Lipedema, Part 1: Lipedema vs. Lymphedema

Have you ever heard of "lipedema"? Until a few years ago, I hadn't. Yet I quite likely have it, and rather significantly too. I wonder how many other fat women might have it and never realized it's a separate diagnosis from being fat?

However, when I have tried to research the condition, I've been turned off by many lipedema websites. Some pay lip service to being size-friendly but when you dig deeper, there is a whole lot of food neuroses and weight-loss rhetoric, which can be very triggering for those trying to practice Body Love and Health At Every Size®.

After looking around again recently, I decided that it's time for a more size-neutral resource on the topic. Since June is Lipedema Awareness Month, here's a summary of what I've learned about lipedema so far, presented as size-neutrally as possible. I have used a multi-part format for length considerations:

• Part One - Symptoms and appearance of lipedema; lipedema vs. lymphedema
• Part Two - Progression and stages of lipedema
• Part Three - Fat distribution types and diagnostic criteria
• Part Four - Possible causes; conditions often associated with lipedema
• Part Five - Possible treatment options, both traditional and alternative
• Part Six - Practical advice for living and dealing proactively with lipedema, as well as sharing a few women's stories* of lipedema

As always, I'm not a healthcare professional and don't offer medical advice. Consult your own healthcare providers. And remember, there is no one "right" way to treat any condition; inform yourself, consult the experts, and then figure out what works best for you. 

Terminology

Very few care providers in the US are aware of lipedema. Never has ANY care provider mentioned the possibility of it to me, despite my very distinct symptoms of it.

Lipedema is such an under-recognized condition that until just recently, it did not have a MESH search term in the National Library of Medicine. Nor does it yet have an International Classification of Diseases (ICD) code. The condition was only recognized by the National Health Service (NHS) in the United Kingdom in 2012. Awareness of lipedema is emerging, but very slowly in some quarters. 

One problem is terminology. Many care providers confuse lipedema with lymphedema. The spelling and the pronunciation are so similar that it's no wonder many people confuse them. However, while the two conditions can overlap somewhat, they are not the same.

Lipedema is the abnormal deposition of excess fat, usually in the extremities, whereas lymphedema is the collection of protein-rich lymph fluid in tissues, causing swelling. 

Lymphedema is pronounced "limf-eh-deem-ah." Lipedema is pronounced "lip-eh-deem-ah." In Europe and Australia they call it "lipoedema" (lye-poh-eh-deem-ah). Terms in the medical literature include:

• Adiposis dolorosa (painful fat syndrome)
• Lipalgia
• Adiposalgia/Adipoalgesia
• Lipomatosis dolorosa of the legs
• Lipohypertrophy dolorosa
• Painful column leg
• Painful lipedema syndrome
• Lipedema (U.S.), lipoedema or lipodema (U.K.), lipödem (Germany)

Here in this post, we'll just use "lipedema" for ease of use.

What is Lipedema?

In layman's terms, lipedema is an abnormal storage and distribution of fat deposits, usually in the lower body but sometimes also in the arms.

Lipedema is considered a R.A.D, a Rare Adipose Disorder. The medical definition, as defined by one source, is:

A chronically progressive, symmetrical accumulation of fat in the subcutaneous tissue with orthostatic edema occurring almost exclusively in women. 

Wikipedia defines it as:

...a chronic disorder of adipose tissue generally affecting the legs, which causes the legs and sometimes the arms to accumulate fatty tissue.

Once in a while it's called "Riding Breeches Syndrome." Some women have described it as like being held prisoner inside a fat suit on their lower body, a fat suit shaped like pantaloons (when the leg to the ankle is affected) or riding breeches (when the waist to the knees is affected). 

According to Rebecca Morris, the founding president of the National Lipedema Association (NLA), lipedema is distinctive in four ways: 

1. It can be inherited
2. It occurs almost exclusively in women
3. It occurs in women of all sizes, from the anorexic to the very heavy
4. Lipedemic fat generally is not mobilized by diet and exercise

Wikipedia adds two more defining characteristics:

1. It involves the excess deposit and expansion of fat cells in an unusual and particular pattern – bilateral, symmetrical and usually from the waist to a distinct line just above the ankles
2. a pathognomonic [definitive] indicator of lipedema is that the feet are spared

What Does Lipedema Look Like?

Here are some pictures to help illustrate the most important characteristics of lipedema. Be warned ─ pictures of the more severe presentations are hard to look at.

Don't panic; remember that not everyone progresses to the severe stages and that even if you do, treatment is available. The pictures merely serve as warning of why early diagnosis and effective treatment are so important.

Disproportionate Body

In the beginning, lipedema is often just a significantly disproportionate "pear" shape. Often women wear a different size on top than on the bottom.

One part of the body (often the hips and upper thighs at first) tends to be much larger than the rest of the body, as in the picture to the left. Some people think of this as "thunder thighs" but it's more than just legs that rub together a bit.

As time goes on, more and more fat begins to be preferentially deposited in the legs and hips. Often the area around the knees begins to develop extra fat pads, and the area just above the ankles starts to get thicker. If you look closely at the picture on the left, you can see the beginnings of these deposits.

In lipedema, the lower half of the body typically is disproportionately larger than the rest of the body and can become even more disproportionate with time.

There are some exceptions to this; some women with lipedema also have significantly larger arms and sometimes chest too. Sometimes there's a lot of fat between the waist and the knees but the lower legs are not nearly as affected. However, the majority of women with lipedema start off with the classic "pear" shape and a lower body that is larger than the rest of her body.

Bilateral and Symmetrical

Lipedema is characterized by really heavy legs which are bilaterally and symmetrically affected. 

Bilateral means BOTH legs are affected (not just one). In the picture to the left, notice that both legs are indeed pretty equally affected.

Symmetrical means the fat deposits are fairly even, not all lumped up in one area. The picture shows this as well. The fat is pretty evenly distributed down the leg until it reaches the ankle, and the two legs look quite alike. 

Bilateral and symmetrical means the same even pattern of fat deposition is seen on both legs. That's very important in distinguishing lipedema from lymphedema, as you will see below.

Does Not Involve the Feet

One of the most defining characteristics of lipedema is that it ends at the ankle and does NOT involve the feet.

It's not just fat legs; it's disproportionately fat legs without fat feet too.

