Plea for Help in the U.K.

This comment was left on a recent post on this blog.  It is a plea for help from a pregnant women in the U.K.

I am only going to address one aspect of her concerns, the one I find most disturbing; I hope others will step up and address some of the rest of her concerns.

Please please please, can someone help me. I am 10 weeks pregnant and currently have a BMI of 35.  

Firstly, I have suffered with severe sickness since 5 weeks and doctor said it was ok as I 'could do with losing some weight' and refused to give me medications, and now I have had my first midwife appointment today and was told that more than 50 percent of maternal deaths in pregnancy and childbirth are obese mothers and that I will have to have special monitoring and won't be allowed to have a natural birth at the birth centre and will have to be under consultant care and be constantly monitored throughout labour (meaning no water birth, no moving around, no getting into positive positions to birth).  

I am so scared and disappointed, I feel like I am an unfit mother already and feel that the drs think I do not care about the health of my unborn baby. Now I know that this will not go down well with some people but I am considering a termination so that I can lose more weight before carrying a child (I have currently lost 70 pounds). 

I came across this blog and I am aware that you are based in the US and I am in the UK so some things are different...for instance I can't actually choose a provider and am stuck with who I have :(...but please, any advice would be so appreciated. Both myself and my partner are concerned and do not know what to do. 

There are so many things to cover here, it's hard to know where to start.  Please comfort and reassure this woman that she CAN do this.  She needs to hear from many people, not just me.  Please leave some encouraging comments at the end of this post.*

In the meantime, here is my response.  First, dear Reader, please don't terminate this pregnancy over these scare tactics or your fears.  Chances are that everything will be okay.  Many MANY women with a BMI well over 35 have had healthy pregnancies and babies.  My BMI is 48, far over yours, and I had 4 healthy pregnancies and babies, and am none the worse for wear for it. I know so many women your size and far larger who have had healthy happy babies.  You can read some of their birth stories here and here.

No, no one can promise you with 100% certainty that you and this baby will be fine, but the odds are certainly in your favor, "obese" or not. Most obese women have healthy babies; some do have complications like GD or high blood pressure, but even then, most of the time, these conditions are able to be treated and everyone is still fine.  So don't panic over the scare tactics they are giving you.

To be fair, the doctors and midwives are trying to do what they think is their job, to apprise you of possible risks associated with "obesity" and pregnancy, but the problem is that they have gone so far overboard in stating these that they are frightening women unduly, making them think that almost no women of size have healthy pregnancies or babies, when in fact, most do.

In some cases, care providers lay on the scare tactics so strongly that they bully women into weight loss surgery, risky diets, over-intervention, and even terminating the pregnancy.  That is NOT good health care, that's medical bullying. And for God's sake, this poor woman has already lost 70 lbs., but despite the fact that she followed typical medical advice to lower her BMI before pregnancy, she is still being punished and scared half to death.  Where is the justice in that?

Yes, there are some risks associated with pregnancy in obese women, but NO, the answer is not in scaring women into terminating an established pregnancy until they reach a "normal" BMI.

Shame on these providers for laying the scare tactics on so strongly that someone would even consider terminating a pregnancy simply because of their weight.

Yes, among those rare women who have died during pregnancy or birth, obese women are overrepresented somewhat.  That does NOT mean that 50% of obese women who are pregnant die during pregnancy─that's a misunderstanding of what the care providers were trying to say. Death is an extremely rare occurrence for childbearing women in the developed world, and although very high BMI women are somewhat overrepresented in that group, the actual numerical risk of it happening to any one obese woman is quite low.

And the reason why fat women do die during pregnancy or birth boils down to three main causes, some of which is preventable:

• Complications from general anesthesia during a cesarean
• Complications from hypertensive disorders (high blood pressure and resulting disorders) in pregnancy
• Blood clots (usually in conjunction with cesareans)

So to lower the risk for these problems, consider the following:

• Don't let them push you into a cesarean you don't need. If a cesarean is required at some point, make sure they are prepared to use an epidural or spinal block instead of general anesthesia. Have an anesthesia consult ahead of time to be sure they have the equipment needed on hand if it were needed
• Make sure you are monitoring your blood pressure carefully (you can get a home BP monitor if your readings are questionable at all), make sure they use the correct-sized BP cuff so that that readings are accurate, and get regular exercise and have great nutrition to lower your risk for developing gestational diabetes or blood pressure issues 
• Regular exercise also lowers the risk for a blood clot during pregnancy; for certain people, low-dose aspirin therapy (only under the supervision of a care provider) is sometimes advised. If you have a cesarean, discuss with your provider the use (and proper dosage) of blood thinners, and be sure to move your legs around and walk as early as you can tolerate after the surgery. There are also special wraps and cuffs that can help reduce your chances of a blood clot after a cesarean; make sure to request these if you have a cesarean, and note any increase in shortness-of-breath to your providers

If this woman were in the U.S., I'd tell her to change care providers ASAP because it's difficult to overcome a really deep-set provider bias about obesity in just a few months, and it often influences the care a high-BMI mother receives.  However, I'm not sure what your options are for alternatives in the U.K.

