This is a WOM article submitted by Kmom.
Most articles about pregnancy in obese women emphasize an increased risk for cesarean section. But is this really true? Can the cesarean rate be lowered among women of size? And what can a big mom do to lower her personal chances for a cesarean?
Why Not A Cesarean?
Some people today see a cesarean as just another way to give birth. Unfortunately, they don’t fully understand the risks of cesareans. 1
Certainly no one opposes truly necessary cesareans. But nowadays, more and more women are being convinced into a cesarean that’s not really necessary. Unfortunately, this has many health implications, many of which are not explained fully when deciding about a cesarean.
A cesarean is major abdominal surgery. It carries twice the risk for maternal death as a vaginal birth. It can cause severe bleeding, injuries to the bladder and bowels, life-threatening blood clots, painful internal scar tissue, long-term pelvic pain, and infections. Many women experience pain and problems for years after their cesarean.
Cesareans are also risky for babies. Some babies are cut during the surgery, risking infection and causing scarring. Babies born after cesareans are more likely to experience severe breathing problems, have low Apgar scores, and to be admitted to intensive care units. Breastfeeding is also less likely to succeed after a cesarean, which can have long-term health consequences for the baby.
A prior cesarean puts a woman at more risk for future birth complications like tubal pregnancies, placental abruption, premature birth, uterine rupture, and severe placental implantation disorders. Each successive cesarean raises these risks even higher.
Cesareans are even more risky for obese women. 2 There are increased risks for blood clots, anesthesia problems, severe bleeding, wound problems, and infection. Doctors should be doing everything in their power to lower the cesarean rate in obese women, but instead are doing far more cesareans in this group than ever before, risking the health of both big moms and their babies.
Skyrocketing Cesarean Rates in Women of Size
Just how high is the cesarean rate in big moms? Numbers vary greatly between studies, but several recent studies found that one-third to nearly one-half of obese mothers ended up having a cesarean. 3, 4 The rate in supersized women is even higher. 5 But it doesn’t have to be that way.
Doctors today assume that being fat interferes with the ability to give birth vaginally, and that a high cesarean rate is the logical outcome of obesity. However, in the past, the cesarean rate among women of size was significantly lower and many studies did not find a higher cesarean rate among obese women. 6, 7 If the cesarean rate was low in the past for obese women, it means that most fat women CAN give birth vaginally under the right conditions, and that a high cesarean rate is not an inevitable outcome of obesity.
While the overall cesarean rate has increased over time, the cesarean rate in women of size has increased proportionately far more than for women of average size. This suggests that attitudes and management protocols have changed the cesarean rate in women of size far more than obesity itself.
In fact, many of the cesareans in women of size today are “iatrogenic” — that is, caused by the attitudes and management protocols of the doctors, rather than by the woman’s size. This echoes the anecdotal experience of many big moms, who have found that when they shift to a less-interventive care model and become more empowered, they experience better outcomes and fewer cesareans.
The good news is that there are many things that a big mom can do to lower her risk for a cesarean. These include:
- Be proactive in health habits
- Choose a less-interventive care model
- Educate yourself about childbirth issues
- Choose a size-friendly care provider
- Choose natural birth whenever possible
Be Proactive In Health Habits
Get regular exercise – Women of size are at higher risk for high blood sugar and high blood pressure during pregnancy, thereby inviting more interventions and cesareans. Regular exercise can cut the risk for blood sugar and blood pressure problems significantly.
Practice excellent nutrition – Great nutrition is vital to a healthy pregnancy. Moderation is the key. Quantity of food is less important than quality of food, and overall nutrition should be emphasized over rigid weight gain goals.
- Pay careful attention to the baby’s position – If the baby is not in a good position, it does not fit through the pelvis as easily and can cause long hard births. Some research shows that obese women have a higher rate of malpositioned babies, 8 so preventing a malposition is especially important for them. Women can encourage a well-positioned baby by not slouching back when sitting, by keeping their hips higher than their knees, and by adopting forward-leaning positions as much as possible. 9
- Get regular chiropractic care – Because obesity is a strong mechanical stressor on the body, it can throw the back and pelvis out of alignment, and this may be another cause of fetal malpositions. Chiropractic care can help correct breech 10 and other malpositions, so regular chiropractic care may be another important way to help lower the risk for cesarean.
