagnosis
First, getting a diagnosis of lipedema and/or lipo-lymphedema can be overwhelming emotionally. It's hard to know what questions to ask, which treatments to consider, or where to go for answers.
Sarah Bramblette, a lipedema activist and advocate who has been a great voice for education about this condition, discusses what to do when you are new to the topic or diagnosis of lipedema. Read her really helpful article here.
Remember, even when lipedema is recognized and correctly diagnosed, patients are often not given adequate information about it or treatment for it. You will probably have to be very proactive about educating yourself about this condition and your treatment options.
If you need help educating your care provider about lipedema, try printing out some of these materials:
Lipedema Brochure from fatdisorders.org - excellent quick-glance brochure, with clear pictures illustrating the progression of lipedema through the classic four stages. Start with this
NHS informational page on lipedema - basic introductory informational page on lipoedema from the National Health Service in the United Kingdom
Lipedema Description Page from fatdisorders.org - a more in-depth look at lipedema's symptoms, treatment choices, and diagnosis differentials, with study references (download it to another file and edit it to make it easier to read)
Lipedema History, Stages, and Types - short informational article from liposuction specialty center on the history of lipedema's diagnosis, with a quick summary of its stages and types
Fife 2010 article on lipedema - educational article, written for provider, on lipedema, its stages, its progression, diagnosis differential, etc. Full text freely available, with helpful pictures showing advanced stages and differing presentations. Does have some weight bias; advocates "rigorous weight control" and seems to suggest bariatric surgery for some cases
Because most doctors have not heard of lipedema as a condition, they can respond in varied ways to a patient who raises this concern. Although some respond very helpfully, many women experience resistance from their providers.
Some providers use a deny-or-ignore approach. Some want to completely deny that such a condition exists, and may even accuse the patient of "making excuses for being fat." There's not much you can do with these providers except find a new one. Don't let them discourage you so much that you avoid care or don't pursue treatment.
Some providers are sympathetic but tend to ignore the concern. They may not feel qualified to diagnose this condition themselves and aren't sure who to refer you to. Many feel stymied by the lack of ICD-9 diagnostic code (coming but not approved yet). If you have one of these providers, ask them to at least insert a note regarding lipedema under the "obesity" diagnosis in your chart. This creates a record of it and precedent for treatment if you experience complications.
Sometimes patients are given a doom-and-gloom diagnosis that tells them that they have an incurable progressive disease, that nothing much can be done to treat it, and that they will get progressively more and more disabled with time. Don't believe these providers. There are options for treating lipedema, and there is hope that its progression can be halted or slowed. We are still in the infancy of learning about lipedema, but it is NOT hopeless.
Some care providers diagnose lipedema readily but have an advocate-for-yourself approach. They feel too pressed for time to educate themselves about treatment options, or feel they can't refer patients for treatments because of the lack of ICD-9 code. As a result, too many people with lipedema just live with the condition instead of getting treated. That's what this series is for ─ so lipedema patients can become proactive about advocating for their treatment needs with their providers.
If you need more information about lipedema and its various treatment choices, consider watching this video about lipedema. It's 24 minutes long and does have weight-loss rhetoric so I won't embed it here, but it also has some good basic information about lipedema. It has interviews with many of the leading doctors who treat lipedema, interviews with people who suffer with it, and information about some of the treatment options people have used for it (with an emphasis on liposuction).
Summary of Treatment Options
Basically, in this series we discussed four types of treatment options for lipedema:
Traditional medical treatments
Weight and nutritional approaches
Liposuction
Alternative medicine
What little research we have on lipedema is mostly on traditional mainstream treatments. Because lipedema was most often discovered by lymphedema doctors, many treatments come from that modality and focus primarily on dealing with edema.
Research shows that Manual Lymph Drainage plus compression (Complex Decongestive Therapy) is very effective for lessening the worst symptoms, particularly if lipo-lymphedema has developed. This treatment is well-accepted in the medical world, and most insurance covers at least part of these treatments.
Exercise is also very important in keeping lymph flow as normal as possible. The lymph system does not have a pump like the vascular system does, so it needs exercise to keep the lymph moving in the system. Exercise is a powerful tool, especially in the early stages to keep the lipedema minimal. Water exercise, rebounding, exercise bikes, and yoga are all good size-friendly options. Although advanced lipedema makes exercise quite difficult, it's helpful to find something that you can do to keep that lymph flowing and prevent infections.
Weight loss is often still recommended to lipedema patients, even though lipedemic fat is quite resistant to weight loss and any loss usually returns. Anecdotally, a few women have been able to lose significant amounts of weight with lipedema long-term, but the majority end up in a long-term yo-yo pattern that tends to increase weight, not decrease it. Women with severe lipo-lymphedema are often driven to bariatric surgery because of health issues and mobility concerns, but even then, much of the weight tends to return in time and complications like nutrient deficiencies can impact quality of life.
Although some care providers still prescribe weight loss and bariatric surgery, others simply emphasize trying to prevent further weight gain. While it is important to have healthy habits, providers need to be careful not to blame women if gain does occur. Some aspects of weight are not within our control, and lipedema flares can cause weight gain no matter how careful our habits.
As an alternative to a weight-centric approach, some patients choose Health At Every Size® instead, emphasizing healthy habits but without engaging in restrictive eating, extreme exercise, or an emphasis on the scale. For many women who have struggled with their weight, eating behaviors, or judgmental providers, this can be a very freeing and healthy approach.
Many lipedema websites promote special nutritional plans as a way to control lipedema symptoms. The most popular is the RAD anti-inflammatory diet, which suggests avoiding gluten, sugar, red meat, and dairy, among other things. Although promoted as the treatment of choice for lipedema, the efficacy of this diet has never actually been researched. Other nutritional plans include low-carb or paleo approaches. While some women seem to have good anecdotal results with various plans, there is a very slippery slope between these plans and eating-disordered behaviors.
Lymph-sparing liposuction is the lipedema treatment getting the most buzz lately. Although traditional liposuction was disastrous for lipedema patients, new techniques using either tumescent liposuction or Waterjet-Assisted Liposuction (WAL) seem to show great promise. Although long-term research is limited so far, short-term research on this approach is quite promising. It shows that lymph-sparing liposuction may offer the best hope for putting lipedema into remission, lessening pain, and giving patients years of mobility back.
Finally, some lipedema patients use alternative treatments, and many leading lipedema doctors recommend them in addition to mainstream treatments. Research is limited on alternative treatments, but some research supports the efficacy of certain herbs and supplements such as Selenium and Butcher's Broom.
Conclusion
Although we have no way yet to cure lipedema, the symptoms can be treated in several ways, including mainstream medical treatments, nutritional approaches, liposuction, and alternative medicine.
And of course, you don't have to be a purist; many women mix different types of treatments. It's not unusual to hear of women using Complete Decongestive Therapy, exercise, a RAD diet, supplements, dry lymph brushing, acupuncture, and Epsom salt baths to treat their lipedema. Many hope to access lymph-sparing liposuction as it becomes more widely available.
Whatever the approach, the point is to not take lipedema lying down. One site says:
...We have established an international organization to promote lipedema healing. We are in a good place. We are not waiting to die or be pushed around in wheel chairs. We are not waiting to get help from doctors who do not yet have answers. We are working with researchers internationally to begin clinical trials.
Decide on a way to be proactive about your lipedema. Keep an open mind, educate yourself about your options, consult a knowledgeable care provider, and then be willing to experiment with the different options available.
In time, you will find the choice that is right for you.
References and Resources
Resources
*Trigger Warning: Many of these sites are not size-friendly. However, because they also contain valuable information about lipedema and its treatment, they are included here.
http://lipedmeasimplified.com - Website of Catherine Seo, a leading advocate for raising awareness about lipedema; has information about various treatment choices
http://www.lipomadoc.org/lipedema.html - Website of Karen L. Herbst, PhD, MD, one of the most pre-eminent researchers on lipedema. She is an endocrinologist practicing in Arizona
Typically their positions were more upright so as to use gravity to help move the baby down, although other positions were seen as well.
Today, though, let's talk about one practice found in both traditional societies and in modern hospital obstetrics that may actually be harmful ─ fundal pressure.
Fundal Pressure
As we have mentioned before, although ancient societies had a great deal of birth wisdom, ancient is not always better. Just because an ancient society used a particular position or technique does not necessarily make it a good idea.
One technique that is occasionally found in some ancient or tribal cultures that is not supported by research is Fundal Pressure (pushing down on the top of the mother's uterus to try to hurry up labor or force a baby out).
Sadly, this is one ancient practice that is still found in the modern obstetric world ─ but it shouldn't be. It is probably not helpful and is often harmful ─ especially when used during shoulder dystocia.
Managing a difficult labor in Siam by
pulling down for fundal pressure;
Englemann book*
Several cultures used the pressure of a birth helper's arm to press down on the woman's uterus during labor. Usually this was just added during a difficult birth as a last resort, since few other options existed and a cesarean was only done if the mother had already died or was dying. Most of the time, it was truly an option of last resort.
Using a sheet to exert fundal pressure during labor;
Drawing by G. Devy from Witkowski book*
However, sometimes it was used routinely during labor in certain cultures and times, as in the image above from California in about 1840. Although this downward squeeze was less forceful and more gradual than other fundal pressure techniques, it also holds some risks.