There are, of course, private midwives that you could hire from outside the NHS system, and it seems to me like this would be well worth the money to do if you can manage it.  I bet we could find a private midwife who would take you on as a client and who would work with you to find a way to make it financially feasible.  I know there have been women of size who have had great out-of-hospital births in the U.K. with private midwives.

But if that's absolutely not an option, then you will have to work within the system, and the way to do that is to push back against the care providers who are giving you a hard time.  I'm hoping some of my U.K. readers will pop in and leave some suggestions about how to do that.

At the very least, one of the best things you can do is to find a Pregnancy Buddy, an advocate familiar with size-friendly care practices, who will come with you to appointments and help you speak up for quality care and question fat-phobic practices.  A doula who really "gets" weight stigma and has a Health At Every Size approach could be a great help for you in advocating for more size-friendly care.

Best wishes to you, and I sincerely hope you will not let your fears (and the scare tactics of the providers) keep you from enjoying this pregnancy and this baby.  Be as healthy as you can in your habits without obsessing over them, find a Pregnancy Buddy or Size-Friendly Doula to help you speak up for yourself, and don't be afraid to push back against the bias of your providers and even report them to their superiors if necessary.

Pregnancy is one of the best times to learn how to advocate for yourself, your baby, and your needs (whatever size you are), and you deserve to have loving, respectful care, regardless of your BMI or whether you lose enough weight to fit into their narrow definition of "normal".  Start demanding that care now, and don't settle for second-best.  You and your baby deserve no less.


*Please keep your comments civil and kind and aimed towards helping this woman's specific situation or about commenting on weight-biased scare tactics, rather than about pushing a particular point of view on abortion. This is not a forum for abortion debates, and I will be vetting comments before I publish them.  Please stay kind and helpful in your words.  Thank you.

Birth Story Video: Jennifer's Waterbirth

Here is the birth story and wedding/birth video of a plus-sized mama I thought readers might enjoy.  It's not a short video (about 6 minutes) but it's well worth watching!

Below is the mother's story (which includes 4 previous miscarriages) and what she wants other women of size to know about pregnancy and birth.

My name is Jennifer. I live in southern Oregon and am a midwife apprentice. I have attended many births and have caught 4 babies under supervision. Of the many births I have attended, a good handful have been to plus-size mommas. 

Two off the top of my head were between 300-400 lbs. Both mommas had very healthy uneventful pregnancies and wonderful easy labors, and both mommas delivered in water at home. Water is great for plus-size mommas because it allows you to move more easily into different positions.  

I myself am a plus size momma. I am 5'6" and started my pregnancy at 232 lbs., about size 18. I finished my pregnancy at 276. I know doctors like to tell you to only gain 15 lbs. if you're "obese" but that's one of many reasons I didn't choose a doctor! I am a firm believer that as long as you gain your weight on healthy food then you gain what you need, and restricting food can cause issues in pregnancy. Nutrition is key in pregnancy, especially protein!   

I had a wonderful very healthy pregnancy with a midwife, and gave birth to a beautiful baby at home on Christmas eve.  A baby girl,  9 lbs. 12 ounces, 20.5 inches. 

Being plus size and pregnant is a challenge but I think it's because we set up obstacles in our minds. Will I look pregnant, how much weight will I gain, will I be able to handle the physical demands of labor, will I be bullied into tests and procedures because I'm overweight? 

Remember that you are a strong, intelligent, beautiful woman who can birth a healthy baby, regardless of your weight. If you aren't comfortable being your own advocate, then hire a doula! Get educated, know your options, and don't forget to celebrate this beautiful rite of passage!

Waterbirth Video of Plus-Sized Mom

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Here is the video of her birth:



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

Italian Waterbirth Study

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

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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

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

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

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

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

PMID: 20595945

The Fat Vagina Theory: "Soft Tissue Dystocia"

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

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

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

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

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

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

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

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

But what does the evidence say? 

The Research, Such As It Is

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Alternative Explanations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What About Shoulder Dystocia?

