Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery
As a woman of size I had read a lot about how many providers are more apt to tell a larger woman that she can't vaginally have a child. This was a huge concern for me however, I was lucky enough to have a provider that didn't think that way and encourages not only vaginal births but also unmedicated births. Here is an article that I found though that addresses this.
Most articles about pregnancy in obese women, and even many childbirth providers, assume two things: that being fat interferes with a woman’s ability to give birth vaginally; and that the sky high cesarean rate among women of size is the logical outcome of obesity.
Women of size do have very high cesarean rates today. But is this high rate really medically necessary? Or is some of the increase caused by misguided assumptions about obesity and by unneeded interventions and protocols commonly used with women of size? If so, what can a big mom do to lower her personal chances of having a cesarean?
Cesareans can be truly necessary and life-saving. But nowadays, more and more women—especially obese women—are having cesareans that are not really needed. This puts them—and their babies—unnecessarily at risk.
Women of size can give birth vaginally and safely, but to do so they have to be even more proactive about their childbirth choices than women of average size.
CESAREANS ARE MORE RISKY FOR OBESE WOMEN
A cesarean is major abdominal surgery and as such poses risks for women of any size. Women who undergo surgical births are more likely than women who have vaginal births to experience severe bleeding, infections, painful scarring, blood clots, bowel obstructions, readmissions to the hospital, and longer-lasting pain.1
In addition, having a cesarean birth increases a woman's chances of having future reproductive problems, including decreased fertility and an increased rate of placental problems. As the number of cesareans increases for a woman, the risk of complications in future pregnancies also increases.2
Cesareans are even more risky for big women. Obese women who have surgical births have higher rates of anesthesia problems, severe bleeding, wound problems, and infections than non-obese women who have surgical births.3
Babies born via cesarean section also face more risks than babies born vaginally: they are more likely to have respiratory problems in the newborn period, more likely to have difficulties establish breastfeeding, and more likely to experience asthma in childhood and adulthood.4 (For more information, see "Comparing the Risks of Cesarean Births Versus Vaginal Births.")
Doctors should be doing everything in their power to lower the cesarean rate in obese women, but instead they are performing far more cesareans in this group than ever before, risking the health of both big moms and their babies. This must change.
SKYROCKETING CESAREAN RATES IN WOMEN OF SIZE
Just how high is the cesarean rate in big moms? Several recent studies found that nearly one-half of obese first-time mothers ended up with a cesarean.5, 6 The rate in “supersized” women is even higher.7 But it doesn’t have to be this way.
In the past, the cesarean rate among women of size was significantly lower than it is today. In fact, a 1978 article in the American Journal of Obstetrics and Gynecology noted:
|"In agreement with most other studies, no significant increase in Cesarean sections or operative forceps delivery was noted in [the obese group.]" 8|
Many of the cesareans in women of size today may be “iatrogenic”—that is, caused by the attitudes and management protocols of the doctors, rather than by the woman’s size. This echoes the real-life experience of many big moms, who have found that when they shift to a less-interventive care model, they experience fewer cesareans and their babies have better outcomes.
The good news is that there are many things that a woman can do to lower her risk for a cesarean. The ones that are particularly important for women of size include:
- Be proactive in your health habits
- Choose truly size-friendly care
- Avoid routine medical interventions during labor unless clearly needed
- Do not intervene for a big baby
Be Proactive In Your Health Habits
- Be proactive about your health before pregnancy
Certain diseases can cause pregnancy complications, and heavy women have a higher risk of having some of these diseases.9 Before you get pregnant, check your blood sugar, blood pressure, and thyroid function, do what you can to stabilize them if needed, and address any other outstanding health concerns.
- Get regular exercise and practice excellent nutrition
Good nutrition and exercise can cut the risk for blood sugar and blood pressure problems during pregnancy significantly, by one-third to one-half.10 While weight itself is often blamed for many health problems, evidence shows that exercising and eating healthy foods – whether or not they lead to weight loss -- have clear positive benefits for women of all sizes and can improve pregnancy outcomes. Eating well and getting sufficient exercise may also help you be more physically prepared to take on the work of labor and birth.