Choose a Less-Interventive Care Model
- Hire a midwife – Hiring a midwife to attend your birth lowers your risk for a cesarean significantly. This is especially true for women of size. 11 Some women assume that an OB offers better care, but research shows that outcomes are actually better with a midwife. 12 Some midwives practice in the hospital and can prescribe medications and labor drugs. Others attend births at home or in birth centers. Most are covered by insurance and work in consultation with area doctors if labor complications make a cesarean necessary. 13
- Consider non-traditional birthplaces – Most people think that hospital births are safer than non-hospital births. In fact, many studies have shown that birthing center and home births are just as safe as hospital births, yet much less likely to end in a cesarean. 14 Birth at home or in a birth center, attended by a midwife, is a reasonable choice. 15 Obese women can have out-of-hospital births too, and many big moms find that they have excellent outcomes and much more satisfying birth experiences in these settings.
- Hire professional labor support – Professional labor support (a “doula”) can lower cesarean risk by up to 50%. 16 Doulas can be an amazing resource during the process of pregnancy and birth. They are especially helpful if you are birthing in the hospital.
Educate Yourself About Childbirth Issues
- Be an informed health-care consumer – There are many controversies about the best way to manage pregnancy and birth. Understand the pros and cons of important issues so that you can make informed decisions about them. Read The Thinking Woman’s Guide To A Better Birth, by Henci Goer.
- Take an out-of-hospital childbirth education class – Hospital childbirth classes are cheap, but you get what you pay for. Taking a good non-hospital class will help educate you about childbirth issues and becoming an empowered healthcare consumer.
- Understand the pros and cons of prenatal tests – Prenatal testing can be a double-edged sword. Its benefits often come at a price of further invasive testing and interventions. Understand exactly what is being tested and its benefits/risks. Remember that you always have the right to decline testing too.
Choose a Size-Friendly Care Provider
- Choose a truly size-friendly provider – Being truly “size-friendly” means using size-appropriate equipment (like large blood pressure cuffs), not using extra interventions because of size, and not restricting nutrition or weight gain. A truly size-friendly provider believes in your ability to give birth vaginally and knows that spontaneous natural labor is the best way to achieve this. \When interviewing caregivers, ask open-ended questions, like “What extra tests or interventions might I need as a large woman?” and then just listen for the provider’s underlying attitudes to reveal themselves as they talk.
Date the pregnancy accurately – Many women of size have longer menstrual cycles, 17 but doctors rarely account for this. This can make your due date artificially early, increasing the chances of induction or cesarean for an “overdue” pregnancy. If your cycles are longer than about 32 days, your due date should be adjusted accordingly.
- Choose a provider comfortable with the possibility of a big baby – Although most big moms do not have big babies, statistically they do have more, and this scares doctors. They are convinced that all fat women have huge babies who will get stuck on the way out. 18 Sadly, the fear of big babies is one of the strongest factors driving the high rate of cesareans in women of size. Your best bet is to find a provider who is comfortable with the possibility of a big baby and who will not try to rush the baby out too soon.
- Don’t agree to estimate fetal weight – Many care providers order an ultrasounds to estimate the baby’s weight. Research shows this is very inaccurate for predicting big babies, and greatly increases the risk for cesareans. 19 Choose a caregiver that does not do fetal weight estimates.
- Don’t intervene for a big baby – If a big baby is suspected, many providers induce labor early. Research clearly shows that this strongly increases the risk for cesareans. 20 Other doctors insist on elective cesareans for big babies; research has also found this harmful. 21 Big babies are more likely to be born safely if labor is spontaneous, natural, and if the mother has full mobility during labor and pushing. Ask your provider if he/she would induce early or do a cesarean for a big baby, and if so, find another provider.