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

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

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

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

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

But What If Soft Tissue Dystocia is Real?

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

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

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

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

Fat Women can VBAC

As a nice antidote to all the depressing VBAC news lately, here is the lovely story of a friend of mine, a woman of size, who just had her second VBAC a couple of weeks ago.

Nice to get some good news in the midst of all the doom and gloom stuff on how hard VBAC is to get anymore!

Because VBAC is so hard to get in the hospital these days (and particularly so for women of size) a lot of women are birthing outside the hospital in order to get a real shot at a VBAC. Of course, like anything else, this has its pros and cons, risks and benefits.....but so does birthing inside the hospital.

This mom chose to birth at home with a midwife in attendance. She gave birth in the water. Her other children were nearby, and her husband helped catch the baby. (Those are his hands you see in the picture.)

She wanted me to be sure to pass on that by many doctors' estimates, she'd "never" be able to VBAC....and yet she did.

She is a woman of size (about 250 lbs. pre-pregnancy), and some doctors won't let women of that size even have a trial of labor. Others will "let" you, but will try to convince you that your chances of success are very small because of your size, so best to just sign up for that repeat cesarean. Yet somehow, she managed to VBAC.

She is short and she had a big baby this time. She specifically wanted me to mention that, because the combination of short and fat and a big baby often will make doctors risk you out of a VBAC. And yet, somehow she managed to VBAC anyhow. (So did I, another short fat woman with big babies!)

She was told her pelvis was too small with her first baby (who was only 6 lbs., 14 oz), but both her VBAC babies were bigger than her cesarean baby. Somehow she managed to VBAC an 8 lbs., 3 oz. baby out of that "too small" pelvis, and this baby was even bigger at 9 lbs. 8 oz. So much for her small "deformed" pelvis.

Obviously, there are things that are more important than maternal size or baby size; fetal position is a critical part of the whole story. If the baby is in a poor position, even a small baby can have trouble getting through. If the baby is in great position, even big babies usually get through just fine. More on that in a future post!

For now, let's just savor the fact that despite a VBAC ban in half the US hospitals, despite the tremendous bias against fat women even trying for a VBAC, despite all the factors "working against" her in many docs' eyes.....she managed to VBAC.......and not once but TWICE.

FAT WOMEN CAN VBAC.

You can read her complete story on her blog,

www.birthislife.blogspot.com. In the meantime, here are some pictures and links to her stories. Enjoy!

Her cesarean story can be found here.

Her first VBAC story (a hospital transfer to a hospital......which banned VBACs no less!) can be found here.

Pictures of her second VBAC can be found here.

So Why the BMI Restrictions in Waterbirth?

Waterbirth offers unique advantages to women in labor. According to http://www.waterbirth.net/,

Lying in warm water increases venous pressure so that veins can return blood to the heart more efficiently and your baby receives more oxygen. It enhances cardiac action and slows the pulse rate. Total relaxation in the warmth and comfort of the water helps the uterus to contract more effectively. Water also counteracts the force of gravity and any pressure a woman feels inside her body, so there is a further pain relieving effect. Water helps the woman surrender to the birth process and it creates a feeling of tranquility to the whole birth experience.

However, as we discussed previously, some birth facilities have restricted fat women from having access to water during labor and/or birth.

On the other hand, some facilities are very supportive of it, even in very large women. It all depends on the facility and the provider.

However, with the increasing trend towards seeing fat women's pregnancies as extremely "high risk" (regardless of whether they actually experience complications), I anticipate that we will see more and more BMI restrictions against waterbirth and other "alternative" birth modalities take root.

But are they justified?

So Why Not Have Waterbirth Access for Fat Women?

The following are some of the reasons typically given for restricting fat women's access to waterbirth, along with an analysis of the attitudes and reasoning behind them.

Waterbirth Is Only For "Low-Risk" Women

Of the hospitals that have embraced waterbirth, some have embraced it tepidly, with many restrictions. In particular, hospitals that are tentative about waterbirth usually restrict its use to "low-risk" patients only.

Since fat women are automatically seen as "high-risk" by many doctors (even when they have not developed any complications at all), some hospitals have BMI cutoffs, above which waterbirth is not an option anymore.

Applying the "high risk" label (and accompanying restrictions) across the board to all women of size is ridiculous. If a fat woman has had a healthy pregnancy, developed no complications, and is a reasonably active and mobile person, there is no justification for keeping her from resources in labor (like walking, immersion in water, a birth ball, position changes, etc.) that just might help her labor progress more "normally" and avoid an unnecessary cesarean.