Although not common, fundal pressure was a technique seen in some ancient cultures. However, its use in modern settings is highly questionable.
Still Used in Many Hospitals
Fundal Pressure on a birthing mother Photo credit: Lieve Blancquaert, WHO Reproductive Health Library
This ancient technique was brought into the hospital because in the mid-20th century, women birthed flat on their backs with feet elevated into stirrups (the "lithotomy" position). Usually the women were heavily drugged and had difficulty helping the baby to move down. Babies needed to be born as quickly as possible because of frequent fetal distress due to the drugs and the on-the-back position. As a result, hospitals tied women down, cut giant episiotomies to widen the vagina, and had nurses use fundal pressure to push while the doctor used forceps to pull the baby out as quickly as possible.
Despite the fact that such dangerous drugs are not used anymore, fundal pressure is a technique still seen in some hospitals. In the medical literature, it is often called the Kristeller Maneuver, after Samuel Kristeller, the doctor who wrote about its use.
Fundal pressure is when someone presses down on the top of the mother's uterus, on the area nearest her ribs at full term. Sometimes it's done with steady continuing downward pressure, as when an arm or a tightening abdominal binder is used, and sometimes it was a series of short, sharp, very forceful pushes on the top of the uterus during contractions (Kristeller's Maneuver**).
It is most often added during a slow labor, or when the mother is perceived as not being able to push very hard because she is tired or has an epidural. Care providers theorized it would increase intra-abdominal pressure, resulting in greater expulsive forces. In some areas of the world, it is added routinely during pushing to get the baby out faster.
Some hospitals have even been experimenting lately with routinely using an inflatable abdominal binder on women with epidurals, who may have difficulty moving the baby down through the pelvis because the muscles in that area are partially paralyzed from the epidural. [This is probably similar to the sheets used in the California picture in the last section, a slow squeeze downward.]
Fundal pressure used to be used routinely in U.S. hospitals, but its use has declined. However, some do still use it.
Listening to Mothers II, a 2006 survey of birthing women in the United States, found that 17% of mothers reported having fundal pressure applied during their births. If nearly 1 in 5 mothers are still experiencing fundal pressure that recently, then it is still a fairly common intervention that must be examined closely.
Some care providers utilize fundal pressure in the belief that it shortens labor, especially in the pushing stage. A Cochrane Review and the World Health Organization review have found few randomized controlled trials on its use and have concluded that there is not enough good evidence to evaluate this practice.
However, a randomized controlled trial published after the Cochrane review found no reduction in the duration of pushing. Even in studies that have found modest effects on the length of pushing, this was offset by a trade-off of risks, including an increase in perineal lacerations, anal sphincter tears, urinary problems afterwards for the mother, and increased admissions to the Neonatal Intensive Care Unit (NICU) for the baby.
Henci Goer has written a great review of the research examining fundal pressure in labor. She concluded that there are no real benefits, and that more mothers experienced anal sphincter tears and more babies experienced nerve damage injury when fundal pressure was used.
One review suggested that many more injuries from fundal pressure go unreported because the providers are afraid of being sued:
Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved.
Obviously, there can be serious harms with the use of fundal pressure. Yet because of widespread fear around being sued, many of these harms are probably being under-reported, helping to keep this practice alive.
Fundal Pressure During Shoulder Dystocia
Image from elpartoesnuestro.es
Fundal pressure during labor results in little benefit and is associated with some degree of harm. It is a practice that should be stopped.
However, fundal pressure when a baby's shoulders get stuck (shoulder dystocia) is CLEARLY harmful. It should have been abandoned long ago ─ yet it is still practiced in many institutions. Vacuum extraction/forceps plus fundal pressure seems to be a particularly dangerous combination.
Suprapubic Pressure for shoulder dystocia.
This is not the same as fundal pressure
Please note that suprapubic pressure is different from fundal pressure. Suprapubic pressure is a common and accepted maneuver for use with shoulder dystocia. It puts pressure on the mother's pubic symphysis joint ─ down low, not up high like fundal pressure. It is done to try to push the baby's top shoulder (which is stuck behind the pubic symphysis in a shoulder dystocia) under the bone. It accomplishes this by pushing the baby's impacted shoulder down and through, or by pushing the baby's shoulders towards each other, thereby reducing their width and helping them to move through.
Please note that we are also not talking about postpartum fundal massage. This is a technique sometimes done after the baby is delivered to try and help the uterus contract more efficiently and to help reduce significant postpartum bleeding.
Fundal pressure during labor, on the other hand, is pressing forcefully on the TOP of the mother's uterus (the "fundus," which is near the ribs at term), usually while pushing, to try and give more force to move the baby through the pelvis. Here is a picture of what fundal pressure in labor looks like.
Fundal pressure. The pushing is at the top of the uterus (fundus),
unlike suprapubic pressure, where the pushing is much lower,
on the mother's pubic symphysis pelvic joint
Fundal pressure is harmful in shoulder dystocia because the baby's shoulder is already trapped behind the pubic symphysis and pushing harder doesn't resolve the problem, but rather rams the baby harder into the mother's bones.
Fundal pressure combined with the care provider pulling on the baby's head/neck area can damage the baby's nerves, resulting in Brachial Plexus Palsy (BPP). Although many cases of BPP resolve with time, some do not, leaving the baby permanently damaged.
Research shows that the risk for Brachial Plexus Palsy increases in the presence of fundal pressure. One review of obstetric maneuvers for shoulder dystocia states (my emphasis):
Excessive force must not be applied to the fetal head or neck and fundal pressure must be avoided. These activities are unlikely to free the impaction and may cause fetal and maternal injury.
Another review notes that BOTH the Royal College of Obstetricians and Gynaecologists (RCOG) from the U.K. and the American College of Obstetricians and Gynecologists (ACOG) from the U.S. recommend against fundal pressure for shoulder dystocia:
In any case fundal pressure should not be used for the treatment of SD because it could worsen the impaction, with subsequential risk of fetus or mother injury.
In fact, the most recent guidelines on managing shoulder dystocia from ACOG state outright (their emphasis): "CAUTION: NEVER USE FUNDAL PRESSURE."
Similarly, RCOG's latest guidelines state, "Fundal pressure should not be used."
However, despite these recommendations and research that fundal pressure worsens outcomes, recent studies suggest that fundal pressure is still used too often when shoulder dystocia is encountered.
Fundal Pressure Around the World
Image from elpartoesnuestro.es
Unfortunately, fundal pressure is not a remnant of the past. It is still being used today.
Sometimes it is the slow steady downward pressure of an arm, as in the picture above, and sometimes an inflatable belt substitutes for the arm so the nurse doesn't have to be present all the time. And sometimes it is still the short, sharp downward pushes on the fundus (as Kristeller described), seen in the video below.
The good news is that use of fundal pressure has decreased in U.S. hospitals. In 1990, one nationwide survey of hospital nurses found that 84% of their hospitals used fundal pressure at times, but a study from 2005-6 in a Maryland hospital found a huge drop to a 5.9% rate of fundal pressure.
However, also remember that the Listening to Mothers II Survey in the same year reported that 17% of women had experienced fundal pressure during their labors. That's nearly 1 in 5 women.
Recent online discussion has suggested that it is most common in mid-Europe and Eastern Europe, as well as many Spanish-speaking countries. Korean hospitals seem to be pushing the inflatable abdominal binder as a way to use fundal pressure on women with epidurals. Italian hospitals have also investigated inflatable binders.
One hospital in Egypt reported recently that fundal pressure was used in 24% of the births there. A Brazilian study reported the use of fundal pressure in 37% of births.
A recent large study from Japan surveyed 1,430 hospitals and found that 89% of hospitals reported using fundal pressure in at least some of their births. Among the women who birthed vaginally, about 11% experienced fundal pressure. The survey documented six cases of uterine rupture and one maternal death due to complications from fundal pressure. Obviously, this practice can be associated with significant harms, yet the authors did not call for ending its use, only for clearer indications and better training on its use.
One recent study from Spain found that when pushing phases were "prolonged," doctors used fundal pressure nearly 70% of the time. The Ministry of Health and the Spanish Society of Ginecology and Obstetrics (SEGO) estimated that in 2010, the Kristeller Maneuver was used in at least 26% of births. As a result, there is a major campaign to stop the use of fundal pressure in Spanish hospitals at elpartoesnuestro.es.
The above youtube video graphically shows the Kristeller Maneuver in a classic lithotomy birth from 2007. Be warned, it's a very rough video to watch.
There are a number of other youtube videos that showsimilarscenes of fundal pressure, usually with the woman flat or nearly flat on her back. (Be aware that some of them are graphic and involve episiotomies.) Every time I see one of these videos, I think how much simpler and safer it would be to simply get the woman into an upright position instead of using fundal pressure.
From the ease of finding such videos, it seems clear that fundal pressure is a technique still used in many countries today, frequently in concert with on-the-back positioning and episiotomy. It is still an accepted practice in far too many countries. It is time for this barbaric practice to STOP.