Notice that the legs in the picture fit the description. Both legs are affected pretty equally and evenly (bilateral and symmetrical), but the feet are not affected. That's one of the key symptoms doctors will look for when diagnosing lipedema.

However, it should be noted that if severe secondary lymphedema develops, sometimes the feet can also develop swelling. Thus, in the early to middle stages of lipedema, feet will not be affected, but in the later stages, feet can sometimes be affected too. 

Legs That Lose Their Shape

In early stages of lipedema, there is still some shape to the legs and ankles, but as the condition progresses, the shapeliness of the legs begins to disappear.

Lower legs and ankles start to get thicker and the curves begin to disappear.

Sometimes this is called by the lovely nicknames of "columnar" legs, "piano legs," or "stove-pipe" legs.

This is because as the fat deposition progresses, the leg shape is lost and the legs become more like a column, going mostly straight up and down.



"Cankles On Steroids"

Society likes to call thick ankles "cankles" (i.e. calf-ankles), but lipedema involves a much more severe presentation ─ basically, cankles on steroids.

In the early stages of lipedema, the lower legs become slightly thicker than normal but you don't really see cankles.

In the picture to the left, the woman still has shape to her legs but her lower legs are starting to get a bit thicker and you can just begin to see the suggestion of deposits of fat above the ankle. This is an early stage of lipedema.



Little by little (or sometimes in a fairly short period of time in response to a major hormonal change or severe stress), more and more fat begins to be deposited by the ankles.

As the leg becomes more column-like and less curvy, a "stepped" appearance from the feet to the legs begins to appear.

As some doctors describe a "stepped" appearance, if you ran your hands around the feet and then up to the ankles your hand would get stuck momentarily by the increase of fat at or just above the ankles. You would not have a smooth transition from the foot to the leg because of the significant increase at the ankles.


As lipedema progresses, it often looks like you've worn socks that were too tight and this has left a ring on the skin. This "ring" around the ankles is a classic sign of middle-stage lipedema.  If you look carefully, you can see that "ring" in these two pictures.

In time many women with lipedema develop a bump of fat just above the ankles, as you can see in this close-up just above the "ring." This is what gives the leg the "stepped" appearance.

In the later stages of lipedema, the bump gets large enough that it is very distinctive. Many lipedema resources talk about this characteristic "bracelet" of fat just above the ankles on both legs. Some doctors call this bracelet of fat "inverse shouldering" or "overshouldering."  

As the condition worsens, the shape of the ankles begins to disappear. Eventually, the "shoulders" droop down to hang over the ankles.

This makes it extremely difficult to get socks or boots that fit.

When it's severe, the "overshouldering" of the ankles can droop way down past the ankles. Sometimes the swelling extends nearly to the floor. The skin can become quite prone to infections.

In the picture to the left, the woman obviously has developed secondary lymphedema and her legs are severely affected. However, note that the feet are not involved and that both legs are pretty equally affected. This is probably lipo-lymphedema rather than straight lymphedema. At this point, it really is like having a "pantaloon" fat suit over your legs.

Obviously, this is an extreme stage and most women with lipidema do not experience this level of overshouldering. At this point, some major Manual Lymph Drainage treatment and compression wrapping is needed to reduce the size of the ankles and legs and to restore comfortable functioning.

"Mattress" Skin

In lipedema, the skin starts smooth in the early stages, but as the condition progresses, the skin often develops an appearance some people compare to cottage cheese, a mattress, or an orange peel, as in this picture. Beneath the skin, you may feel little nodules or lumps of fat that feel like little peas or beans under the skin. As the condition progresses, these may start to feel larger. This is probably what causes the "cottage cheese" appearance.

Big Hips, Behind, and Abdomen

Although lipedema is usually thought of as happening primarily in the legs, it can occur from the waist down (including abdomen and hips).

Often the person has a lot of "junk in the trunk," with a very large behind. Sometimes it tends to jut out and become what some people crudely call a "shelf butt." Or the lower abdomen can grow quite large, especially with repeated bouts of weight loss/weight regain, after pregnancy, or with secondary lymphedema.

This can make finding clothes very difficult. Often, women must purchase pants that are far too large in the waist in order to find some that fit in the hips, abdomen, or thighs.

Arms Can Be Affected Too

Sometimes the arms develop lipedema too. One well-known expert in the field states that about 30% of people with lipedema also have arms that are affected.

In the picture to the left, notice that the upper arm is very heavy but that the lower arm is not. This is a common lipedema pattern.

These extremely heavy upper arms can make it very difficult to find shirts that fit. Shirts that are wide enough to fit the upper arms are often far too loose on lower arms. Most short-sleeve shirts don't begin to cover the whole upper arm and can cut uncomfortably into the arm.

The proximity of the arms to the face means that upper-body lipedema is more noticeable to others, and women with affected arms often get more remarks and negative attention. Heavy legs can be covered up by loose pants and long skirts, but lipedema arms are more noticeable, covered or not.

Although most women with arm lipedema experience it only in the upper arm, sometimes the lower arm is heavy too, as in this second arm picture. In these cases, the "bracelet of fat" that is usually seen around the ankle can also be seen around the wrist, as in the picture.

Interestingly, for whatever reason, in lipedema the arms do not usually develop the typical "cottage cheese" skin texture as badly as the legs often do. They can have the nodules of fat that the legs get, but they may not be as noticeable.

Folds and Ridges of Fat

As lipedema worsens, more and more fat is deposited on the legs. This begins to deform the leg in different ways with harmful side effects.

Frequently there is a big pad of fat on the inside of the knees, as in the picture to the left. This can begin to alter the woman's gait; an altered gait can in turn lead to issues with the feet, hips, and back.

The extra fat pads and altered gait can make exercise more difficult and painful, leading to decreased fitness as the lipedema worsens.

In addition, fluids from the abnormal fat deposits can leak into the knee itself, making it very prone to arthritis at earlier ages than normal. This, too, increases the pain associated with exercise and makes it difficult to keep up fitness.

In time, large lumps, folds, and ridges can begin to appear. Often these folds and ridges develop around the knees first.

It is very common to develop a mound of fat tissue just below the knees, as you see in the picture to the left. Notice there is also some folds and ridges of fat above the knee as well. The upper leg  has the classic orange peel look, and the abdomen is also enlarged.