The Ticking Time Bomb Theory

Another reason some hospitals restrict waterbirth in women of size is the perception of all obese women as having blood pressure issues (latent or overt), and therefore being at risk to stroke out at any moment during labor. This is a direct result of hyperbole about the perceived risks of obesity and increasing promotion of the idea that a fat woman's pregnancy is ultra high-risk.

Ironically, research shows that being immersed in water actually tends to lower blood pressure, and may actually be a good way to help prevent such an issue. Although it's not true that fat women are ticking time bombs just waiting to stroke out in labor, if it were, hospitals might actually be preventing these women from one intervention likely to help them KEEP normal blood pressure. Talk about short-sighted!

The Shoulder Dystocia Fear

Another concern is shoulder dystocia (baby's head is born but the shoulders get stuck on the way out). Fat women are perceived to be more at-risk for shoulder dystocia, and doctors are afraid that taking time to get the mother out of the water might delay emergency measures needed to get the child born safely.

However, several studies have shown that when baby size and diabetes are controlled for, obese women are no more likely to experience shoulder dystocia than women of average size. Just being fat does NOT increase the risk for shoulder dystocia, and forbidding waterbirth on that basis alone is illogical and unfair.

However, fat women do tend to have bigger babies, on average (although it should be noted that even so, MOST fat women do not have big babies). Because bigger babies have higher rates of shoulder dystocia, many healthcare providers fear having ANY fat woman birth in the water.

Their concern is that being in water might cause a delay in the maneuvers that may be needed to relieve shoulder dystocia. But healthcare providers experienced in waterbirth know that shoulder dystocia may be less likely in waterbirth because of the mother's ability to shift position easily and open up more space in the pelvis by being off the tailbone. One study found a shoulder dystocia in waterbirth rate of 0.16%, hardly a raging epidemic.

Experienced waterbirth providers point out that when they have encountered a shoulder dystocia in the water, often all that needed to be done was have the mother shift to hands and knees, or to stand up in the water with one leg on the side of the tub, creating an asymmetrical space in the pelvis that helps free up the baby's shoulders.

If that didn't work, they note that the process of helping the woman get out of the tub was usually enough to rotate the mother's pelvis around baby's shoulders and get the baby out without further maneuvers. And if it was not, the birth attendant can then do all of the usual maneuvers once the woman is out of the water.

Most providers who are experienced in waterbirth do not believe that potential shoulder dystocia concerns are a reason for forbidding waterbirth.

The Fear of a Getting a Fat Woman Out of Water

Probably the biggest reason why women of size are restricted from waterbirth is the fear of a fat woman passing out or having a medical emergency while in the water, and what might be necessary to deal with that. Because they see fat women as SO high-risk, they view this as a likely possibility, and are acting accordingly.

Although one can understand how a hospital might be concerned about how they would get such a large person out of the water or initiate emergency treatment quickly, we must remember that such a medical emergency is rarely instantaneous and there are almost always warning signs that suggest a change in laboring location and closer monitoring.

The nightmare scenario they fear is extremely unlikely (especially in a spontaneous labor with no drugs or medications, which is what a waterbirth should be). To restrict ALL fat women based on such an unlikely scenario is an extremely unfair balancing of the risks/benefits ratio.

However, let's be frank....the hospital's administration is also worried about potential workmans' compensation claims if a worker injured his/her back trying to get a woman of size out of the water during an emergency. These are understandable concerns from a hospital's risk management point of view, but Barbara Harper (director of Waterbirth International) addresses this below. The long and the short of it is that they may actually put their workers at greater risk by making supersized women birth outside the water, especially since immersion in water tends to make obese women more mobile and easier to help maneuver.

The Solution: Individualize Waterbirth Decision-Making Instead

Barbara Harper suggests that instead of facilities instituting across-the-board BMI restrictions on access to water, they should make case-by-case judgments, taking into account the mother's blood pressure status, her fitness, her general mobility, and whether there there have been any complications during the pregnancy.

Instead of forbidding waterbirth to all women of size, decision-making could be individualized to acknowledge the differences in the spectrum of fat women giving birth. This is a common-sense approach that makes a LOT of sense.

Finally, an important question is whether such BMI restrictions on waterbirth are justified by actual research, or just hospital administrators' fears of risk. Doctors and hospitals are striving to become more evidence-based in their practices; what does the evidence say here?

I wrote to Barbara Harper and asked her this question, and this was her reply:

Thank you for writing in your question about waterbirth studies and policies concerning BMI restrictions for women wanting waterbirths.

I am very much in opposition to such practices, but acknowledge that they do exist in many hospitals and some birth centers.