A Recent U.S. Fundal Pressure Story
Although less common in the U.S., fundal pressure is still sometimes used in U.S. hospitals too ─ even during shoulder dystocia when it CLEARLY contra-indicated.
In fact, a personal friend of mine had fundal pressure used on her ONE year ago this month when she experienced a shoulder dystocia in the hospital. It is in honor of that child's upcoming first birthday that I write this post.
I wasn't at the birth, but from the description of a nurse and midwife (who was acting as a doula) and the grandmother, the pulling force on the baby and the fundal pressure used on the mother was quite excessive.
I questioned them very closely about what exactly was done, and it seems clear that indeed it was fundal pressure and not suprapubic pressure that was done ─ and done very strongly. The traction on the baby was also VERY significant. Frankly, it's truly a miracle this baby did not sustain a BPP injury.
In the end, the baby's arm was broken and her ability to move was damaged for several months. The mother suffered significantly postpartum as well, with excessive bleeding, retained placental fragments, swelling, an infection, and urinary retention for more than a week. The mother needed a D&C eventually to get out all the placental fragments, and she had a long hard physical recovery.
With treatment (mostly Craniosacral Therapy, which is amazing for birth trauma), the baby is doing well now. Her broken arm has healed and she seems to have regained full use of it. They still have some concerns about her movement, but by and large she seems to have healed. She is lucky that she (apparently) didn't suffer more permanent damage, considering the amount of force that was used. The mother has also physically recovered, but was emotionally quite traumatized. Indeed, both the grandmother and the doula were left with significant emotional scars as well.
It's important to acknowledge that the mother had insulin-dependent Gestational Diabetes, a strong risk factor for shoulder dystocia, but the baby was average-sized and perfectly proportionate. The mother was also average-sized, athletic, and in very good shape, yet she still had a significant case of GD.
Because of her GD, it's possible this mother may truly have had a difficult shoulder dystocia no matter how the birth was managed, but it seems to me there is a good chance this highly traumatic birth could have been avoided if the mother had not been induced, kept in bed, kept on her back, and had fundal pressure and traction used in her birth. The doula (who is also nurse and midwife, remember) felt strongly that this birth had been badly managed.
And of course, the mother has been told that she HAS to have a cesarean for any subsequent children, which she is naturally happy to consider after the emotional and physical trauma of this birth. So the mother will likely endure the invasive trauma and all the risks of surgery in the future for a situation that might have been avoided (or at least better handled).
I am outraged by the subpar treatment this mother received, angry that her baby was endangered, and APPALLED that fundal pressure was used during a shoulder dystocia in this day and age, despite all the professional recommendations to the contrary.
Remember, this story happened only last year, and it was in the U.S. where fundal pressure is fairly uncommon now. Imagine how many stories similar to my friend's story must be happening in non-U.S. hospitals, where fundal pressure is far more common. This practice must stop.
Summary
Image from elpartoesnuestro.es
Fundal pressure was done in tribal societies, but was done largely as a desperate, last-measure resort in a difficult and prolonged labor. Since they did not have recourse to a safe cesarean as an alternative during a difficult labor, fundal pressure became part of the folk tradition. Although a few cultures did use it as a regular part of their labor practices, it was mostly reserved for prolonged, obstructed labors.
While much wisdom can be gained from tribal and historic birthing practices, that doesn't mean that everything they did is appropriate anymore. We do have safer and more humane alternatives for some things nowadays; fundal pressure is not the only option anymore when faced with a long, hard labor.
Fundal pressure came into use in hospital settings in response to highly-drugged mothers in order to get the babies out as quickly as possible. The potential harm from fundal pressure was seen as less dangerous than the risk for fetal distress from drug exposure and hypoxia (low oxygenation).
However, birth conditions today are much different than they were in the mid-1900s. While many women are still exposed to drugs through epidurals today, the fetal exposure in epidurals is considerably lower than the IV drugs of the past, and the drugs used now are safer than the ones used previously. Labor does not have to be rushed in order to minimize the risk for fetal distress and hypoxia anymore.
There are simpler, safer and more humane alternatives to fundal pressure during labor.Research shows that these include:
Simply get the mother more upright. This helps the mother work with gravity instead of having to push against it. A Cochrane review shows that this can shorten labor significantly
Avoid routine epidurals. Research shows that epidurals are a significant risk factor for malpositions and stalled labor. Although women should always have the choice for epidurals if they want them, many could go without epidurals if they had better support during labor and alternative options for pain relief (like water immersion).
If an epidural is used, utilize delayed pushing and passive fetal descent. In many hospitals, once full dilation is reached, the mother is instructed to push immediately and forcefully. However, substantial research shows advantages to delaying pushing, letting the mother "labor down" first, using passive fetal descent before active pushing is begun
Be more patient instead of rushing labor. Oftentimes, baby just needs time to shift into a better position for birth or for its head to mold more fully. Once that is done, many cases of "stalled labor" progress just fine. Avoid arbitrary timelines and judge each case individually
Be more proactive if the baby is malpositioned. Many cases of prolonged labor are due to a poorly-positioned baby. If mobility, positions, and more time do not work, consider manual rotation of the baby, as this has a high rate of success with far less risk than fundal pressure
If none of these techniques help, then a cesarean can be considered. Although cesareans are a significant surgery and should not be used without true need, they are far safer now than they used to be. Sometimes they can be the best choice in a long, hard, non-progressive labor.
Similarly, even during the obstetric emergency of shoulder dystocia, there are FAR better alternatives than fundal pressure:
McRoberts plus Suprapubic Pressure - The first procedure usually recommended for shoulder dystocia is to flex the mother's knees back towards her shoulders (McRoberts maneuver), combined with suprapubic pressure. These two maneuvers together resolve about half of all shoulder dystocias without need for further maneuvers
Internal Rotational Maneuvers - There are a number of maneuvers that involve the care provider putting their hands inside the mother and helping the baby rotate its shoulders into an oblique (diagonal) presentation, which gives more room for the baby to get out. In addition, the posterior arm can be delivered, which reduces the width of the shoulders
Move the Mother's Position - Many midwives know that moving the mother is often even more effective than internal maneuvers. Although most doctors have not been trained in these maneuvers anymore, rolling the mother onto all fours (the Gaskin maneuver), moving her into an asymmetric position so that one hip is higher than the other, or raising the mother's pelvis and having her arch her back strongly (Walcher's Position) are all positional changes that can work for resolving shoulder dystocia. Many of these were recommended in old obstetric textbooks but have gone out of routine practice; it is time for these to be re-explored in modern obstetrics
To summarize, research suggests that there is no real benefit from fundal pressure during labor. Any possible benefits of a slightly shorter labor in a very few studies have been offset by more perineal damage, more babies in the Neonatal Intensive Care Unit (NICU), and more fetal nerve damage. Furthermore, sometimes fundal pressure can even result in catastrophic damage such as uterine ruptures, uterine prolapse, or even deaths.
Furthermore, fundal pressure during shoulder dystocia is a disaster waiting to happen. Every major organization recommends against its use during shoulder dystocia, yet my friend's horrendous story from only a year ago shows that it is STILL being used in response to shoulder dystocias, despite these recommendations. It is time for hospitals to make a concerted educational effort to eliminate its use.
There are other options that work just as well or better than fundal pressure, and with far less risk. Upright positions, fewer epidurals, delayed pushing, more mobility, more patience, and manual rotation are all options to help a labor that is slower than expected. If shoulder dystocia occurs, McRoberts position plus suprapubic pressure resolves most cases; other maneuvers usually resolve the rest. Fundal pressure in a shoulder dystocia only makes the problem worse and often damages the baby or mother.
Although the use of fundal pressure has decreased, more education is obviously needed, both against "routine" fundal pressure during pushing, and particularly against fundal pressure during shoulder dystocia.
With all we know about the risks of fundal pressure and its lack of any real benefit, it is appalling that fundal pressure is still being used during labor or shoulder dystocia in many hospitals around the world. It is clearly a procedure that is outdated and associated with far too many risks.
Unlike our ancestors, we have other options now. There is just no excuse for fundal pressure to still be in such common use in the world today.
References
Obstet Gynecol Surv. 2005 Sep;60(9):599-603. The role of uterine fundal pressure in the management of the second stage of labor: a reappraisal. Merhi ZO1, Awonuga AO. PMID: 16121114
Among the maneuvers that are used in the second stage of labor, uterine fundal pressure is one of the most controversial. The prevalence of its use is unknown. We reviewed the existing literature to assess whether there is justification for the use of fundal pressure in the contemporary management of the second stage of labor. Only one randomized, controlled study and a few prospective studies, review articles, and case reports have been published. No confirmed benefit of the procedure has been documented and a few adverse events have been reported in association with its use. Alternative management strategies in the second stage of labor exist and should be considered whenever possible. In conclusion, the role of fundal pressure is understudied and remains controversial in the management of the second stage of labor. We believe that caution should be exercised using this maneuver until it is proven to be safe and effective....