This picture shows a variation in lipedema in that there is less of the typical bracelet of fat around the ankles. This woman has a slightly different type of lipedema, the "riding breeches" version, where the excess fat extends from the waist down to just below the knee and mostly spares the ankles. Anecdotally, this type seems to be particularly prone to secondary lymphedema.

As lipedema progresses into more severe stages, even larger masses of tissue can develop and the leg can become quite large.

This woman probably also has the "riding breeches" form of lipedema that is heaviest from waist to just below the knee. She does have a small bracelet of fat around the ankle, but she is much larger in the abdomen and top two-thirds of her leg.

Secondary lymphedema has developed here, causing additional folds and ridges of fat to appear. Notice the fold on the outside above the knee, the fold and ridge below the knee, the fold on the inner thigh, and the "saddlebag" fold near where the hip and thigh meet. This kind of deformation is common with lipo-lymphedema and can often be reduced considerably with treatment.

Summary

Lipedema presents with certain key characteristics, including a disproportionate body shape, bilateral and symmetrical fat deposition on the legs, dimpled "mattress" skin, and a bracelet of fat around the ankle in many (but not all) cases. Probably the most definitive characteristic of lipedema is the lack of involvement of the foot. This is one feature that doctors particularly look for when trying to differentiate lipedema from other possible diagnoses.

If lipedema worsens, folds and ridges of fat can occur. If secondary lymphedema develops, these can become extremely large, severely deforming the leg and making it difficult to walk. Sometimes the lymphedema also spreads into the foot at this stage.

The good news is that treatment may be able to help slow down or even prevent progression of the condition into lipo-lymphedema.

Other Symptoms of Lipedema

Although the strongest characteristics of lipedema are the ones described above, there are other symptoms commonly found among many people with lipedema. These include:

• High sensitivity to pain in the legs
• Tendency towards easy bruising on the legs
• Cold legs and feet
• Edema/swelling at times
• Spider veins/varicose veins
• Tendency towards unexplained weight gain
• Difficulty losing weight, especially in the lower body

Let's discuss each one of these a bit more closely.

Pain in the Legs

One classic sign of lipedema (but not lymphedema) is high sensitivity to pain with even minimal pressure on the legs, especially on the shins and calves. This sensitivity to touch does not extend to the whole body. Lower leg massage may be too painful, but massage on the back is fine (unless there is fibromyalgia). The pin-point pressure of a cat walking up the leg can cause extreme pain, whereas the same cat walking on the abdomen is fine.

In addition, many women with lipedema report a deep, aching pain from inside the legs, which is why it is sometimes called Painful Fat Syndrome. Some sources believe that this is a separate condition (Dercum's Disease), while others believe that it is part of the spectrum of lipedema. But because Dercum's Disease can occur in several places in the body and onset is usually around menopause (lipedema mostly occurs in the lower body and onset is usually puberty), they are usually considered separate conditions.

Easy Bruising

People with lipedema also tend to bruise easily due to increased capillary fragility. Although women with lipedema are not usually covered in bruises, they do tend to bruise more easily than others, and often have bruises on their legs they can't explain away easily.

Cold Legs and Feet

Many women with lipedema experience cold legs and feet (hypothermia of the skin), although this symptom tends to get overlooked a lot. The woman may have cold feet or legs even when others around her are comfortable, or the skin on her legs may be much colder than on her upper body. This can be a significant source of discomfort for some.

Anecdotally, some women find that it takes significant outside heat sources (hot pads, other people, etc.) to warm up their feet or legs in cold weather. The best guess is that the increased adiposity in the legs interferes with blood and lymph flow, making it harder to regulate temperature.

Swelling

Many women with lipedema experience swelling in the extremities during hot weather or after a long day on their feet. They may find that their fingers swell so much during a walk on a hot summer's day that they cannot tolerate wearing rings at all in the summer.

At first, this swelling resolves pretty easily with rest and elevation, but as lipedema progresses, the swelling tends to not resolve as well due to the lymph system becoming increasingly compromised.

Spider and Varicose Veins

Spider veins and varicose veins are also common in people with lipedema. Spider veins ("telangiectasias") are tiny red veins you can see on the surface of the legs. This is probably due to damage to capillary blood vessels. Varicose veins are also often found.

Unexplained Weight Gain

Many women with lipedema have a history of large, unexplained weight gains, especially associated with major hormonal changes (puberty, pregnancy, perimenopause, and perhaps hormonal birth control) or stress (which increases cortisol and can trigger an inflammation cascade).

Some experience sudden weight or fat gains even when their habits have not changed. Sometimes this gain is mild, sometimes it is extreme. Often it occurs despite aggressive attempts to stop it via diet and exercise.

Difficulty Losing Weight

Many women with lipedema have great difficulty losing weight, especially in the lower half of their bodies. Most have tried very hard to diet away the extra fat. Sometimes weight loss occurs, but is lower in amount than what would be expected by caloric count, and it often returns with a vengeance afterwards. Some even gain weight while on a diet and stringent exercise plan.

Even when weight is lost in the upper body, very little is lost in the lower body, including after bariatric surgery like gastric bypass. All this suggests strongly that there is something going on here beyond simplistic "calories in, calories out" calculations.

Summary

All of this is part of the symptom spectrum of lipedema. You don't have to have all of these symptoms to have lipedema, but if you have most of them, you probably have lipedema. If in doubt, consult your doctor ─ just make sure he/she is well-educated about lipedema first so you can get an accurate evaluation.

Lipedema vs. Lymphedema

Lymphedema is much different than lipedema. Lipedema is caused by the abnormal deposition of fatty tissue. Lymphedema has to do with impaired flow of lymph fluid and the resulting swelling.

Again, although people with latter-stage lipedema often develop lymphedema as a complication because fatty deposits can impair lymph flow, the reverse is never true ─ people with lymphedema do not develop lipedema as a complication.

One definition of lymphedema can be found here:

Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue that causes swelling, most often in the arm(s) and/or leg(s), and occasionally in other parts of the body. Lymphedema can develop when lymphatic vessels are missing or impaired (primary), or when lymph vessels are damaged or lymph nodes removed (secondary). 

When the impairment becomes so great that the lymphatic fluid exceeds the lymphatic transport capacity, an abnormal amount of protein-rich fluid collects in the tissues of the affected area. Left untreated, this stagnant, protein-rich fluid not only causes tissue channels to increase in size and number, but also reduces oxygen availability in the transport system, interferes with wound healing, and provides a culture medium for bacteria that can result in lymphangitis (infection).

In contrast to lipedema, lymphedema affects feet as well as legs, as can be observed in the picture to the left. This is one of the most important ways to distinguish between the two conditions.

In lymphedema, the swelling often starts in the toes and continues upwards, whereas with lipedema the fat deposits start near the waist and extend downwards to the ankles.

Occasionally, lipedema patients will also have swelling of the feet, but typically this only happens with either temporary lymphedema due to trauma like surgery, or when secondary lipo-lymphedema has developed.

Onset during puberty is common with lipedema, whereas with lymphedema, onset can occur at any age. Lymphedema is often seen after major cancer surgeries, for example, when the lymph system has been damaged.

Another important difference is that lymphedema often affects only one limb, and is usually not symmetrical all over. Note in the picture to the left the difference in size between the leg. Notice also that one foot is swollen and the other is not. This is clearly lymphedema.

Sometimes lymphedema does involve both legs, but that's unusual, and if it happens, the pattern of swelling almost always involves the feet.
.
Here is another picture of a lymphedema case. Notice that only one leg is affected, and there is a huge difference in size between the two legs. Notice also that while there is "overshouldering" of the ankle on the affected leg, the foot is also affected and is much larger than the foot on the other leg. Nor does the skin have the characteristic "orange peel" or "mattress skin" look that you would expect if the leg on the right were truly from lipedema.

Lymphedema can occur in males or females, whereas lipedema is usually limited to females. There is no increased bruising with lymphedema, and the skin texture is harder or more fibrotic, while it is more rubbery with lipedema. Sometimes there are changes in skin color with lymphedema, whereas this is less common with lipedema (unless secondary lymphedema or an infection has developed).

In addition, people with lymphedema may get pitting edema (where you press down the skin and it stays down), as seen in the picture to the left. Pitting edema is rare in lipedema, however, unless secondary lipo-lymphedema has also developed.

Abnormal retention of fluid and difficulty moving lymph is part of both syndromes. In lymphedema, it's usually caused by trauma to the area (like surgery, radiation, chemotherapy) or from vascular anomalies.

Lipolymphedema

In lipedema, lymph issues are caused by the abnormal deposition of fat cells blocking lymph flow. As noted, this causes severe swelling and deforming ridges and folds of fat.

Notice that while the woman on the left clearly has lymphedema, both legs are affected, the feet are much smaller, and there are characteristic fat pads at the knees and over-shouldering around the ankles. This is a LIPEDEMA patient who has also developed secondary lipo-lymphedema.

When lipedema patients develop significant secondary lymphedema, it can become very extreme and debilitating, even life-threatening. The goal of diagnosis and treatment of lipedema is to keep it from progressing to these severe stages.

Summary

Lipedema was first described in the medical literature in 1940 by Doctors Allen and Hines of the Mayo Clinic. However, it did not become well-known among U.S. providers. European providers were also slow to recognize lipedema, but generally have more awareness of it today than U.S. providers. Many countries outside of Europe and the U.S. have even less awareness of it.

One important point is that we do not truly know how common lipedema is. It is called a "Rare Adipose Disorder" but it is probably not that rare. The Lipoedema Australia Support Society (LASS) says that 5-15% of women may have it. One epidemiological study estimated that about 11% of women have lipedema. If around 1 in 10 to 1 in 20 women have a condition, that's not "rare."

Since these figures are only guesses, they could be over-estimates, but then again they may not be counting many early cases which are hard to identify. Does every woman with a pear-shaped body have lipedema? Hard to say. Best guess is that the women with true lipedema are those with pronounced "pear" shapes and whose bottom halves put on fat in response to hormonal challenges or major stress. But what percentage of women fit this criteria is hard to say.

Because it is relatively unknown, it is common for women to go for years without being diagnosed. Women with lipedema are simply seen as fat by the public and by most doctors. Often they are pressured into diets, weight loss surgery, and/or extreme exercise to treat it. Many are shamed and mistreated due to obesity stigma and prejudice.

However, the unique pear-shaped silhouette, the sparing of the hands and feet, and the progressive nature of condition despite all attempts at diet and exercise certainly suggest that it is a real medical condition that is more complicated than "just" obesity.

Sometimes, lipedema is shrugged off as lymphedema, but the two conditions have very distinct differences. However, the lines can be blurred in the late stages because lipedema patients can develop lipo-lymphedema.

Often, lipedema patients are only diagnosed because they have been referred to lymphedema specialists who have more recognition of lipedema as a condition. By that time, however, the lipo-lymphedema has often advanced so far that the condition has become quite disabling or even life-threatening.

A significant percentage of fat people probably have lipedema and are going undiagnosed and untreated for it. This is why I want to bring particular attention to it on this blog.

This lack of recognition is probably leading to many cases of severe lipo-lymphedema that might have been prevented by having more awareness and earlier treatment of lipedema.

It is time for more care providers and consumers to learn about lipedema and how to care for it. It is time for the general public to learn about lipedema so there is less stigma attached to it. And it is time for women with lipedema to take back their power and learn to live proactively with it.

*Do you have a Lipedema story you'd like to share? Please email it to kmom AT plus-size-pregnancy dot org. 

Resources and References

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://www.curelipedema.org/# - Cure Lipedema 
• 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
• http://fatdisorders.org/fat-disorders/lipedema-lipoedema-description - Website of the Fat Disorders Research Society 
• http://www.lipv.nl/Lipedema%20a%20frequently%20misdiagnoseds%20and%20misunderstood%20syndrome.pdf - Educational article on lipedema for care providers, good but technical in parts. (Not size-friendly; advocates "rigorous" weight control and suggests bariatric surgery)
• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309375/ - United States National Library of Medicine, National Institutes of Health 
• http://en.wikipedia.org/wiki/Lipedema - Wikipedia article on lipedema
• http://www.nhs.uk/conditions/lipoedema/Pages/Introduction.aspx - United Kingdom's NHS website page on Lipedema 
• http://www.lymphedema-therapy.com/Lipedema.htm - Lymphedema Therapy website 
• http://www.hanse-klinik.de/englisch/Lipoedema.pdf - article on lipedema from one of the foremost clinics in Germany that treats lipedema
• http://www.lymphedema.com/lipedema.htm - Peninsula Medical summary of lipedema
• http://www.lymphedemapeople.com/wiki/doku.php?id=lipedema - Lipedema page from a website specializing in lymphedema information (Lymphedema People)
• http://www.webmd.com/women/guide/lipedema-symptoms-treatment-causes - WebMD article 
• http://www.lipedemaliposuctioncenter.com/about-lipedema.html - Liposuction clinic specializing in lipedema patients 
• http://www.lymphedemablog.com/2012/12/13/a-closer-look-at-lipedema-and-the-effects-on-the-lymphatic-system/ - Effect of lipedema on the lymphatic system
• Differential Diagnosis for lipedema vs. lymphedema - how to differentiate these conditions
• http://rlbatesmd.blogspot.com/2010/02/lipedema-lymphedema-lipolymphedema.html - blog entry on lipedema vs. lymphedema, written by a plastic surgeon
• http://www.mdjunction.com/forums/dercums-disease-discussions/articles/2888889-lipolymphedema-dercums - details about lipedema and lymphedema
• http://www.thelymphoedemacliniclondon.co.uk/pages/treatment-for-lipedema-and-lipo-lymphoedema.php - treatment options for lipedema and lymphedema
• http://blog.wegohealth.com/2014/09/15/the-phases-of-a-lipedema-diagnosis/ - Guide to navigating a lipedema diagnosis, written by Sarah Bramblette, a prominent lipedema activist

Blogs, Websites, and Facebook Pages from Those Dealing with Lipedema

• http://lipedema-simplified.org/ - blog and advocacy from Catherine Seo, who is dealing with lipedema and who is the maker of the new film "Born To Be Fat" about lipedema. (Caution, weight loss and diet talk, but still a worthwhile resource for Fat-Acceptance folk)
• lipladyfab.wordpress.com - blog of woman dealing with lipedema and undergoing liposuction
• http://www.biglegwoman.com - blog of woman dealing with lipedema
• http://born2lbfat.com/category/livingwithlipedema/ - blog of woman dealing with severe lipedema, including her journey with gastric bypass
• http://lipedemagirl.tumblr.com/me - tumblr account of a woman dealing with lipedema and lymphedema, including having had lap band surgery
• Big Fat Legs http://www.bigfatlegs.com/ - blog of woman dealing with lipedema
• Lipoedema Ladies (U.K.) - http://www.lipoedemaladies.com/ - U.K. support group for lipedema
• http://www.tillysmidt.nl/LIPEDEMA_Englisch_for_Lipoedeem.html - website of Dutch woman with lipedema who was an early voice for treating lipedema (not a size-friendly resource)
• https://www.facebook.com/lilithnixroadtorecovery/posts/537379969717549 - Facebook page of a woman with lipo-lymphedema (this link takes you to her biography and lipedema story)
• http://www.thedoctorstv.com/videos/living-with-lymphedema-and-lipedema - video biography of Sarah from "The Doctors" episode (she has stage 4 lipolymphedema)
• http://www.nursevirginiablog.com/?s=lipedema - Nurse Virginia's blog  (not size-friendly)
• https://mylipedemajourney.wordpress.com/ - a thin woman's journey with lipedema and tumescent liposuction to treat it
• http://www.lass.org.au/ - Lipoedema Australian Support Society (LASS)
• http://www.talklipoedema.org/ - U.K. support and information group for lipedema
• https://livingwithlipoedema.wordpress.com/ - a British woman's journey with lipedema, particularly focusing on its emotional effect and the treatments she has tried
• http://www.laurajdavis.com/blog/category/lipolymphedema - one woman's history of lipo-lymphedema, failed attempts at weight loss, and treatment difficulties

General Information about Lipedema

Med Hypotheses. 2014 Aug 23. pii: S0306-9877(14)00295-3. doi: 10.1016/j.mehy.2014.08.011. [Epub ahead of print] Pathophysiological dilemmas of lipedema. Szél E1, Kemény L2, Groma G2, Szolnoky G2. PMID: 25200646

Lipedema is a common, but often underdiagnosed masquerading disease of obesity, which almost exclusively affects females. There are many debates regarding the diagnosis as well as the treatment strategies of the disease. The clinical diagnosis is relatively simple, however, knowledge regarding the pathomechanism is less than limited and curative therapy does not exist at all demanding an urgent need for extensive research. According to our hypothesis, lipedema is an estrogen-regulated polygenetic disease, which manifests in parallel with feminine hormonal changes and leads to vasculo- and lymphangiopathy. Inflammation of the peripheral nerves and sympathetic innervation abnormalities of the subcutaneous adipose tissue also involving estrogen may be responsible for neuropathy. Adipocyte hyperproliferation is likely to be a secondary phenomenon maintaining a vicious cycle. Herein, the relevant articles are reviewed from 1913 until now and discussed in context of the most likely mechanisms leading to the disease, which could serve as a starting point for further research.

Obese Women Need Increased Access to Midwifery Care

Here is a study that looked at the pregnancy care of "obese" women with a BMI of 40 or more.

98% of these women saw a midwife only at the first screening appointment and never again, despite the fact that the majority of them did not develop complications.

And guess what, their cesarean rate was nearly 50%. This is far too high.

One of the most potent ways to lower the cesarean rate for women is to give them access to midwifery care. Yet this study shows that most higher-weight women are routinely being re-directed out of midwifery care.

This is not an isolated trend. If anything, maternity care is tilting towards an approach where women of size are not allowed to access midwives or low-intervention care.

We need to EXPAND midwifery care for healthy women of size, not restrict it.

In some areas, women of moderate obesity are able to access midwives and other low-intervention care choices, but Class III obese women (BMI of 40 or more) are often routinely given NO choice. In some areas, not even women of moderate obesity are being given access to low-intervention care.

Basing a decision like this simply on a number on a chart is short-sighted and probably results in many unnecessary cesareans. Instead, the decision should be made on a case-by-case basis, based not on the woman's size but on her health and particular circumstances.

If high BMI women have or develop complications, then sure, they should at least have an OB consult at some point, and can be co-managed by a midwife and OB if circumstances necessitate it. If their complications are significant enough, then care should be managed by a OB specialist or in a special bariatric center in some cases.

But women of size who do not experience complications do NOT need to be managed in a high-risk, high-intervention model of care, and they should not be routinely re-directed out of midwifery care. 