The water is THE VERY BEST PLACE for an overweight parturient woman. She can move in the water, control her body, respond better to the movements of the baby and feel much better physically after the birth because of the buoyancy effect on her muscles and cardiovascular system.

I don't see why every hospital isn't seeing that they could save hundreds of cesareans on plus-size women by PUTTING them in water as an intervention.

But, the great liability monster raises its ugly head and the hospital then becomes fearful of employees hurting their backs if they had to get a woman out of the water during an obstetric emergency. Thus the development of policies to protect the hospital against workers compensation cases.

When I teach the professional Waterbirth Credentialing workshop I do address BMI weight restriction policies and insist that hospitals treat each woman individually and not restrict the woman who presents in labor at 250 pounds who has gained 60 pounds during her pregnancy, just on the basis of the final number. I implore them to look at activity levels and pre-pregnancy weight and pre-pregnancy activity levels.

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

There is no available scientific evidence one way or the other, with the exception that we did a search both in the US and in the UK to find workers compensation cases for back injuries in labor and delivery settings. There were some, but none related to water. Holding the leg of a 300 pound woman while she is pushing is much harder than helping her in and out of the bath.

--Barbara Harper, RN, CLD, CCE
Founder/Director of Waterbirth International
www.waterbirth.org

Waterbirth IS a Reasonable Choice for Fat Women

Waterbirth is a very viable choice for women of size. Although it offers advantages for all women, it offers additional advantages for women of size, ones which might help improve birth outcomes in this group.

If doctors and hospitals really are interested in lowering the rate of cesareans and other complications in women of size, waterbirth is one more important tool to have in their toolbox. It shouldn't be automatically removed from the equation, based simply on size.

Although some fat women are discouraged from waterbirth, rest assured that many women of even very large sizes have labored and even birthed their babies in the water. If this is something YOU are interested in, it IS still a choice. As a woman of size, you might have to work harder in order to access this choice than a woman of average size, but it IS still a choice.

Some birth centers have waterbirth options. Some of these may have BMI restrictions, but some do not. Some may be amenable to negotiation about these restrictions; some may not. It can't hurt to ask. If they won't permit waterbirth in a woman of size, take your business elsewhere.

Most hospitals these days offer the option to at least labor in water. Again, some deny this to obese women, but many do not. However, if you encounter a hospital that won't allow you even to labor in water simply because of size, it's likely that they are not size-friendly in many other ways either, and you should strongly consider another birth place if at all possible.

Although waterbirth (actually pushing out the baby in water) is not as common in US hospitals as it is in European hospitals, there ARE a number of hospitals that do offer it. If you prefer to birth in a hospital, you can check with Barbara Harper to see if there are any in your area that are open to waterbirth. She keeps a list of waterbirth-friendly hospitals.

Additionally, Barbara's organization, Waterbirth International, has worked in the past with hospitals who have a "no waterbirth" policy. If you give plenty of advance notice so they can review this policy, if you have a provider supportive of the idea of waterbirth, and if you are willing to act as a strong advocate with the hospital, they may be able to help you establish waterbirth policies in that hospital, or to at least allow an exception to the rule for you as an individual. They do ask that you join Waterbirth International and make a donation to help cover their costs while doing this, but they say they are able to work with many hospitals and find an acceptable compromise.

And of course, waterbirth is always a choice at home, and homebirth is a more reasonable option than most people think. Many homebirth midwives offer waterbirth services (often including rental of a waterbirth tub, or information on other waterbirth choices) as part of the spectrum of their care. Many of the women of size that I have known who have actually given birth in water have done so at home. It's where I had my own waterbirth.....and it was an AWESOME experience.

Wherever you choose to give birth, waterbirth remains a possibility.....and it may be especially advantageous in women of size. It's definitely something for you to further research if you interested in it. I also urge hospitals, birth centers, and birth professionals to work to keep immersion during labor and waterbirth itself an option for women of ALL sizes.

*The waterbirth photo at the top of the entry is of a "morbidly obese" medical professional who gave birth to her third child in the water at home.

There is also a lovely waterbirth video at:http://www.youtube.com/watch?v=MrbXXZ2Fqg0

General Information about Waterbirth

In previous posts, we have been discussing BMI restrictions on laboring and birthing in water, and whether by restricting waterbirth in women of size, they are depriving fat women from an option likely to improve birth outcomes.

The first question that has to be addressed is why waterbirth isn't more common for ALL women, regardless of size. If it's so advantageous, why the resistance to waterbirth in general in the United States? And I'm sure many readers from the fatosphere have some basic questions about waterbirth in general.

So today's post contains basic information about waterbirth and addresses the typical concerns people might have about waterbirth.

In another post soon, we will discuss why some birth facilities have BMI restrictions on who can labor and birth in the water, and whether those restrictions really have any merit or not.

Why the Resistance to Waterbirth?

If laboring in water could help a woman have a shorter, less painful labor, lessen the chances of an episiotomy, and help her be more mobile during the birth......all without the significant risks of epidurals and pain medications...........shouldn't doctors and hospitals be interested in such a low-risk intervention?

You would think doctors and hospitals would be falling all over themselves to embrace waterbirth........but the sad truth is that they're not. Some are still stuck in the technological model of birth, resistant to information about the efficacy and safety of waterbirth.

The following are the main concerns about waterbirth usually brought up by doctors and hospitals, along with research showing lack of harm from these issues, and how they can be dealt with proactively and safely.

How Does The Baby Breathe?

The first concern usually raised is that the baby born in water might inhale the water with its first breath and drown. This concern is addressed in detail at the waterbirth FAQ from Waterbirth International's website. According to them:

There are four main factors that prevent the baby from
inhaling water at the time of birth:

1. Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements. When the baby is born and the Prostaglandin level is still high, the baby's muscles for breathing simply don't work, thus engaging the first inhibitory response.

2. Babies are born experiencing mild hypoxia or lack of oxygen. Hypoxia causes apnea and swallowing, not breathing or gasping.

3. Water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

4. The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled.

As long as the baby is not in distress and as long as the baby is brought to the surface in a timely manner, research shows that waterbirth is safe. After all, babies were in a liquid in-utero environment already; being born in water simply eases the transition from the uterus to the outside world.

Concern about Infection

Some doctors are concerned about potential risk for infection, even though research shows no greater risk for neonatal infection or maternal infection in waterbirths.

Proper hygiene measures are vital of course, but as long as these are followed, there is no increase in the risk of infection.

Lack of Access to the Perineum

Some doctors object to anything impeding their view of (and access to) the perineum at birth. Of course, less access to the perineum means less chance to cut episiotomies, which is one of the major advantages of waterbirth.

Because they have been trained to be very "hands-on" during delivery, less access to the perineum tends to make doctors feel less in control, and this makes them nervous. But once doctors become experienced in attending waterbirths, they adjust to this approach just fine. It's all a matter of willingness to learn a new approach.

Difficulty of Evaluating Blood Loss During Waterbirth

The difficulty of evaluating blood loss during waterbirth is a legitimate concern. In all births, care providers must watch mothers carefully to be sure they are not bleeding excessively after the placenta detaches. Care providers learn how to estimate blood loss in land births, but this is more difficult in water because the water dilutes the blood. As a result, some hospitals forbid waterbirth altogether, while others require women to get out of the water after the baby is born and to birth the placenta on dry land.

However, this is not necessary....most providers learn how to estimate blood loss in waterbirths over time. As with every other obstetric skill, it is acquired through teaching from other experts, observation, and practice. As they learned to estimate blood loss in land births, so they will learn to do so with waterbirths. Again, it simply requires the willingness to learn.

Cost of Facilities

Costs of facilities is another potential concern as well. However, costs of adding permanent waterbirth facilities could be easily accounted for by charging extra for access to them. In addition, waterbirth is immensely popular as a concept; having these facilities and promoting their use should bring extra business to the hospital, thus helping to pay for themselves in time.

However, if the capital outlay for permanent waterbirth tubs is too high, portable pools can be rented by parents instead and brought into the hospital; many companies carry them. With these, a hospital incurs no capital outlay at all.

Conclusion

While many doctors have professed concern about waterbirth due to worries about newborn breathing, infection, lack of immediate access to the perineum, difficulty in evaluating blood loss, and cost of facilities, research has shown that each of these concerns can be addressed. When approached with attention for hygiene and appropriate care guidelines, waterbirth is a safe and reasonable choice.

Waterbirth: A Choice Whose Time Has Come!

More and more hospitals are beginning to embrace the use of water in birth. Many hospitals now offer access to tubs for labor, although they still make the mother get out once she starts pushing. Others have waterbirth "suites" where women can both labor and birth in water.

Waterbirth is increasingly popular particularly in European countries, and can be found as well in many Canadian, Australian, and New Zealand hospitals. In the U.K., the majority of hospitals are reported to have water immersion options, and the government has recommended that all hospitals provide women with the option of a birthing pool. Some third-world countries also have options for waterbirth, particularly in specialty birthing clinics.