MCN Am J Matern Child Nurs. 2001 Mar-Apr;26(2):64-70; quiz 71. Fundal pressure during the second stage of labor. Simpson KR1, Knox GE. PMID: 11265438
The role of fundal pressure during the second stage of labor is controversial and can result in clinical disagreements between nurses and physicians. Clearly the time for resolution of this issue is not when there is a physician request at the bedside in front of the patient. A prospectively agreed upon plan specifying how this request will be addressed is ideal. In order to develop this plan, risks, benefits, and alternative approaches to the use of fundal pressure should be reviewed by an interdisciplinary perinatal team. Much of the data about maternal-fetal injuries related to fundal pressure are not published for medical-legal reasons; however, anecdotal reports suggest that these risks exist. Unfortunately, it is therefore difficult to quantify with any degree of accuracy the exact number of maternal-fetal injuries that are directly related to use of fundal pressure to shorten an otherwise normal second stage of labor. However, there is enough evidence to suggest that if injury does occur when fundal pressure is used, there are significant medical-legal implications for the health care providers involved. This article will review what is currently known about fundal pressure including risks, benefits, and alternative approaches. In that context, suggestions will be offered for a safe approach to managing the second stage of labor.
J Obstet Gynaecol Res. 2014 Apr;40(4):946-53. doi: 10.1111/jog.12284. Epub 2014 Jan 15. Fundal pressure during the second stage of labor in a tertiary obstetric center: a prospective analysis. Moiety FM1, Azzam AZ. PMID: 24428496
...This was a prospective observational study set in a tertiary teaching and research obstetric hospital [in Egypt]. A total of 8097 women in labor between 37 and 42 gestational weeks with a singleton cephalic presentation were enrolled. Subjects were subdivided into two groups: fundal pressure group (n=1974 women) and control group (n=6123 women). The primary outcome measure was the duration of the second stage. The secondary outcome measures were maternal outcomes (immediate or delayed) and neonatal outcomes. RESULTS: The prevalence of fundal pressure in our center was 24.38%. Fundal pressure maneuver significantly shortened the duration of the second stage among primiparous women, increased the risk of severe perineal laceration and admission to neonatal intensive care unit in comparison to the non-fundal group. Delayed maternal outcomes showed significant increase in dyspareunia and de novo stress urinary incontinence in the fundal pressure group. CONCLUSION: Although fundal pressure maneuver shortens the duration of the second stage of labor among primiparous women, it should not be used except when indicated, and under strict guidelines owing to its adverse maternal and fetal outcomes.
J Turk Ger Gynecol Assoc. 2010 Jun 1;11(2):95-8. doi: 10.5152/jtgga.2010.07. eCollection 2010. Shortening the second stage of labor? Mahendru R1. PMID: 24591907
...A pilot study comprising 209 primigravidae between 37 and 40 gestational weeks with singleton fetus in cephalic presentation admitted to the delivery suite were considered and were randomly allocated into two groups: I (n=101) and II (n=108), with or without manual fundal pressure, respectively, during the second stage of labor...RESULTS: There were no significant differences in the mean duration of the second stage of labor and secondary outcome measures. Significant adverse findings having no mention in the earlier literature, were noticed which were: one case each of retained placenta and uterine prolapse besides increased evidence of maternal exhaustion and perineal injuries (including one case of complete perineal tear) in the group where fundal pressure was exercised. CONCLUSION: Application of uterine fundal pressure in a delivering woman was not only ineffective in shortening the second stage of labor but added to the risks during parturition.
...In this prospective observational study, the station of the fetal head was measured using the angle of progression (intrapartum ultrasound) just prior to the intervention of the managing obstetrician in 52 women with prolonged second stage of labor. The managing obstetricians were blinded to the sonographic results. The decision of performing a Kristeller maneuver was taken by the obstetricians based on digital palpation and their experience...RESULTS: Kristeller maneuver was performed in 36/52 (69.2%) cases. There were no significant differences between the Kristellerand the non-Kristeller group regarding the angle of progression. There were no significant differences between both groups with respect to delivery mode, perineal tears, episiotomy, bleeding, Apgar score, and umbilical artery pH value. CONCLUSIONS: Our study failed to define any criteria followed by obstetricians when performing a Kristeller maneuver in cases of prolonged second stage of labor. There was no relation between the angle of progression and the decision to perform a Kristeller maneuver.
Acta Obstet Gynecol Scand. 2009;88(3):320-4. doi: 10.1080/00016340902730326. The effect of uterine fundal pressure on the duration of the second stage of labor: a randomized controlled trial. Api O1, Balcin ME, Ugurel V, Api M, Turan C, Unal O. PMID: 19172441
...One hundred ninety-seven women between 37 and 42 gestational weeks with singleton cephalic presentation admitted to the delivery unit. METHODS: Random allocation into groups with or without manual fundal pressure during the second stage of labor...CONCLUSION: Application of fundal pressure on a delivering woman was ineffective in shortening the second stage of labor.
Arch Gynecol Obstet. 2009 Nov;280(5):781-6. doi: 10.1007/s00404-009-1015-2. Epub 2009 Mar 5. Use of uterine fundal pressure maneuver at vaginal delivery and risk of severe perineal laceration. Matsuo K1, Shiki Y, Yamasaki M, Shimoya K. PMID: 19263062
...All vaginal delivery records between 1 January 2005 and 30 April 2006 were evaluated...Six hundred sixty-one vaginal deliveries were evaluated. Fundal pressure maneuver was performed in 39 cases (5.9%, 95% CI 4.4-7.1)...One case of shoulder dystocia following uterine fundal pressure maneuver was reported (2.5 vs. 0%). Episiotomy (76.9 vs. 44.9%, P < 0.001) and vacuum extraction (41.0 vs. 3.8%, P < 0.001) were frequently performed with uterine fundal pressure maneuver. Uterine fundal pressure maneuver increased the risk of severe perineal laceration (28.1 vs. 4.8%; odds ratio 2.71, 95% CI 1.03-7.15, P = 0.045). The risk of severe perineal laceration was synergistically increased with the concurrent use of uterine fundal pressure maneuver with vacuum extraction and episiotomy. CONCLUSION: Uterine fundal pressure maneuver during the second stage of labor increased the risk of severe perineal laceration. The use of the maneuver must be cautioned and careful attention must be paid to its application.
J Perinat Med. 2014 Nov 8. pii: /j/jpme.ahead-of-print/jpm-2014-0284/jpm-2014-0284.xml. doi: 10.1515/jpm-2014-0284. [Epub ahead of print] Uterine rupture after the uterine fundal pressure maneuver. Hasegawa J, Sekizawa A, Ishiwata I, Ikeda T, Kinoshita K. PMID: 25389983
...A questionnaire was sent to 2518 institutions in Japan. We received a response from 1430. RESULTS: Of reporting institutions, 89.4% used fundal pressure in at least some of their deliveries. Among the 347,771 women who delivered vaginally in this study, 38,973 (11.2%) were delivered with the assistance of fundal pressure. There were six cases of uterine rupture associated with uterine fundal pressure, with one case resulting in maternal death secondary to amniotic fluid embolism....
*Historical birth illustrations were taken from the following resources. [Be aware that these books are products of their times and contain outdated attitudes and language]
The illustrations by Georges Devy in "A History of Childbirth of All the People" by G. J. Witkowski (1887) [see the National Library of Medicine website]
**Ginekol Pol. 2008 Apr;79(4):297-300. [Kristeller's procedure--Expressio fetus, its genesis and contemporary application]. [Article in Polish] Waszyński E1. PMID: 18592869
The aim of the article is to introduce the original version of Kristeller's procedure - Expressio fetus. The author of the procedure, Samuel Kristeller, was bom in 1820 in Ksiaz Wielkopolski. He worked as a physician in Gniezno, then in Berlin. He is known as the creator of the described procedure - pushing out the foetus...In 1867, Kristeller published a study in which he described a procedure, of which he was the author, of pushing out the foetus (manual assistance), its technique, conditions and recommendations for its application. The main idea of the procedure meant strengthening uterine contractions during labour by massaging the uterus and pressing it many times shortly, towards the long axis of the birth canal. Nowadays this procedure has become warped in its form; there remains also the controversy whether or not to use external force directed on the uterine fundus during labour, due to the risk of intrauterine foetal anoxia and other complications.
Well, it's long past time for our seventh annual Well-Rounded Mama's Turkey Awards! Somehow 2014 got away from me, so we are doing this in spring of 2015, as our finale for Cesarean Awareness Month.
The Turkey Awards are the "prizes" I hand out to highlight fat-phobic treatment of people of size from care providers, biased attitudes or studies from researchers, or troubling trends in the care of fat pregnant women these days.
This year it's time to shine a critical spotlight on the astronomically high cesarean rates in high-BMI women in some studies, and the failure of some care providers to take any responsibility for the management policies that have led to these astoundingly-high rates.
Many studies decry the abysmally high c-section rates in "morbidly obese" women, but for the most part only use it to call for more stringent weight loss campaigns, rather than recognizing their own role in creating these rates.
These atrocious c-section rates will continue (and even escalate) until care providers can:
Acknowledge their own responsibility in creating these high rates
Examine objectively common protocols for managing pregnancy and birth in women of size and evaluate whether these protocols are helping or harming
Find other tools for lowering cesarean rates besides expecting women to lose weight
This doesn't mean that women of size have no responsibility for their health habits.Of course they do, as all people do. Women should optimize their health habits before and during pregnancy in order to improve outcomes. There is nothing wrong with encouraging reasonable health habits.