- Pay careful attention to the baby’s position
A baby in poor position may 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,11 so preventing a malposition is especially important in this group. Because obesity can be a strong mechanical stressor on the body, it can throw the pelvis out of alignment, which in turn may cause a fetal malposition. One small study found that chiropractic care was able to lower the rate of malpresentations in women at term,12 and many women of size have found it helped them to have a more comfortable pregnancy.
Choose Truly Size-Friendly Care
- Check for subtle size-bias in your care provider
It’s not enough to find a provider that seems “nice” and doesn’t scold you about your weight. Being truly size-friendly means not using extra interventions simply because of size, and knowing to use size-appropriate equipment (like large blood pressure cuffs). 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. Ask your provider open-ended questions, like “What extra tests or interventions might I need as a large woman?” and then listen carefully. If she or he believes that lots of extra tests are needed, that labor will probably need to be induced early, that a cesarean is very likely, or if she or he recommends rigid nutrition/weight gain guidelines, this is not a size-friendly provider, no matter how “nice.” Find a provider who is both “nice” and who truly believes that fat women can give birth normally, without intervention.
- Choose a doctor or midwife with low rates of intervention
Some women of size assume that because of their weight, they should see an obstetrician or even a high-risk perinatologist. However, unless you have a pre-existing disease like diabetes or uncontrolled high blood pressure, you can choose from the range of providers.
Some caregivers have much lower rates of labor and birth interventions than others. While rates of intervention will vary depending on the population served, they also vary by the type of provider and the practice style. Although there are many exceptions, family physicians tend to have lower rates of intervention than obstetricians, and midwives generally have the lowest rate of all.13
While there are no randomized controlled studies that directly compare the safety and satisfaction of birth experiences among obese women attended by different kinds of providers, the best available research suggests that women cared for by midwives have fewer cesarean sections, lower rates of other birth interventions, and comparable and possibly better outcomes than women attended by obstetricians.14 Even women who have medical complications can often work with a midwife in collaboration with other specialists.
Choosing a provider who follows a midwifery model of care (also known as a physiologic model) may be the most important step you can take to increase your chances of having a safe and satisfying vaginal birth. (For more information, see “Models of Maternity Care.”)
- Consider non-traditional birthplaces
Many studies have shown that low-risk women who give birth in a birthing center or at home have excellent outcomes and are much less likely to have a cesarean birth.15 Birthing at home or in a birth center is a reasonable choice for healthy women of size too, and many women of size have had satisfying and healthy experiences in these birth settings.
- Date the pregnancy accurately
Many women of size have longer menstrual cycles,16 but doctors rarely account for this, making the due date artificially early. This increases the chances of induction or cesarean for “overdue” pregnancy, and it can also throw off prenatal testing results. If your cycles are longer, your due date should be adjusted accordingly. If your provider will not adjust your due date, you need a new provider. If your cycles are extremely long or irregular, it may be helpful to get an early transvaginal ultrasound in order to help date the pregnancy more accurately and reduce the rate of induction for “postdates.” Charting your ovulation before you get pregnant can also help document the need to adjust a due date.
- 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.17 Furthermore, tests tend to be less accurate in women of size18 and are often the first step on the slippery path that leads to cesareans in this group. Yet some providers require extra testing in women of size. Always learn exactly what the test is, the benefits and risks, the possible downstream outcomes, and whether there are any alternatives. Remember also that you always have the right to decide about prenatal testing, regardless of your size. (For more information, see “Introduction to Prenatal Testing”)
- Arrange for continuous labor support
Arrange for a doula (a trained labor support companion) or a friend or family member who is experienced with birth to be with you throughout your labor and birth. Women who receive continuous, one-on-one support from a person who comes into the hospital for this purpose are less likely to have a cesarean section or "assisted" childbirth with vacuum extraction or forceps, have fewer complications, and greater satisfaction with their birth experiences.19 (For more information, see “Labor Support Doulas”)
- Be an informed health-care consumer
Because women of size are subject to a higher level of intervention, it is especially imperative that they understand the risk/benefit ratio of common obstetric procedures. An excellent introduction to these is Our Bodies, Ourselves: Pregnancy and Birth and The Thinking Woman’s Guide To A Better Birth by Henci Goer.20 Also, take a good non-hospital childbirth education class.