Although slower to catch on in the U.S. than abroad, waterbirth has been added to a number of U.S. hospitals as well. Monadnock Community Hospital in Peterborough, New Hampshire was the first hospital in the United States to install a permanent waterbirth pool in 1991. Many other hospitals have followed suit since then.

If your local hospital does not have waterbirth choices available, Waterbirth International can work with you to try and change their policy. They have been successful in a number of facilities already. And of course, you always choose waterbirth at home if your hospital is not amenable.

For more information about waterbirth in general, see the following sites:

• http://www.waterbirth.org/


• http://en.wikipedia.org/wiki/Water_birth


• http://www.waterbirthinfo.com/


• http://www.waterbirth.net/


• http://www.gentlebirth.org/archives/watrbrth.html

There are many other online resources about waterbirth available. Do a simple search and you will find many. If you would like to see what waterbirth might look like, "Birth Day" is a lovely waterbirth video of a Mexican midwife giving birth to her own baby in water with her family nearby. YouTube has a number of brief waterbirth videos as well. And stay tuned to this blog for more pictures of women of size laboring and giving birth in water!!

Why Waterbirth Is So Great for Women of Size

[Part Two in a Series on Obesity and Waterbirth]

As we discussed previously, some birth facilities have restricted fat women from having access to water during labor and/or birth. On the other hand, some are very supportive of it, even in very large women. It all depends on the facility and the provider.

I believe that waterbirth is uniquely beneficial for women of size because it offers a number of advantages over "dry" labor and birth. For example:

• Waterbirth makes women of size much more mobile and buoyant, so they are able to change positions easily and quickly


• Waterbirth helps women assume a variety of positions, which may help create more room in the pelvis and help big moms labor and push more effectively


• Waterbirth lessens the need for pain medications/epidurals


• Waterbirth often shortens labor


• Waterbirth makes you less likely to have an episiotomy

The Mobility Factor

The mobility factor is one of the best things about waterbirth. Being hugely pregnant at term is a challenge for women of ANY size, let alone a woman who already started out larger than average. Being in the water makes you feel lighter and more mobile, and fat works to our advantage in water, making fat women particularly buoyant. That's why swimming and water aerobics are so frequently recommended for women of size in pregnancy.....so why not use the same thing to our advantage during labor and birth?

If you are in a bed and you want to change positions during labor, you have to haul yourself up and over.....not the easiest thing to do when hugely pregnant! And especially so for women of size. But if you are in water, it's simply a matter of shifting position a little; the water supports your weight and makes it easier to move.

Furthermore, there is less risk to the backs of support personnel when helping you shift because, in effect, you "weigh less" in the water than you would on land due to buoyancy.

Position Changes May Open Up The Pelvis More

Waterbirth makes it easier to change position so you can create more room in the pelvis for the baby to come out.

In the water, it's easy to sit upright, kneel, get onto hands and knees, have one knee up/one knee down, stand, or even float on your back. These position changes tend to reduce pain and give the baby more room to descend than the usual semi-sitting position we see so often in typical hospital bed births.

Think about it.....the tailbone is one of the most mobile joints in the pelvis. If the woman is semi-sitting or on her back, her weight rests against the tailbone and presses it into the pelvic outlet, reducing the space available for the baby. But if the mother is upright or on hands-and-knees, the tailbone and the sacrum actually move outwards with the descent of the baby, allowing more room.

Being in water facilitates this kind of positioning much more easily than being on dry land, and allows mothers to change positions quickly in response to the baby's needs during pushing.

Many doctors believe that in women of size, extra fat "pads" the pelvis of the mother, reducing the space for the baby to pass through. Although I personally think this is highly dubious, if so-called "soft-tissue dystocia" were real, wouldn't getting a little extra space from opening up the tailbone area be particularly important in women of size?

If waterbirth can help women of size into "non-traditional" positions more easily, then it may just help create more pelvic space for their babies too.

Less Need for Pain Medications

Being in warm water helps lessen labor pain a LOT. This is one of the best parts about waterbirth!! You step into that lovely warm water when you are in serious labor and your body just goes, "Ahhhhhhh!" Think of how relaxing sitting in a hot tub is; consider how good this might feel during the strongest labor contractions!

To be fair, laboring in water doesn't take away all of the pain, and mothers should maintain realistic expectations about it.....but it does help lessen the pain, and more importantly, it helps you cope with it more constructively.

Research supports this; several studies show that laboring in water results in "reduced analgesic requirements" (less pain meds and epidurals). Studies also show that upright positions (which are easier to assume in water) tend to reduce pain also.