But "obesity" is a complex thing. It can be the result of poor lifestyle choices, but often it is the result of genetics, medical conditions like PCOS or lipedema, or certain medications. Sometimes we don't know why some people are fat and others are not. What we DO know is that it is statistically very unlikely that most women of size will be able to "normalize" their BMI before pregnancy...or even close.
If care providers are serious about lowering cesarean rates in women of size, they need to expand the discussion beyond the usual rhetoric of shaming, blaming, and putting women on diets.
It's time for a more realistic approach that doesn't rely on finger-pointing and improbable weight loss expectations, but instead uses concrete steps that can be done right now, regardless of whether or not women lose weight.
Unconscionably High Cesarean Rates
First, let's look at some studies that show just how bad the problem has gotten.
Check out this study from 2013 which documented cesarean rates in high-BMI women in Tennessee. Note the underlying high cesarean rates in every group in this institution; it's not just fat women that are getting cut. But then note how this cesarean-oriented culture results in especially high rates in "morbidly obese" women:
"Underweight" women (BMI less than 18.5) - 26.0%
"Normal Weight" women (BMI 18.6 - 24.9) - 31.4%
"Overweight" women (BMI 25 - 29.9) - 39.1%
"Obese" women (BMI 30 - 34.9) - 40.8%
"Morbidly Obese" women (BMI 40+) - 56.6%
This reminds me of a similar study from Kentucky, showing cesarean rates in morbidly obese women near 60% also.
You can find studies with even higher rates too, like this very large, multi-state study from more than a decade ago which found a c-section rate of 71% for women with a BMI of 52 or more.
Or a more recent study that found a nearly 70% c-section rate in women with a BMI of 35 or more.
Then there's this study from Michigan, which had a total cesarean rate of MORE THAN 80% for women with a BMI over 50. Seriously....they had a vaginal birth rate of only 19% in this group! Absolutely inexcusable. But of course the authors promptly blamed it on the women themselves and made an even stronger call for pressuring women for "weight control" before pregnancy.
I'm all for improving health before pregnancy, whatever your size, but this doesn't necessarily mean "weight control." I wish more care providers understood that the two things don't necessarily equate. I also wish they realized that these pushes for "weight control" often end up with rebound gain, making the patient fatter in the long run rather than thinner. When will doctors realize that the prescription they typically give for "getting healthier" actually often results in more weight rather than less?
But that's not what bothered me the most. What really bothers me is that none of these authors acknowledge IN ANY WAY that they or their policies could have any role in these insanely high cesarean rates. They only blame the women and call for weight control. My question is...WHERE IS THE ACCOUNTABILITY FOR THESE EXTREME RATES?
Lack of Accountability and Concern
Why aren't hospitals having their feet held to the fire for 60-80% c-section rates in obese women??? Why doesn't anyone care about all these women being cut? Where is the concern for obese women's health with all this surgery?
We know that surgery has more complications for high-BMI people; this is also true for cesareans. You'd think care providers would be doing all they could to lower cesarean rates rather than just passively accepting these sky-high rates and hoping against hope that fat women will lose weight before pregnancy next time.
Yes, we get it. As a group, fat women have more risks, more complications, and they are much harder to do surgery on if a cesarean is needed. I don't blame providers for being honest about the potential complications involved in serving high-BMI women and therefore wanting to see fewer extremely fat women because of the potential complications in attending them. I totally get that.
Many just sign fat women up for planned cesareans before labor even starts, or induce so many that it's no wonder their cesarean rate is so high. That's not good medicine. Providers are there to serve ALL women, even the more challenging cases, and to serve them with respectful care that doesn't add more risk.
The silence from researchers and care providers on this issue is deafening.
Where is the research that questions such high cesarean rates in obese women?
Where are the community care providers who are protesting and saying that this rate of cesareans in women of size is totally unacceptable?
Most importantly, where is the research that is actively trying to find ways to lower the cesarean rate in obese women?
The authors of studies like these throw up their hands like they are powerless against the tide of fatness and they have no choice but to cut because everyone knows that fatness interferes with the ability to give birth vaginally. These women brought it on themselves, right?
To which I say, BALONEY.
Historically, fat women did not have such astronomically high cesarean rates, and often their cesarean rates were similar or slightly higher than "normal" BMI women. The picture is far different today.
One German study we discussed recently showed that while cesarean rates have increased in all groups over time, they've increased the most in "morbidly obese" women. Look at their comparison of cesarean rates between 1990 and 2012 by BMI group:
Category 1990 2012 Increase
Underweight 14.4% 27.9% 13.5%
Normal 16.1% 31.4% 15.3%
Overweight 19.5% 38.8% 19.3%
Obese I 22.3% 45.1% 22.8%
Obese II 25.0% 50.2% 25.2%
Obese III 26.9% 55.2% 28.3%
Cesarean rates have increased across the board in all groups, but the increase in cesarean rates in "normal" weight women was 15.3%, whereas the increase in Obese Class III women was 28.3%.
In just 22 years, the cesarean rate in Class III Obese women went from 26.9% to 55.2%.
Why? What changed? These stats compare women of the same size, so it wasn't the women who changed. Most likely it was the management of those women that changed, and the fear levels around their pregnancies.
If the cesarean rate in higher weight women has increased from 27% to 55% in 22 years, how far will it go in the next 20 years?
SOMETHING has to change in order to alter that trajectory. Let's start having a conversation about realistic things that can be done to change it.
Cesarean Practice Rate Variation Among Obese Women
As I've pointed out before, there was a large recent British study that found a 30% cesarean rate in "super-obese" women (BMI 50 or more) who were given a chance to labor. Yes, 70% of these super-obese women were able to give birth vaginally ─ when given the chance to do so.
Yet hospitals in Kentucky and Tennessee, as cited above, had c-section rates of around 60%, nearly TWICE the British rate. And the Michigan study had rates even higher than that. Why?
These differences suggest that there are key differences in how high BMI women are being managed that is resulting in such wide variations in cesarean rates in this group, both over time and by location.
The good news is that means that there ARE things that can be done to lower the cesarean rate in higher weight women. So why isn't anyone studying what the Brits are doing that helps them have half the rate of c-sections in this group? (And I bet that their rates could be lowered, too, as the U.K. is certainly no haven for size-friendliness either.) Why isn't anyone studying what changed in the management of obese women in the previously-mentioned German study that made their cesarean rates go up so much?
It's time for care providers to start focusing on the cesarean practice rate variation in obese women and learning from it.
Once we acknowledge that there is a wide range in the obese cesarean rate, we can more easily start studying the things that help lower the risk for cesarean in this group, and hospitals can work on meaningful changes that will improve outcomes. But I have yet to see one study that seriously addresses this issue.
Why Not Diets?
Sadly, the response of the obstetric community has mostly been one of shaming, blaming, and diets instead of willingness to look more closely at these patterns.
Of course, there are good providers are appalled at the poor treatment many women of size experience, and many try their hardest to provide gentle, respectful care to women of size. BRAVO to them.
However, too many providers still believe the myths around fatness and pregnancy, like the popular "soft tissue dystocia" theory. Many are convinced that the only real way to lower the cesarean rate in obese women is to get them to lose weight first.
Many will undoubtedly protest that it is a care provider's job to promote healthy habits and to help patients be healthier, so of course they should be pushing them to lose weight. After all, why not?
It's true that care providers should be promoting healthy habits...but it doesn't follow that losing weight is the result. This is part of the common misperception that fat people are only ever fat because they are "doing something wrong" and that fatness is always a voluntary choice based on laziness and lack of healthy habits.
Nope, obesity is far more complex than that ─ but that doesn't fit in with the narrative many care providers want to hear. They only want to blame fat people for their fatness, rather than acknowledging that the truth is much more tangled.
Should caregivers promote healthy habits? Absolutely ─ for women of all sizes. Programs that gently promote reasonable nutrition and exercise are fine, but they should apply to all women since poor lifestyle can be found in every body size. And contrary to public opinion, many fat people have very normal habits. Let's stop buying into the illusion that promoting healthy habits will automatically result in permanent weight loss and a "normal" body size in everyone. It won't, and there is LOADS of research to support that.
While some providers acknowledge that "normalizing" BMI is very unlikely for most obese people, many still suggest pursuing a 5-10% weight loss. Some higher-weight people may choose to do this because some research suggests that a small weight loss can be at least temporarily beneficial.
What care providers don't want to acknowledge is that even modest weight-loss attempts are basically a game of Russian Roulette, where high BMI people balance the possibility of temporary health improvements against the strong likelihood of regain and often, worsened health in the long run.
While many people of size are happy to pursue weight loss, many with a strong history of weight cycling are not willing to risk further bouts on the yo-yo merry-go-round. This choice, too, must be respected. Improving the health and outcomes of obese people should not rest solely on weight loss.
Deal with the reality of the complexity of obesity and develop some alternative strategies to lower the cesarean rate in this group besides demanding weight loss. Consider Other Solutions
If weight loss is the only tool in the toolbox for lowering the cesarean rate in obese women, then evidence suggests it's a doomed effort since most women don't lose weight permanently and many become pregnant unexpectedly without losing weight first. Cesarean prevention needs other tools in the toolkits besides weight loss.