Avoid routine medical interventions during labor unless clearly needed
- Avoid routine induction of labor
In first-time moms, women whose cervix is not yet soft and ready to open, or mothers who have not yet had a vaginal birth, induction of labor is one of the strongest risk factors for cesareans.21 Yet obese women are induced at very high rates;22 this is a major factor driving their high rate of cesareans. One study found a cesarean rate of 19% in obese women in spontaneous labor, versus 41% in those who were induced.23 Unless there is a clear medical reason to induce labor, let your baby choose its own birthday.
- 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.24 This may be particularly important in women of size, because some research shows that these labors tend to take a little longer to get well-established.25 A supportive provider working with your 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.
- Labor spontaneously
Let your labor progress on its own timetable. Rushing labor by augmenting with artificial drugs may increase the risk of cesarean.26 Similarly, breaking the bag of waters may increase the risk of cesarean.27 Unless there is a clear medical reason to perform an intervention, let labor progress naturally, at its own pace.
- Choose intermittent monitoring
Many hospitals insist on continuous electronic fetal monitoring (EFM) of the baby. This is necessary when labor is induced or drugs are used, but is usually not necessary with spontaneous, unmedicated labor. EFM increases the likelihood of both cesarean sections and operative vaginal births (births in which forceps or a device known as a vacuum extractor are used to help pull the baby out of the birth canal).28 In addition, monitoring is more difficult in women of size because of extra tissue, so many larger women end up virtually motionless, or with an internal monitor instead (which increases the risk of infection). Periodic monitoring tracks the baby’s condition adequately, allows more mobility, and lessens the chance of a misleading reading. (For more information, see "Fetal Monitoring.")
- Avoid routine hospital protocols for women of size
Some hospitals require that obese women have their waters broken on arrival to insert an internal monitor, or encourage all big moms to get an early epidural, “just in case.” These set up a self-fulfilling prophecy for a cesarean. Ask lots of questions about protocols, and choose the least interventive birthplace. Also remember that you have the right to refuse interventions if you don’t want them.
- Educate yourself about pain relief
Because all pain-relieving medications can have adverse effects, it is generally best to approach labor with the idea of using no-risk or very low-risk pain relief strategies first, and then proceeding to the next higher level of intervention only if needed. Epidurals are less effective and more difficult to place in women of size;29 use them only when truly needed. (For more information, see "Coping with Labor Pain: Introduction" and "Coping with Labor Pain: Epidurals and Spinals.")
- 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 absolutely love giving birth in water.
Do Not Intervene for a Big Baby
- Choose a provider comfortable with the possibility of a big baby
Although most big moms do not have big babies, statistically as a group they do have a higher rate.30 The fear of big babies is one of the strongest factors driving the high rate of cesareans in women of size; however, having a big baby is not in and of itself a valid medical reason for having a cesarean. Whether or not you actually have a big baby, your best bet is to find a provider who is comfortable with the possibility of a big baby and who will not intervene based on possible fetal size.
- Do not be overly restrictive to get a smaller baby
Many providers follow guidelines that restrict weight gain in obese women. Some providers fear big babies so much they place women of size under draconian dietary restrictions or tell them not to gain any weight. However, the safety of these restrictive policies has not been well-established; some research shows that very low weight gain in obese women is harmful.31 It is unclear how much control we have over how much weight we gain in pregnancy. Instead of trying to manipulate weight gain and fetal size through caloric restriction, it makes more sense to focus on eating healthy and getting regular exercise and letting your baby be its intended genetic size.
- Don’t estimate fetal weight
Many care providers order ultrasounds to estimate the baby’s weight. Research shows this is inaccurate at predicting big babies; simply the prediction of a big baby causes a strong increase in the cesarean rate, even if the baby was truly small instead.32 Choose a caregiver that does not do fetal weight estimates.
- Labor spontaneously if a big baby is suspected
If a big baby is suspected, many providers induce labor early, thinking it’s a good idea to start labor before baby gets “too big.” However, research clearly shows that this strongly increases the risk for cesareans instead.33 Other doctors insist on elective cesareans for big babies; research has also found this harmful.34 Big babies are more likely to be born safely if labor is spontaneous and if the mother can move around freely during labor and pushing. Ask your provider if he or she would induce early or do a cesarean for a big baby, and if so, find another provider.