There's a reason why laboring in a birth-tub is jokingly called "the aquadural" by a lot of moms! It's sort of like an epidural....but without the risks.

Remember, all medications present potential risks. Narcotics can cause respiratory depression in the baby, epidurals can cause a mother's blood pressure to crash, and there are small but real risks of rare events like paralysis, infection, and even death.

Furthermore, epidurals are particularly difficult to perform adequately in women of size and tend to be less effective; therefore, wouldn't it make sense to encourage these women to be in the water and thus lessen their need for medications/epidurals?

A Shorter Labor

Several studies also show that being in water may shorten the length of labor, especially the first stage of labor (dilation). On average in these studies, being in water shortened the first stage of labor by an hour to an hour and a half. Remember, every little bit helps when you're in pain and waiting anxiously to meet your baby!

Furthermore, other research shows that women of size tend to have longer labors. If simply putting fat women into water could help their labors progress more efficiently, wouldn't that be worth trying? Seems like a low-risk intervention that might help prevent some cesareans for "failure to progress."

Less Chance of an Episiotomy

Waterbirth also significantly lessens the chances of episiotomies (deliberate cuts made by doctors to widen the vaginal opening, which often result in significant perineal trauma to the mother).

One study found a 0.38% episiotomy rate in the waterbirth group (less than one-half of one percent!) vs. a 23% episiotomy rate when birthing in a bed.

Because women of size tend to heal more slowly and have more wound infections than women of average size, avoiding surgical wounds like episiotomies whenever possible is greatly to their advantage.

Conclusion

If laboring in water could help you have a shorter labor, a less painful labor, could lessen your chances of an episiotomy, and help you be more mobile during the birth......all without the significant risks of epidurals and pain medications...........why wouldn't you be interested in that?

And why shouldn't fat women have equal access to such options? Especially when they offer fat women such unique advantages?

Obesity and Waterbirth: A Match Made in Heaven?

When I first started this blog (before I enabled comments), I got emails with questions on various plus-sized pregnancy and parenting topics. I will try to respond to them periodically as I have time.

First up is whether waterbirth is contraindicated in obese women. One woman wrote:

I have recently discovered that there are some care providers that are telling women that if their BMI is too high that they risk out of having a waterbirth.

This is not the first time I have encountered this question. I have heard similar questions from others over the years, wanting to know if waterbirth is okay in women of size, whether waterbirth was restricted from women of size across the board in all facilities, or whether there was real research justifying weight-based restrictions in waterbirth.

The answer is a little complex and will take me several blog entries to adequately answer.

But yes, there are some birthplaces where women of size are risked out of waterbirth (or even laboring in water) entirely. However, this is not an across-the-board policy. Policies vary greatly from facility to facility.

In many birthplaces, women of size are "permitted" to labor in water, and in some they can actually push the baby out in water too. In fact, many women of size have given birth in water just fine. You'll find many such waterbirth stories on my website in the BBW Birth Stories FAQs.

Are these restrictions against waterbirth in women of size justified? In my opinion, no, they are not. Barbara Harper, a leading waterbirth expert, also agrees. More on that in a future post.

In fact, for a variety of reasons, many people feel that waterbirth is the perfect choice for women of size. I agree wholeheartedly. Frankly, waterbirth is uniquely well-suited to women of size, as well as being one of the COOLEST experiences ever. I would urge women of size to explore the possibility and consider it for their own labors whenever appropriate.

Disclaimer: Of course, I have to admit I am biased in the matter. I labored in water for 3 of my 4 births (including one hospital labor), and my last child was actually born into the water. My waterbirth was by far my best birth, and I found being in the water TREMENDOUSLY helpful. I have heard from many other fat women who feel similarly about their waterbirths.

So I am a INCREDIBLE fan of waterbirth, particularly for women of size. But even had I not had personal experience with it, waterbirth makes simple common sense for healthy women of size. Restricting access by BMI is an incredibly short-sighted rule on the part of hospitals and birthing centers, and it needs to be changed.

Rest assured, if you are interested in waterbirth, there ARE birthplaces where fat women can labor (and birth) in water, if they choose to.....including hospitals, birth centers, and of course at home. But you have to choose your place of birth carefully and ask a lot of questions if you want the waterbirth option.

I look forward to the day when waterbirth is universally available to all women, regardless of size.

P.S. The photo above is of labor in water in a "morbidly obese" woman, just before crowning (just before the head appears). The baby was born safely into water shortly after this picture was taken.

Coming Soon: Why Waterbirth Is So Great For Fat Women