That includes Class III obese women (BMI 40+) ─ and Class IV obese women (BMI 50+) too. In fact, most probably would do better NOT being managed in a high-intervention model of care.

Size alone should NOT disqualify women of size from midwifery care, yet in the real world it often does. This needs to change.


Reference

Women Birth. 2013 Sep;26(3):179-84. doi: 10.1016/j.wombi.2013.05.001. Epub 2013 Jun 5. Pregnancy care and birth outcomes for women with moderate to super-extreme obesity. Slavin VJ1, Fenwick J, Gamble J. PMID: 23746783

PURPOSE: To describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity. BACKGROUND: Maternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40. METHOD: Women with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women. RESULTS: 153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1-16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n=150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n=74, 48.4%). CONCLUSION: Clinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.

Fundal Pressure: An Outdated Technique

Image from humanrightsinchildbirth.org  

We blogged recently about common hospital birthing positions and "alternative" birthing positions used in many historical and traditional societies.

We discussed how traditional societies, both now and in the past, used different birthing positions than the ones usually seen in the hospital.

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.

There are a number of case reports of uterine rupture occurring in an unscarred uterus after fundal pressure during the pushing stage. In addition, there are isolated case reports of rib fractures/hemothorax and uterine prolapse after fundal pressure. There have also been fetal deaths and maternal deaths that have occurred which may have been associated with use of fundal pressure.

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.

Fundal pressure during labor is even more common in many non-U.S. hospitals. Hospitals in Italy, Bulgaria, Brazil, Turkey, Japan, and India have published recent research on the use of fundal pressure, and I've read recent anecdotal reports on its use in Germany and Honduras.

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 show similar scenes 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
• Keep the mother mobile during labor. Encouraging the mother to be mobile during labor may help lower her chance for cesarean. In addition, certain positions may give more room in the pelvis or help poorly-positioned babies turn during labor into more optimal positions 
• 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
• Encourage spontaneous pushing efforts. Although holding the breath and bearing down ("Valsava pushing") is standard management of the pushing phase in many hospitals, research shows that encouraging spontaneous pushing works just as well or even better
• 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.

J Perinat Med. 2015 Mar;43(2):171-5. Intrapartum ultrasound prior to Kristeller maneuver: an observational study. Cuerva MJ, Tobias P, Espinosa JA, Bartha JL. PMID: 25032803

...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....

Shoulder Dystocia Guidelines

• http://www.aafp.org/afp/2004/0401/p1707.html - American Academy of Family Physicians
• http://www.acog.org/-/media/Districts/District-II/PDFs/Optimizing-Protocols-In-OB-HTN-Series-3.pdf - American College of Obstetricians and Gynecologists
• https://www.rcog.org.uk/globalassets/documents/guidelines/gtg42_25112013.pdf - Royal College of Obstetricians and Gynaecologists

*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 1882 book, "Labor Among Primitive Peoples," by Dr. George Engelmann 
• 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.

A Midwife-Laborist Care Model Reduces Cesarean Rates

Here is brand-new research showing that a midwife-physician laborist care model resulted in lower cesarean rates than a private practice OB care model.

This could be one potent way to reduce stubbornly-high cesarean rates on a more widespread basis.

But first, let's start by discussing what a "laborist" is, since many readers may not be familiar with this model of care.

What is a "Laborist"?

More and more hospitals are beginning to implement "laborist" programs in their maternity wards. But what the heck is a "laborist"?

According to the American College of Obstetricians and Gynecologists:

The term laborist most commonly refers to an obstetrician–gynecologist who is employed by a hospital or physician group and whose primary role is to care for laboring patients and to manage obstetric emergencies.

Laborists are based on the "hospitalist" concept from other medical fields. A hospitalist is a physician that only works in the hospital and does not have care responsibilities elsewhere. Their focus is on hospitalized patients, not private patients.

A hospitalist might work up patients admitted to the hospital from the emergency room, get information from all the patient's doctors, order tests, look for potential cross-reactions between medications, and develop a plan of care for the patient's hospital stay, release, and after-care. The patient's main doctor collaborates with the hospitalist, but having a hospitalist assigned to a patient assures the patient of having a doctor immediately available if necessary, as well as someone who will coordinate care between various providers.

Basically, a laborist is a hospitalist in the OB-GYN field.

There are several different laborist models around so details can differ, but generally a laborist stays in the hospital and is in charge of consulting on patients in labor during his/her work shift. He/she would not be responsible for any other other duties or office hours, but instead manages whatever issues come up during that shift, including emergencies.

If a minor problem occurred, the woman's regular care provider and the laborist would consult on how to manage it. If there was an emergency that required immediate response, the laborist would handle it. If a c-section was needed, the laborist would do it (or would do it in conjunction with the woman's care provider). If a woman in labor came into the E.R. without an assigned physician from that hospital, the laborist would take the case. In addition, if the emergency room had an E.R. patient with a gynecological problem, the laborist would consult.

In the non-laborist model of care, a private OB group covers its own patients when they are in labor. This means that doctors must juggle covering office hours, meetings, and routine appointments with managing patients who are in labor. If there is an emergency, the doctor must drop everything to run over to the hospital and respond to the crisis. Regular patient appointments must often be rescheduled or covered by colleagues back at the office because of the unpredictable nature of labor.

Like hospitalists, the laborist care model is a rapidly expanding model of care. One survey showed that about 40% of the U.S. hospitals surveyed had moved to a laborist model, and this number is likely to increase over time.

That means it's time to have a more in-depth look at the pros and cons of laborist programs.

Advantages and Disadvantages of Laborists 

The biggest advantage of having a laborist is that an obstetric surgeon is always right at hand in the hospital, ready to intervene at a moment's notice if a true emergency occurred. 

This is HUGE in the field of obstetrics where sudden emergencies sometimes do occur. Most birthing women are surprised to learn that most hospitals don't have a doctor always on hand, ready to intervene. Thus there can be a critical delay while waiting for a physician to arrive from off-campus.

Private duty OBs juggle regular office hours with monitoring their patients in labor. They are usually on-call at a nearby office or home within a certain number of minutes, but that is not the same as being at the hospital 24/7. Having a laborist always on duty means that someone is always available right away on those rare occasions when immediate action is needed.