Most importantly, caregivers need to acknowledge that how obese women are managed during labor significantly impacts the resulting cesarean rate.
They need to actively pursue programs that try to reduce the cesarean rate in this group, and once they do, they need to evaluate the results of those programs to see if their efforts actually work. They also need to acknowledge the impact of their own beliefs and biases on cesarean rates and any intervention to reduce them. Sometimes improvements may be less about the actual intervention itself and more about the providers' belief that it will improve outcome, which then changes their surgical threshold or use of other interventions.
For example, some studies have shown lower cesarean rates in obese women who gain less weight during pregnancy. The question is whether this is a real effect of lower weight gain itself, or whether the woman's lower weight gain then changed her provider's threshold for intervention. Caregivers are usually not blinded to a woman's weight gain; they may manage those who gained more weight with greater interventions and a different surgical threshold than those who gained less weight.
A similar effect may be true for those who manage to lose weight between pregnancies. Is it really the weight loss that makes a difference or is it the provider's perception of lower risk and therefore less use of interventions?
Providers' beliefs about fatness influence their management of fat women, and that in turn influences the cesarean rate. These factors must be untangled carefully in research if outcomes are to be improved.
The British and German studies discussed above show that cesarean rates do not have to be excessive in very obese women. It's time that a serious effort is made to actually lower c-section rates in higher-weight women, especially where they are particularly excessive. The good news is that a few providers have started to ask the important questions on how to do this.
Start with the Basics
To start lowering the cesarean rate for high-BMI women, care providers first need to start applying the lessons they have learned in reducing cesarean rates in average-sized women to the management of women of size.
For example, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recently recommended several steps to help lower the primary cesarean rate, including:
Allowing prolonged latent (early) phase labor
Considering cervical dilation of 6 cm (instead of 4 cm) as the start of active phase labor
Allowing more time for labor to progress in the active phase
Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural
Using techniques to assist with vaginal delivery, which is the preferred method when possible. This may include the use of forceps, for example
Encouraging patients to avoid excessive weight gain during pregnancy
These steps are widely acknowledged as helping to lower cesarean rates, but somehow are rarely applied to women of size when they labor(except, of course, the advice to avoid excessive weight gain, which women of size hear constantly).
The first step towards lowering cesarean rates in obese women is to allow more time in labor as long as mother and baby are doing well.
Most cesareans performed on high BMI women are done in the first stage of labor, not once these women reach the pushing stage. Studies have shown that labor is often terminated earlier in women of size, sometimes before active labor is even really achieved, and that more patience in labor may be particularly important with obese patients.
One famous VBAC and obesity study, for example, found only a 13% VBAC rate in women over 300 lbs. and has been widely used to deny VBACs to women of size. When you look more closely at the data, however, you see that nearly all these women had their VBACs induced (which decreases the chances of success) and that their trials of labor were terminated at an average of 4.5 cm of dilation, which was barely into active labor even by the definitions of the time (4 cm). By the new guidelines, they wouldn't even have been considered in active labor. The providers paid lip service to the idea of VBAC in these women but barely gave them a chance to really labor.
Happily, a few researchers have begun to encourage allowing more time in labor for women of size. That's a great step in the right direction but we need more than a vague theoretical encouragement. Most providers don't follow the expanded guidelines yet, and particularly not for women of size. Hospitals need to develop accountability programs where they track the labors of high BMI women to see if they are being given adequate time in labor before surgical intervention.
Another important idea is to increase doula utilization among women of size. While the ACOG/SMFM document didn't list doula support in their top recommendations for preventing primary cesareans, they do acknowledge later on that doulas/continuous labor support is one of the most effective and least interventive ways to lower the cesarean rate, stating:
Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Given that there are no associated measurable harms, this resource is probably underutilized.
Care providers should be encouraging higher-weight women to hire doulas and helping establish programs for low-cost doula support for those who cannot afford a private doula. Yet many women of size go without doula support, despite consumer-based programs to connect them with size-friendly doulas. Doula support is underutilized by women of size; this is an area ripe for change.
Interventions for big babies are another major factor driving cesarean rates in obese women. In my many years of collecting the birth stories of women of size, I've noticed that many fat women are pressured into planned cesareans or inductions based on dubious fetal weight estimates. These interventions have not been shown to improve the outcome and often worsen it, yet they are still extremely common interventions in higher-weight women.
In one of my favorite parts of the consensus statement, ACOG and SMFM state (my emphasis):
Suspected fetal macrosomia is not an indication for delivery and rarely is an indication for cesarean delivery. To avoid potential birth trauma, the College recommends that cesarean delivery be limited to estimated fetal weights of at least 5,000 g in women without diabetes and at least 4,500 g in women with diabetes...Screening ultrasonography performed late in pregnancy has been associated with the unintended consequence of increased cesarean delivery with no evidence of neonatal benefit.Thus, ultrasonography for estimated fetal weight in the third trimester should be used sparingly and with clear indications.
They stop just short of telling doctors to STOP doing fetal weight estimations late in pregnancy, but they are certainly hinting broadly in that direction. And they are pretty clear that barring a very big baby (~11 lbs.) in a non-diabetic woman (or nearly 10 lbs. in a diabetic mother), doctors should not be performing a cesarean for "big baby." Yet care providers routinely do fetal weight estimations in obese women and then scare them into having a planned cesarean or induction based on the results.
So right there are three major things that ACOG/SFMFM recommend to lower the cesarean rate that probably are particularly applicable to high BMI women. Yet far too often, caregivers apply these recommendations to other women but not to women of size.
It's past time for caregivers to apply their own advice to the management of obese women too.
Re-examine Management Practices of Obese Women
The suggestions from ACOG and SFMFM are good starts, but they don't go far enough. We need a plan of action specific to higher-weight women to reduce cesarean rates in this group.
The problem is that all we have is guesswork to guide us in how to do this. There is NO study that has prospectively studied a strategy to lower the cesarean rate in high BMI women...and isn't that fact alone quite telling?
Given cesarean rates of 50%, 60%, 70%, and even 80% in this group, not to mention the higher complication rates of people of size after surgery, why hasn't this been studied?
Thankfully, a few studies in recent years have made some suggestions by extrapolating from what data we do have. Based on the evidence, my suggestions for lowering the cesarean rate in women of size would include:
When induction is used, wait until the mother's cervix is ripe and ready for labor. Research strongly suggests that obese women are often induced when their cervix is less ripe and that this is linked to the higher failure rate of induction of labor in this group
Reduction in the overuse of common interventions in obese women, like early breaking of water, early epidurals, and routine pitocin augmentation. For example, some research suggests that keeping the waters intact early in labor may help lower chances for a primary cesarean. Re-examine whether these common protocols for managing labor in women of size actually help or hurt
Encouraging women of size to stay home longer in early labor, since research shows that coming into the hospital too early is strongly associated with higher intervention and higher cesarean rates. Yet women of size are often hospitalized earlier in labor. Since obese women tend to have longer and slower-moving labors on average, and since doctors often have a lower threshold for surgical intervention in this group, going in too early may be particularly harmful
Giving women of size MUCH more time and patience in labor. As discussed above, obese women have a slower dilation curve and a longer first stage of labor. They may simply need extra time in labor before surgical intervention
More utilization of midwifery care for obese women with minimal health complications, since midwifery care has often been shown to lower cesarean section rates. Yet the current trend is to force even healthy obese women with no complications into the care of obstetricians and high-intervention bariatric obstetrics specialty centers. Recognize that many otherwise-healthy obese women have generally good outcomes in pregnancy and can benefit from midwifery care
Strongly encouraging use of doulas and professional labor support for women of size. As noted above, labor support has been shown to decrease the rate of cesareans in a number of studies. If a woman of size cannot afford her own doula, make low-cost or free doulas available
A re-emphasis on the importance of properly-sized equipment like blood pressure cuffs, since miscuffing remains a problem and anecdotal evidence suggests it sometimes results in cesareans, early inductions, or other interventions for falsely high blood pressure
More attention to preventing and treating fetal malposition in women of size (who may be more at risk for fetal malpositions). The utility of regular chiropractic care in this group should be studied, and more caregivers should be trained in how to turn malpositioned babies during labor, as this has been shown to significantly reduce cesarean rates
More freedom of movement in labor and utilization of alternative positions in pushing, instead of immobilizing the obese woman in bed. Research shows that a more upright position in labor can shorten labor and lower the risk for cesarean, and alternative birth positions may also help create more space in the pelvis or even help encourage a malpositioned baby to turn
Encouragement of alternative methods of pain relief, including utilization of immersion in water (many hospitals strongly encourage or require early epidurals in women of size; women of size are not permitted to access birthing tubs in many hospitals)
A revival of VBAC access for high BMI women, and more patience during their VBAC "trial of labor." Many obese women are not "allowed" to VBAC or are talked out of it. Even when they try a VBAC, induction is common, which decreases the chance of VBAC and may increase the chance for uterine rupture. In addition, more than half of their VBAC labors are cut short, often before they even reach active labor. More support for a VBAC trial of labor, fewer inductions, and a lot more patience during labor is needed to help reduce the high rate of repeat cesareans in women of size
Summary
Research is clear that while cesareans can save lives when used appropriately, they also present more harm than benefit when used too liberally.
The risks of cesareans are particularly strong in obese women, yet cesarean rates in this group have been reaching unconscionable heights lately. Rates of 50-80% are not uncommon. Although some of these cesareans are medically necessary, it's very doubtful that all ─ or even most ─ of them are.
Most care providers and researchers shrug off the extreme cesarean rates in women of size as a natural consequence of their obesity, and imply that this is simply the price they pay for daring to have a baby without losing weight first. They call for increased weight loss interventions before pregnancy rather than looking more deeply into the issue.
But focusing on weight loss to lower the cesarean rate will not result in much change because of the high failure rate of most weight loss attempts. In addition, it may result in more obesity rather than less for many women. Instead, re-evaluating how obese women are managed in labor can likely make a bigger dent in cesarean rates.
Historically, cesarean rates in higher-weight women were much lower than they are today. The cesarean rate has increased markedly in obese women in recent years, and there is a great deal of variation in the obese cesarean rate between institutions. This means that many fat women can give birth vaginally under the right conditions, and a high cesarean rate is not an inevitable outcome of obesity. It also likely means that there are ways to lower the cesarean rate in higher-weight women ─ if we are willing to study how and make change a priority.
Far too many of the cesareans in women of size today are “iatrogenic”— that is, influenced more by the attitudes and management protocols of the care providers than by the woman’s size. Far too many high BMI women are sectioned before labor even starts, induced before their bodies are ready, or have their labors cut short because of impatience or fear. But research has shown that women of size cangive birth vaginally if they are just given a real chance to do so.
With a little research and some brutally honest introspection about management of this group, the cesarean rate in women of size can likely be reduced considerably. A few brave researchers have begun to speak out about this, but others continue to hide their heads in the sand and make excuses.
It's time for care providers to be held accountable for astronomical cesarean rates in women of size. And it's long past time for them to start actively working on ways to lower the cesarean rates in obese women besides focusing on weight loss.
References
Extreme Cesarean Rates in Women of Size
Tenn Med. 2013 Jan;106(1):35-7, 42. Association between cesarean delivery rate and body mass index. Berendzen JA, Howard BC. PMID: 23477241
...Twenty-six percent of underweight and 31.4 percent of normal weight women required cesarean delivery, while 39.1 percent of overweight, 40.8 percent of obese and 56.6 percent of morbidly obese women required cesarean delivery....
Am J Perinatol. 2011 Oct;28(9):729-34. doi: 10.1055/s-0031-1280852. Epub 2011 Jun 9. Extreme morbid obesity and labor outcome in nulliparous women at term. Garabedian MJ1, Williams CM, Pearce CF, Lain KY, Hansen WF. PMID: 21660900
...Using Kentucky birth certificate data...we examined the prevalence of CD by body mass index (BMI; in kg/m2)...CD was most common among women with a prepregnancy BMI ≥ 50 (56.1%)....
Obstet Gynecol. 2014 May;123 Suppl 1:159S-60S. doi: 10.1097/01.AOG.0000447159.35865.07. Perinatal outcomes in the super obese: a community hospital experience. Papp MM1, Lindsay A, Mariona F, Chatterjee S. PMID: 24770057
...Ongoing observational study involving pregnant women with body mass index equal or above 50 kg/m. The study was approved by the Wayne State University institutional review board...A total of 44.24% were delivered by primary cesarean delivery, 36% by repeat cesarean delivery, and 19% by vaginal delivery...[Kmom note: That's an 80% cesarean rate!] Public health officials and clinicians must join efforts to increase the population awareness of the implications of obesity during pregnancy and the postpartum period. The effect of maternal obesity on the offspring should prompt a community effort to improve preconception health and weight control to improve the maternal and neonatal health.
Am J Obstet Gynecol. 2012 May;206(5):417.e1-6. doi: 10.1016/j.ajog.2012.02.037. Epub 2012 Mar 7. Maternal superobesity and perinatal outcomes. Marshall NE1, Guild C, Cheng YW, Caughey AB, Halloran DR. PMID: 22542116
OBJECTIVE: The purpose of this study was to determine the effect of maternal superobesity (body mass index [BMI], ≥ 50 kg/m(2)) compared with morbid obesity (BMI, 40-49.9 kg/m(2)) or obesity (BMI, 30-39.9 kg/m(2)) on perinatal outcomes. STUDY DESIGN: We conducted a retrospective cohort study of birth records that were linked to hospital discharge data for all liveborn singleton term infants who were born to obese Missouri residents from 2000-2006. We excluded major congenital anomalies and women with diabetes mellitus or chronic hypertension. RESULTS: There were 64,272 births that met the study criteria, which included 1185 superobese mothers (1.8%). Superobese women were significantly more likely than obese women to have preeclampsia (adjusted relative risk [aRR], 1.7; 95% confidence interval [CI], 1.4-2.1), macrosomia (aRR, 1.8; 95% CI, 1.3-2.5), and cesarean delivery (aRR, 1.8; 95% CI, 1.5-2.1). Almost one-half of all superobese women (49.1%) delivered by cesarean section, and 33.8% of superobese nulliparous women underwent scheduled primary cesarean delivery....
BJOG. 2011 Mar;118(4):480-7. doi: 10.1111/j.1471-0528.2010.02832.x. Epub 2011 Jan 18. Planned vaginal delivery or planned caesarean delivery in women with extreme obesity. Homer CS1, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M. PMID: 21244616
OBJECTIVE: To compare the outcomes of planned vaginal versus planned caesarean delivery in a cohort of extremely obese women (body mass index ≥ 50 kg/m(2))...Five hundred and ninety-one extremely obese women delivering in the UK between September 2007 and August 2008...This study does not provide evidence to support a routine policy of caesarean delivery for extremely obese women on the basis of concern about higher rates of delivery complications, but does support a policy of individualised decision-making on the mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes. [Kmom note: The cesarean rate was 30% in women with a BMI of 50+ who were allowed to labor.]
Lowering Cesarean Rates in Obese Women
J Midwifery Womens Health. 2014 Jan 8. doi: 10.1111/jmwh.12073. [Epub ahead of print] Intrapartum Management Associated with Obesity in Nulliparous Women. Carlson NS, Lowe NK. PMID: 24400789
...Nulliparous obese women are at higher risk for unplanned cesarean birth when compared with their normal-weight counterparts, and much of this increased risk is associated with labor management differences...Intrapartum interventions used significantly more often for healthy, obese nulliparous women when compared with normal-weight women were induction of labor, augmentation of labor, and cesarean birth. It is unclear if assisted vaginal birth occurs more frequently among obese women. Epidural anesthesia, artificial rupture of membranes prior to 6 cm of cervical dilation, and early hospital admission were shown in separate studies to be used more often in obese women. Intrapartum interventions were used more frequently in obese women in a dose-dependent manner by body mass index...Implications for clinical practice from this systematic review are that healthy, nulliparous obese women are exposed to common intrapartum interventions more often than normal-weight women. In the absence of evidence on the use of appropriate use of intrapartum interventions in this population, health care providers should carefully monitor management choices when working with healthy, nulliparous obese women.
J Obstet Gynaecol Can. 2011 May;33(5):443-8. Higher caesarean section rates in women with higher body mass index: are we managing labour differently? Abenhaim HA, Benjamin A. PMID: 21639963
BACKGROUND: Higher body mass index has been associated with an increased risk of Caesarean section. The effect of differences in labour management on this association has not yet been evaluated. METHODS: We conducted a cohort study using data from the McGill Obstetrics and Neonatal Database for deliveries taking place during a 10-year period...RESULTS: Data were available for 11 922 women, of whom 2289 women had normal weight, 5663 were overweight, 3730 were obese, and 240 were morbidly obese. After adjustment for known confounding variables, increased BMI category was associated with an overall increase in the use of oxytocin and in the use of epidural analgesia, and with a decrease in use of forceps and vacuum extraction among second stage deliveries. Higher BMI was also found to be associated with earlier decisions to perform a Caesarean section in the second stage of labour. When adjusted for these differences in the management of labour, the increasing rate of Caesarean section observed with increasing BMI category was markedly attenuated (P less than 0.001). CONCLUSION: Women with an increased BMI are managed differently in labour than women of normal weight. This difference in management in part explains the increased rate of Caesarean section observed with higher BMI.
J Matern Fetal Neonatal Med. 2013 Apr;26(6):547-51. doi: 10.3109/14767058.2012.745506. Epub 2012 Nov 28. Cesarean delivery in obese women: a comprehensive review. Wispelwey BP1, Sheiner E. PMID: 23130683
...A thorough review of the literature indicates that a decreased cervical dilation rate, an increased induction rate, the presence of comorbid conditions, concern about shoulder dystocia, and weight gain in excess of recommendations during pregnancy all may contribute to the high rate of CD in obese women. Obese women are at increased risk of CD-related complications including anesthetic complications, wound complications, venous thromboembolism (VTE), and failure of vaginal birth after CD. CONCLUSIONS: Given the excess risks associated with CD in obese women, and that some of the rationale for the procedure (e.g. slower labor, concern about shoulder dystocia) may not be justified based on current evidence, a reassessment of the threshold at which obese women are recommended for CD is necessary.