- If you have had a prior cesarean, consider a vaginal birth for future pregnancies – Many doctors strongly discourage women of size from Vaginal Birth After Cesarean (VBAC), and this plays a very significant role in the high cesarean rate in obese women. Yet many women of size DO have VBACs, 22 given proper laboring conditions. The cesarean rate could be reduced significantly if more obese women were given a fair chance at giving birth naturally in future pregnancies.
Choose Natural Birth Whenever Possible
- Avoid induction of labor – Induction of labor is one of the strongest risk factors for cesareans, especially in first-time mothers, and carries significant risks. 23 Yet obese women are induced at far higher rates than other women, and this is one of the strongest factors driving their high rate of cesareans. For example, one study 24 found a cesarean rate of 19% in obese women in spontaneous labor, versus 41% in those who were induced. Let your baby choose its own birthday and you are much more likely to have an easy birth.
- Labor spontaneously – Let your labor progress on its own timetable. Many hospitals rush labor by augmenting with artificial drugs or by breaking the bag of waters. This carries risks to the baby. Let your labor progress naturally, at its own pace.
- Don’t go to the hospital too early – The cesarean rate is lowest in women who labor at home until labor is well-established and intense. 25 A doula can help you decide when it is time to go to the hospital if you are unsure, or you can give birth at home and not have to worry about when to leave at all.
- Choose intermittent monitoring – Many hospitals insist on constant monitoring of the baby’s heartbeat. However, constant monitoring does not improve outcomes, and “false positive” readings cause many unnecessary cesareans. Intermittent monitoring helps track the baby’s condition just fine and lessens the chance of a “false positive” reading.
- Avoid routine hospital protocols for women of size – Some hospitals require that all obese women have their waters broken on arrival to insert an internal monitor, or require all big moms to get an early epidural, “just in case.” These set up a self-fulfilling prophecy for a cesarean. Choose a less interventive birthplace.
- Labor naturally – Although pain relief sounds alluring, remember that it comes at a price. Baby is exposed to drugs, labor slows, and the risk for cesarean increases. 26 Laboring naturally is very doable, especially with the help of a doula or warm water. Epidurals come with a high price; use them only when truly needed.
- Labor with full mobility and change positions often – Moving around freely during labor is very helpful and can lessen labor pain. Upright positions use gravity to help move the baby down, increase pelvic space, and help position babies better for birth. Immersion in water can especially help increase mobility in women of size during labor, and many women of size report absolutely loving laboring or giving birth in water.
Websites that offer only scare tactics about pregnancy at larger sizes emphasize how high the cesarean rate is in women of size. And it is true that the rate is high—–far too high. But it doesn’t have to be that way.
Research from the past proves that the cesarean rate was not always so high in women of size, and that in many studies, it was no higher for larger women than for average-sized women. That means the cesarean rate does NOT have to be so high in women of size, and we can all help normalize that rate.
The first step belongs to consumers. Women of size must take responsibility for their health; they must be sure they are healthy before pregnancy, they must be proactive about nutrition and exercise during pregnancy, and they must learn to research childbirth issues so they understand the benefits and risks of all proposed interventions. They can benefit from using a less-interventive model of care and from choosing their care provider and birthplace more wisely.
The second step belongs to healthcare providers. They must recognize that modern practice patterns and biases have raised the cesarean rates much more than obesity itself. They must stop inducing labor at such high rates, they must stop intervening for “big babies,” they must stop forcing women of size into unnecessary and debatable procedures, and they must become more vigorous in their promotion of spontaneous natural labor for women of size.
When allowed to labor naturally and with excellent support, women of even very large sizes have given birth vaginally, and with very good outcomes. But until women take responsibility for their own health and childbirth decisions, and until healthcare providers recognize the harm they cause with routine interventions for women of size, the cesarean rate in this group will only continue to climb.
1http://www.motherfriendly.org/Downloads/csec-fact-sheet.pdf – Evidence-based summary of the risks of cesarean to mother and baby, published by the Coalition for Maternity Services (CIMS)
2 ACOG Committee Opinion. Obesity in pregnancy. Obstetrics and Gynecology 2005 Sep;106(3):671-5.
3 Weiss JL et al. Obesity, obstetric complications and cesarean delivery rate—A population-based screening study. American Journal of Obstetrics and Gynecology. April 2004. 190(4):1091-7.