Another big advantage of laborist care is a more humane life-style for the care providers involved. In hospitals with laborist models, care providers have more off-duty time, more time with their families, and less need to juggle laboring patients with office hours. In a profession where stress contributes mightily to burn-out and substance abuse issues, a more sane schedule is a tremendous advantage for both care providers and the mothers they attend.

Laborists also offer business advantages. Hospitals with laborist programs have been able to reduce their malpractice premiums and do not have to hold as much money in reserve for possible liability claims. This means that even though laborists cost extra money in salaries, their overall effect often saves a hospital money.

One potential disadvantage of laborist care is less personal care. A woman might not be attended by her personal caregiver during labor. Many women feel strongly about having a personal relationship with a caregiver she knows and trusts, one who has a deep understanding of her medical history and birth preferences. A laborist model has the potential to decrease this. This is a real and substantial disadvantage.

However, the reality of hospital birth is that many caregivers already do not attend their own patients because they are part of large group practices. The mother gets whomever is on duty in the group on the day she goes into labor. Those caregivers who do promise to be there for a woman's labor often do so by inducing her when they are on duty, exposing the mother and baby to all the risks of induction and perhaps raising the risk for cesarean.

Additionally, most laborist models do allow the regular caregiver to attend a particular patient's birth if desired. It doesn't keep them from attending births, it just gives them more flexibility to balance other duties with births. And having a laborist working in conjunction with the regular caregiver might just ease some of the time constraints that caregivers feel and give the mother more opportunity to get the birth outcome she wants.

Possible Effect on Cesarean Rate

One VERY important potential advantage of having a laborist is hopefully lowering both the primary and repeat cesarean rate, while also increasing VBAC access. 

Because a private practice OB has dual duties with office hours and births, the constraints on their time may make them more quick to move to a cesarean. A laborist may have more patience to wait out a long labor because they don't have to rush off to other appointments, and they might be more willing to try alternatives (like mobility in labor, manual repositioning of the baby, etc.) when labor is "stuck." In this way, a laborist may help prevent primary cesareans, which in turn will help prevent many repeat cesareans in the future.

In addition, the current rules of many hospitals make it hard for many care providers to attend Vaginal Births After Cesarean (VBACs). Many hospitals demand that a doctor and anesthesiologist must be IN the hospital with a VBAC patient at all times, making it hard for caregivers to manage regular office hours and VBAC patients. This has resulted in many doctors refusing to attend VBAC mothers, forcing most of them into repeat cesareans.

Having a laborist on duty should boost the willingness of care providers to support VBAC patients.

This could be very important, since about one-third of U.S. hospitals have official VBAC bans, and many more have de facto VBAC bans. Many women are being forced into surgery they do not want or need by the "immediately available" VBAC criteria. Laborists can provide the 24/7 coverage needed to satisfy part of that criteria and may help bring VBAC back to many hospitals.

What Does the Research Say?

The theory has been that if laborists were added to hospitals, some lives would be saved, the quality of life of OBs would improve, and the cesarean rate would go down. But has the laborist model achieved this?

The research so far does seem to support this. In one study from Nevada, the cesarean rate dropped from 39% to 33% when a full-time laborist model was adopted ─ and this was during a period when the cesarean rate was rapidly increasing everywhere else.

[However, it's important to point out that even with the laborist model, the Nevada study still had a fairly high cesarean rate, over 30%, suggesting that there is still room for improvement.]

In 2013, three studies on laborist models were presented at a meeting of the Society of Maternal-Fetal Medicine. All three showed improvements with a laborist model of care, as summarized here:

Hospitals that employed laborists saw about a 15% decline in induction of labor and preterm deliveries after adjustment for other factors compared with centers that do not employ that OB equivalent of a hospitalist, Sindhu Srinivas, MD, of the University of Pennsylvania in Philadelphia, and colleagues reported.  

In a separate study, hospitals that provided 24-hour coverage through use of laborists or other means saw a similar reduction in cesarean delivery rates, with a more than twofold increase in attempted vaginal birth after a prior cesarean, said Yvonne Cheng, MD, PhD, of the University of California San Francisco and colleagues.

...In the third study, Allison Allen, a medical student at Oregon Health & Science University in Portland, and colleagues looked at a computer simulation comparing probabilistic scenarios for two events that require urgent delivery -- umbilical cord prolapse and major placental abruption -- at laborist and nonlaborist hospitals. In a theoretical cohort of 100,000 pregnant women, employment of laborists at hospitals with a volume of 1,000 deliveries a year would be expected to result in 83% fewer stillbirths, 17% fewer cases of major neurologic injury, and 13% fewer neonatal deaths.

So indeed, it does seem that a laborist model should save lives, lower the cesarean rate, and improve access to VBAC. Most OBs agree that it also brings a bit more sanity into their busy schedules and more time for family life.

All of this speaks strongly in favor of a laborist model of care. But what if that model of care could be improved on even further?

One hospital in California asked whether it could lower the cesarean rate even more by using both OBs and midwives in its laborist model.

Midwifery/Laborist Model of Care

Midwifery care has been shown numerous times to lower intervention rates and often c-section rates. Integrating midwives into a laborist care model might make for a particularly potent combination for reducing cesarean rates.

In this study from a community hospital in Marin, California, using both midwives and OBs as laborists helped lower the cesarean rate substantially compared to those handled in private OB practices.

In the study's private practice care model (also called an "out-of-hospital" model), a large practice of 18 OBs and 2 CNMs (Certified Nurse-Midwives) practiced together and handled 57% of the births during the 5-year study period.

In the collaborative midwife-laborist care model (also called an "in-hospital" model), a group of 20 CNMs and 25 OBs practiced together. They handled 42% of the births during the same study period. In this care model, both a midwife and an OB were on duty as laborists 24 hours a day. The care for most patients was midwife-led, with the OB laborist called in as the woman's risk factors and situation dictated.

In this study, women who were cared for in the private OB practice model had more cesareans than those under the care of midwife-laborist model, 31.6% vs. 17.3%. 

That's a HUGE difference. Even after adjusting for confounders, the women in private practice care had twice the risk for cesarean. They also had more inductions and more epidurals.

The midwife-laborist care model was effective for first-time mothers as well as multips. "NTSV" stands for Nulliparous, Term, Singleton, Vertex, and basically means first-time mothers, at full-term, with only one baby, and that baby is head-down. Many researchers feel these low-risk NTSV births are the best target for lowering overall cesarean rates because every primary cesarean prevented in NTSV mothers usually means that a repeat cesarean for a later birth is also prevented.

In this study, 29.8% of NTSV births in the private practice model ended in cesarean, whereas only 15.9% of NTSV births in the midwife-laborist care model ended in cesarean. That's a very important difference.

The difference was also clear in NTSV cesareans where medical judgment plays a critical part of when to move to a cesarean (such as interpreting abnormal fetal heart tracings or dealing with slower labors). In this situation, the private practice model had a 28.1% cesarean rate, versus a 15.6% cesarean rate in the midwife-laborist care model. The authors suggested that the difference may well have had to do with less competing demands for the care provider's time and as a result, more patience in labor.

The midwife-laborist care model was also helpful for mothers who had had a prior cesarean. 71.3% of women with prior cesareans had another cesarean in the private practice model, whereas 41.4% of women with prior cesareans seen in the collaborative care model had another cesarean.

This was probably both a reflection that midwives tend to be more supportive of offering VBACs, as well as the fact that 24-hour laborist care enabled more providers to meet the "immediately available" requirement without having to cancel regular office hours. So while the study did not have specific data on the "trial of labor" or success rates in each group, it's likely that midwife-laborist care model did significantly expand VBAC access at the hospital.

One item I'd particularly like studied in the future is whether a midwife-laborist care model could lower the cesarean rate in women of size. In the study, the authors did not have information on Body Mass Index and could not analyze for its effect. However, they pointed out that the midwife-laborist care model had far more Latina patients than the private OB care model. They noted that Latinas tend to have a higher prevalence of obesity than white women in the U.S. and that if that trend also held true in the study, the midwife-laborist care model "should" have had higher cesarean rates. <roll eyes> Yet the midwife-laborist care model actually had LOWER cesarean rates, despite a population that was probably heavier.

[Hmmmm. Maybe how an "obese" woman's labor is managed makes a big difference? Maybe differing expectations of normalcy make a difference? Maybe midwives should be handling more women of size? Sounds like this is a topic ripe to be studied in further detail, doesn't it?]

The authors concluded:

In this study, we observed a consistent pattern of a higher use of cesarean delivery among women cared for under a private model compared with women cared for under a midwife/laborist model...Based on our findings, the implementation of obstetrician-midwife laborist programs may also have a positive impact on reducing the rate of cesarean deliveries in the United States.

This is a study that deserves to be replicated to see if other hospitals can achieve similarly dramatic results. Heaven knows we need to reduce the amount of non-indicated cesareans we are doing in the U.S., and reducing that rate should help prevent some of the alarming downstream outcomes of a too-high cesarean rate, like placenta accreta, placenta previa, placental abruption, and cesarean scar pregnancies.

I'd also love to see researchers particularly focus on whether a midwife-laborist program can decrease the unacceptably high risk for cesarean among women of size, and thereby decrease their risks for downstream complications too.

Summary

These studies show that a full-time laborist care model can be part of a program to help reduce cesarean rates at the hospital level.

If having a laborist on duty at all times can help lower cesarean rates, make VBAC more accessible, save a few lives, and help make caregivers' lives more humane, then it's a win-win situation all around. Research shows that most women are satisfied with the care received under a laborist care model, despite some care providers' fears that they would not be.

Laborist care models seem like a winning innovation so far, but the California study shows that a midwife-laborist care model is worth looking at even more closely.

Note that the OB laborist program in Nevada reduced its cesarean rate from 39% to 33%, yet the midwife-laborist program in California reduced its cesarean rate from 31% to 17%.

This suggests that a midwife-laborist model of care is even more potent at reducing cesarean rates than an OB laborist model of care.

More research is needed to confirm these results, but this preliminary research is very promising. If hospitals are serious about lowering cesarean rates, then it's time they looked into a midwife-laborist model of care.


References

Am J Obstet Gynecol. 2015 Apr;212(4):491.e1-8. doi: 10.1016/j.ajog.2014.11.014. Epub 2014 Nov 13. Two practice models in one labor and delivery unit: association with cesarean delivery rates. Nijagal MA1, Kuppermann M2, Nakagawa S3, Cheng Y4. PMID: 25446697

OBJECTIVE: The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESIGN: This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS: Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION: In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Am J Obstet Gynecol. 2013 Sep;209(3):251.e1-6. doi: 10.1016/j.ajog.2013.06.040. Epub 2013 Jul 29. Implementation of a laborist program and evaluation of the effect upon cesarean delivery. Iriye BK1, Huang WH, Condon J, Hancock L, Hancock JK, Ghamsary M, Garite TJ. PMID: 23904102

...In a tertiary hospital staffed with private practice physicians, data were retrospectively reviewed for 3 time periods from 2006 through 2011. The first period (16 months) there were no laborists (traditional model), followed by 14 months of continuous in-hospital laborist coverage provided by community staff (community laborist), and finally a 24-month period with full-time laborists providing continuous in-hospital coverage. The primary hypothesis was that full-time laborists would decrease cesarean delivery rates. RESULTS: Data from 6206 term nulliparous patients were retrospectively reviewed. The cesarean delivery rate for no laborist care was 39.2%, for community physician laborist care was 38.7%, and for full-time laborists was 33.2%. With adjustment via logistic regression, full-time laborist presence was associated with a significant reduction in cesarean delivery when contrasted with no laborist (odds ratio, 0.73; 95% confidence interval, 0.64-0.83; P < .0001) or community laborist care (odds ratio, 0.77; 95% confidence interval, 0.67-0.87; P < .001). The community laborist model was not associated with an effect upon cesarean delivery. CONCLUSION: A dedicated full-time laborist staff model is associated with lower rates of cesarean delivery. These findings may be used as part of a strategy to reduce cesarean delivery, lower maternal morbidity and mortality, and decrease health care costs.

Other discussions of various "laborist" models:

• http://www.acog.org/About-ACOG/ACOG-Departments/Practice-Management-and-Managed-Care/The-Laborist---A-Flexible-Concept
• http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/user-defined-tags/hospitalists/debating-laborist-model-care-0?page=full
• http://www.medpagetoday.com/MeetingCoverage/SMFM/37437
• http://www.the-hospitalist.org/article/the-laborist-movement/
• http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/The-Obstetric-Gynecologic-Hospitalist