Induction of Labor and Cesareans in Women of Size
Am J Obstet Gynecol. 2014 Aug 6. pii: S0002-9378(14)00814-X. doi: 10.1016/j.ajog.2014.08.002. The risk of prelabor and intrapartum cesarean delivery among overweight and obese women: possible preventive actions. Hermann M1, Le Ray C2, Blondel B3, Goffinet F2, Zeitlin J3. PMID: 25108139
...We modeled relative risks (RRs) and risk differences of prelabor and intrapartum cesarean delivery by prepregnancy body mass index (obese, ≥30 kg/m2; overweight, 25-29.9 kg/m2; normal weight, 18.5-24.9 kg/m2) in a nationally representative sample of 12,297 French women...Risks of prelabor cesarean delivery were elevated only for obese multiparous women. This reflected not only a higher prevalence of previous cesarean delivery (26.4% vs 17.9% for normal-weight women) but also higher risks of prelabor cesarean delivery for multiparous women with no previous cesarean delivery after adjustment for medico-obstetric factors (RR, 1.82; 95% confidence interval [CI], 1.25-2.64)... Increased intrapartum cesarean delivery risks for primiparous women were related to more frequent labor induction (42.6% vs 23.8% for normal-weight women). CONCLUSION: It may be possible to reduce primary and thus repeat cesarean delivery rates among obese women by preventive actions targeting labor induction in primiparous women and prelabor cesarean deliveries in multiparous women. Further research is needed on the impact of limiting inductions on cesarean delivery risks for obese primiparous women.
Acta Obstet Gynecol Scand. 2013 Dec;92(12):1414-8. doi: 10.1111/aogs.12263. Maternal obesity and induction of labor. O'Dwyer V1, O'Kelly S, Monaghan B, Rowan A, Farah N, Turner MJ. PMID: 24116732
...Compared with women with a normal BMI, obese primigravidas but not obese multigravidas were more likely to have labor induced...In obese primigravidas, induction of labor was also more likely to be associated with other interventions such as epidural analgesia, fetal blood sampling and emergency cesarean section. In contrast, induction of labor in obese multigravidas was not only less common but also not associated with an increase in other interventions compared with multigravidas with a normal BMI. CONCLUSIONS: Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
BMC Pregnancy Childbirth. 2014 Dec 20;14(1):422. [Epub ahead of print] Pre-pregnancy Body Mass Index (BMI) and delivery outcomes in a Canadian population. Vinturache A, Moledina N, McDonald S, Slater D, Tough S. PMID:25528667
...This study is a secondary analysis of the All Our Babies Cohort, a prospective, community-based pregnancy cohort in Calgary, Alberta...(n=1996)...Spontaneous onset of labour was recorded in 71.2% of women with normal pre-pregnancy BMI, whereas 39.3% of overweight and 49% of obese women had their labour induced. For women with spontaneous labour, pre-pregnancy BMI was not a significant risk factor for mode of delivery, controlling for covariates. Among women with induced labor, obesity was a significant risk factor for delivery by C-section (adjusted OR 2.2; CI 1.2-4.1)....
Am J Perinatol. 2013 Jan;30(1):75-80. doi: 10.1055/s-0032-1322510. Epub 2012 Jul 26. Interaction between maternal obesity and Bishop score in predicting successful induction of labor in term, nulliparous patients. Zelig CM1, Nichols SF, Dolinsky BM, Hecht MW, Napolitano PG. PMID: 22836819
STUDY DESIGN: Retrospective cohort study. Prospectively collected database utilized to determine the optimum Bishop score within each prepregnancy body mass index (BMI) category of term, nulliparous patients undergoing IOL....For the total group (n = 696), Bishop score ≥ 5 was most predictive of success (75% versus 56%, p < 0.0001). Within each BMI category, Bishop score ≥ 5 remained most predictive...CONCLUSION: The optimum Bishop score for predicting successful IOL in nulliparous patients was 5 regardless of BMI class. The higher IOL failure rate observed in obese women was associated with lower starting Bishop scores and was compounded by higher failure rates in obese women with Bishop scores < 3.
Aust N Z J Obstet Gynaecol. 2011 Apr;51(2):172-4. Impact of morbid obesity on the mode of delivery and obstetric outcome in nulliparous singleton pregnancy and the implications for rural maternity services. Green C, Shaker D. PMID: 21466521
...We conclude that morbid obesity is associated with a significantly higher risk of pre-existing medical conditions, developing antenatal complications, induction of labour, caesarean section and greater birth weight. However, there was no significant difference in caesarean section rates when adjusted for induction of labour....
Longer Labors, More Patience Needed
Am J Perinatol. 2012 Feb;29(2):127-32. doi: 10.1055/s-0031-1295653. Epub 2011 Nov 21. Effect of obesity on length of labor in nulliparous women. Hilliard AM1, Chauhan SP, Zhao Y, Rankins NC. PMID: 22105434
We compared the duration of labor among nulliparous women with varying body mass index (BMI). Laboring nulliparous women at >37 weeks were included. First visit BMI was used to categorize weight as normal (≤24), overweight (25 to 29.9), or obese (≥30 kg/m(2))...Duration of first stage of labor was significantly longer for obese versus normal-weight women (26.76 ± 0.77 versus 23.87 ± 0.66 hours; p = 0.024) but not between normal versus overweight women (p = 1.00) or overweight versus obese women (p = 0.114). The cesarean delivery rate was significantly different in the three groups (p = 0.0001), highest among obese (47%) and lowest in normal-weight women (24%). When adjusted for age, hypertension, and induction, the likelihood of completing stage I was significantly less among obese nulliparous than those with BMI < 24 kg/m(2) (hazard ratio 0.73, 95% confidence intervals 0.54, 0.99). Compared with those with BMI < 24, the duration of stage I is significantly longer among obese women, even when adjusted for maternal age, induction, and hypertension.
Am J Obstet Gynecol. 2011 Sep;205(3):244.e1-8. doi: 10.1016/j.ajog.2011.06.014. Epub 2011 Jun 23. Contemporary labor patterns: the impact of maternal body mass index. Kominiarek MA1, Zhang J, Vanveldhuisen P, Troendle J, Beaver J, Hibbard JU. PMID: 21798510
...A total of 118,978 gravidas with a singleton term cephalic gestation were studied. Repeated-measures analysis constructed mean labor curves by parity and BMI categories for those who reached 10 cm. Interval-censored regression analysis determined median traverse times, adjusting for covariates in vaginal deliveries and intrapartum cesareans. RESULTS: In the labor curves, the time difference to reach 10 cm was 1.2 hours from the lowest to highest BMI category for nulliparas. Multiparas entered active phase by 6 cm, but reaching this point took longer for BMI ≥40.0 (3.4 hours) compared to BMI <25.0 (2.4 hours). Progression by centimeter (P < .001 for nulliparas) and from 4-10 cm (P < .001 for nulliparas and multiparas) increased as BMI increased. Second stage length, with and without an epidural, was similar among BMI categories for nulliparas (P > .05) but decreased as BMI increased for multiparas (P < .001). CONCLUSION: Labor proceeds more slowly as BMI increases, suggesting that labor management be altered to allow longer time for these differences.
Eur J Obstet Gynecol Reprod Biol. 2013 Nov;171(1):49-53. doi: 10.1016/j.ejogrb.2013.08.021. Epub 2013 Aug 29. Maternal body mass index and duration of labor. Carlhäll S1, Källén K, Blomberg M. PMID: 24041847
Historical prospective cohort study including 63,829 nulliparous women with a singleton pregnancy and a spontaneous onset of labor, who delivered between January 1, 1995 and December 31, 2009...Overweight and obese women were compared to normal weight women regarding duration of active labor. Adjustments were made for year of delivery, maternal age and infant birth weight. RESULTS: The median duration of labor was significantly longer in obese women (class I obesity (BMI 30-34.9) = 9.1h, class II obesity (BMI 35-39.9) = 9.2h and class III obesity (BMI > 40) = 9.8h) compared to normal-weight women (BMI 18.5-24.9) = 8.8h (p < 0.001). The risk of labor lasting more than 12h increased with increasing maternal BMI: OR 1.04 (1.01-1.06) (OR per 5-units BMI-increase).The risk of labor lasting more than 12h or emergency cesarean section within 12h, compared to vaginal deliveries within 12h, increased with increasing maternal BMI. Duration of the second stage of labor was significantly shorter in obese women: in class III obesity the median value was 0.45 h compared to normal weight women, 0.55 h (p < 0.001). CONCLUSION: In nulliparous women with a spontaneous onset of labor, duration of the active phase of labor increased significantly with increasing maternal BMI. Once obese women reach the second stage they deliver more quickly than normal weight women, which implies that the risk of prolonged labor is restricted to the first stage of labor. It is clinically important to consider the prolonged first stage of labor in obese women, for example when diagnosing first stage labor arrest, in order to optimize management of this rapidly growing at-risk group of women. Thus, it might be reasonable to adapt the considered upper limit for duration of labor, according to maternal BMI.
