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Big can be Beautiful and Normal
Plus plus size Pregnancy
Are we serving women well?
Maggie Davies Consultant Midwife
Too hot to handle
Pregnant for the first time why shouldn’t they be excited?
What information will the women find on the internet?
They google everything
They meet their midwife, weighed
and measured, Body mass index calculated. From
then onwards every body starts
to talk them about their BMI
OMG my BMI
They then google increased BMI in pregnancy and what do they find
line?
CHOICES, Your health, your choices
• Miscarriage – one in four 25%
• Gestational Diabetes – three times more likely
• High blood pressure and pre-eclampsia twice as likely
• Blood clots – higher risk when pregnant BMI above 30 additional risk
• The baby’s shoulder becoming stuck during labour
• Heavier bleeding than normal after birth
• Having a baby more than 4kg, 7% risk for a woman who’s BMI is 20 to 30 – doubled to 14% if BMI is over 30
Royal College of Obstetricians & Gynaecologists
‘Why you weight matters during pregnancy and after birth’
• Thrombosis
• Gestational diabetes – BMI 30 three times more likely
• High Blood pressure & pre eclampsia – doubled with a BMI of above 35
Risks for your baby
• Neural tube defect
• Miscarriage
• Baby weighing more than 4kilos
• Stillbirth
Risks during labour and Birth?
BMI of above 40
• Baby born before 37 weeks
• Long labour
• Baby’s shoulder become ‘stuck’ during birth
• An emergency Caesarean section
• More difficult operation, higher risk of complications
• Wound infection
• Complications with general anaesthesia
• Heavy bleeding at time of the Caesarean section or after the birth
So what are these messages saying to women
Hardly
Do plus size women have the same human rights as others ?
Or they have no choices when labour begins
Not allowed to mobilise
Can’t go in the ‘pool’
We come in all shape and sizes including plus size women
Are all obese pregnant women ‘grouped’ together,
Is this right?
Overweight teenager
Older overweight woman
having her first baby
What about women who have had previous normal births?
The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study (Hollowell et al 2013)
• Nulliparous low risk women of normal weight had higher absolute risks and were more likely to require obstetric intervention or care than otherwise healthy multiparous women with BMI>35kg/m2
• Otherwise healthy multiparous obese women may have lower intrapartum risks than previously appreciated
Obesity and Normal birth: A qualitative study of clinician’s management of obese pregnant women during labour (Angela Kerrigan, Carol Kingdon and Helen Cheyne 2015)
Background
• One fifth of women in the UK are obese
• Increased risk of experiencing complications of labour and serious morbidity
• They are more likely to have interventions such as
1. IOL
2. Caesarean section
3. Wound infection
4. DVT
Obesity and Normal birth (Kerrigan et al 2015)
• Reducing unnecessary interventions
• Increasing normal birth rate
• Improve their postnatal health and wellbeing
• Reduce the burden on the NHS – care post operatively
Kerrigan et al(2015) cont.
The aim of the study was to explore practitioners’ experiences of and strategies for providing intrapartum care for obese women.
Three key themes emerged
• Medicalisation of obese birth
• Promotion of normal obese birth
• Complexities and contradictions in staff attitudes and behaviours
Explore practitioner’s experiences of and strategies for providing intrapartum care to obese women
Conclusion
• Care is generally medicalised and focussed on the associated risks
• Conflicting views on care
• Some practitioners do strive to promote normality
• Challenge current practices – utilise some ‘interventions’ facilitate normality and mobility
• Growing health problem
• Positive proactive guidelines to maximise normal birth if the postnatal health of obese women is to be improved
Abertawe Bro Morgannwg University Health Board (ABMU)
Just under 6,000 births per year
Approximately 1200 women have BMI above 30kg/m2 - 900 with a BMI above 35kg/m2
Freestanding birth centre in Neath and Port Talbot hospital
Just under 500 women commence labour in the birth centre every year
Neath Port Talbot Birth Centre
Antenatal surveillance
Consultant Midwife – caring for women with medium risk complications
• 15% of women have a BMI>35kg/m2
• Many asking to give birth in the birth centre
• Weight management plan for all women
• Weighed again at 28 and 36 weeks
• Discussion regarding how to minimise the risks
• Encouraged to walk more
• Glucose tolerance test at 28 weeks
• Gap and grow - serial growth scans
• At 37 weeks a individual management plan is developed
• If spontaneous labour admitted to the birth centre
• All Wales clinical pathway for normal labour
• Intermittent auscultation
• Use of water during labour and the birth
So what has happened over the years?
• Weight gain ranges from 0 kilos to maximum of 12 kilos.
• Less than 1% have a impaired GTT
• Between 25 to 40 obese women give birth in the birth centre every year
• Midwives are confident in caring for these women
• Women mobilise and use water and give birth in the pool
• Women report a positive birth experience
Success story
• Over the past 12 years up to 400 women have commenced their labours or given birth in the birth centre
• Approximately 120 having their first babies
• No shoulder dystocia • No PPH • 50% have laboured and/or
given birth in the pool • Some women have had
several babies either in the birth centre or at home
Public Health Midwife
2016
• A clinic for nulliparous women BMI 35 to 39.9kg/m2 with no other risk factors
• Only recently being seeing parous women
• 20 women seen, 75% normal birth, 25% LSCS
• 20% gave birth in Freestanding birth centre
• 80% Women who underwent a LSCS had a PPH
Comparing data with women who did not attend the clinic
• Average weight gain in pregnancy was 7.9kilos as opposed to 8.5kilos
• 75% achieved a normal birth compared to 52%
• PPH rate was the same at 45% but the majority of these were at LSCS
• No women who gave birth in the Birth Centre had a PPH
• IOL was similar at 52 to 55%
So are we serving the plus plus women well?
To serve them well perhaps we do need to review the place of
birth
Birthplace study 2011 Giving birth is generally very safe Women who planned birth in a midwifery unit had significantly fewer interventions, including substantially fewer intrapartum Caesarean sections, and more ‘normal births’ than women who planned birth in an obstetric unit
How I see the priorities
• In Wales - increase out of OU births to 45% this group needs to be considered
• Working with the women and their families
• Effective antenatal surveillance to minimise the risks
• Effective preparation for birth, including information on the internet
• Strategies that will increase normal birth
1. Place of birth
2. Treating women as individuals – shared decision making
3. Mobilisation
4. Water
Perhaps then we will be serving the plus plus women well and big can be beautiful and normal.