4 Crane SS et al. Association between pre-pregnancy obesity and the risk of cesarean section. Obstetrics and Gynecology 1997 Feb;89(2):213-6.
5 Hood DD, Dewan DM. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology 1993 Dec;79(6):1210-8.
6 Edwards LE et al. Pregnancy in the massively obese: Course, outcome, and obesity prognosis of the infant. American Journal of Obstetrics and Gynecology. 1978. 131(5):479-83.
7 Sicuranza BJ and Tisdall LH. Cesarean section in the massively obese. Journal of Reproductive Medicine. January 1975. 14(1):10-1.
8 Jensen H et al. The influence of prepregnancy body mass index on labor complications. Acta Obstet Gynecol Scand 1999. 78:799-802.
9 See http://www.spinningbabies.com for information on how maternal posture can influence fetal position
10 http://www.chiro.org/pediatrics/ABSTRACTS/The_Webster_Technique.shtml – abstract of a study about the effectiveness of chiropractic care for helping resolve breech malpresentations
11 http://www.cdc.gov/nchs/pressroom/98news/midwife.htm – Center for Disease Control website press release showing that the risk of infant death is lower with a midwife than with a doctor
12 Kaiser PS and Kirby RS. Obesity as a risk factor for cesarean in a low-risk population. Obstetrics and Gynecology 2001 Jan;97(1):39-43.
13 http://www.cfmidwifery.org/midwifery/faq.aspx – Description of different types of midwives available, with a summary of their training and certification requirements
14 Johnson KC and Daviss B. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ (18 June) 2005;330:1416 (abstract available for free online at http://bmj.bmjjournals.com/cgi/content/abstract/330/7505/1416)
15 http://www.maternityservices.com/is_homebirth_with_a_midwife_safe1.htm – Webpage on the safety of homebirth with a midwife
16 http://www.maternitywise.org/mw/topics/laborsupport/index.html – Summary of the benefits of labor support (especially professional “doula” labor support) in improving the quality of the birth experience and the interventions used. See also www.dona.com for information on finding a doula in your area.
17 Symons JP et al. Relationship of body composition measures and menstrual cycle length. Ann Hum Biol 1997 Mar-Apr;24(2):107-16.
18 Robinson H. Is maternal obesity a predictor of shoulder dystocia? Obstetrics and Gynecology 2003 Jan;101(1):24-7.
19 Parry S Ultrasonographic prediction of fetal macrosomia. Association with cesarean delivery. Journal of Reproductive Medicine 2000 Jan;45(1):17-22.
20 Combs CA et al. Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Obstetrics and Gynecology 1993 Apr;81(4):492-6.
21 Zamorski MA and Biggs WS. Management of suspected fetal macrosomia. American Family Physician 2001;63:302-6. Free full-text article available at http://www.aafp.org/afp/20010115/302.html
22 Goodall PT et al. Obesity as risk factor for a failed trial of labor in patients with previous cesarean delivery. American Journal of Obstetrics and Gynecology 2005 May;192(5):1423-6.
23 http://www.motherfriendly.org/Downloads/induct-fact-sheet.pdf – Summary of the risks of induction to mother and baby, published by the Coalition for Maternity Services (CIMS)
24 Usha Kiran TS et al. Outcome of pregnancy in a woman with increased body mass index. BJOG 2005 Jun;112(6):768-72.
25 http://www.ahrq.gov/research/aug03/0803RA13.htm#head3 – Summary of a study that found lower cesarean rates in women who saw nurse-midwives and also in women who waited until active labor was well-established before being admitted to the hospital. Jackson DJ et al, Impact of collaborative management and early admission in labor on method of delivery. Journal of Obstetric, Gynecologic & Neonatal Nursing 2003 Mar;32(2):147-157.
26 http://parenting.ivillage.com/pregnancy/plabor/0,,8jzw-p,00.html – Article on the benefits and risks of epidurals in labor
Other Miscellaneous Resources
Non-Hospital Childbirth Education Organizations: