I recently complained about the negative bias in a hospital trust’s guidance on the management of bigger pregnant women.
How a policy is worded may seem inconsequential, but it can give an indication of general attitudes of senior staff towards patients, and this negativity may influence how the staff we meet perceive and treat us.
But apart from alienating patients, which is likely to reduce the chances of a trusting, co-operative relationship forming, how we are treated when in labour can actually affect how that labour progresses.
Being pregnant is not an illness. Half of the population are designed to be pregnant, after all! While pregnancy, labour and birth are incredibly special, they are also completely ordinary; a commonplace miracle, if you will. We were made to do this, and most women can do it perfectly well when they feel comfortable, supported, and are encouraged to trust their own bodies.
A big/fat/obese/large/plus-size/overweight (choose your own adjective) pregnant woman arrives at the maternity unit in the early stages of labour. Despite being overweight she has somehow magically avoided developing gestational diabetes, high blood pressure, pre-eclampsia, and any of the many other conditions we are told we are so at risk from, her scans show the baby is growing normally, and she has happily gone into labour naturally. This is actually the case for the majority of overweight women, it just doesn’t seem likely once you’ve been fed all the scary statistics about how at risk we are.
The member of staff attending her, having read the hospital’s guidance all about the increased risk of such pregnancies, the increased likelihood of interventions, and how much of a ‘problem’ obese pregnant women are, might be a little apprehensive if he or she is not terribly experienced.
Wanting to do the best for the woman and the baby, and deeming the pregnancy to be ‘high risk’ (despite the fact that neither the woman nor the baby has developed any problems) the woman might be asked to lie on the couch in order to be hooked up to an electronic fetal monitor for a bit to check how labour is progressing and how the baby is responding to contractions.
Normally this can be done by a hand held doppler monitor, just as it has probably been done perfectly accurately by the community midwife throughout the pregnancy, but in hospital, and labelled ‘high risk’, the preference is often to have a paper printout from the Cardiotocograph (CTG) machine. So the woman lies on the bed while two elastic straps around her belly hold the machine’s pads in place, and the CTG does its thing.
But this position is uncomfortable for most labouring women. It is also counter productive, as lying down restricts space in the pelvis, and gravity – naturally moving the baby towards the intended exit when the woman is upright, is now pulling the baby towards her back instead. If the machine isn’t giving a constant and reliable trace of the baby’s stats (often a problem when there’s more flesh to travel through), the likelihood is that the mother will be asked to continue in this position until a ‘sufficient’ amount of data has been collected.
And so, already, the natural flow of the woman’s labour is being interrupted. She is being made more uncomfortable than she needs to be, and may be getting concerned if there is a problem getting a continuous trace. She’s been told all about how her labour is more likely to be problematic and it’s really hurting every time she lies down. She might already be starting to lose faith in her own body.
Worry stimulates the body’s fight or flight mechanism and causes adrenaline to flow, and adrenaline is the natural enemy of childbirth. It stops the production of the hormone oxytocin, which is needed throughout the labouring process, and so adrenaline can slow down and even halt labour in its tracks. There’s a very practical and probably evolutionary reason for this – it would be very useful in an earthquake or other scenario where the labouring mum needs to get to safety to be able to stop labour, but this isn’t a life threatening situation, it’s merely fear and adrenaline getting the upper hand.
Rather than encouraging the woman to get back to as natural a birth process as possible, the midwives attending, in anticipation of that ‘difficult’ labour and birth might start suggesting interventions.
Perhaps attaching an electrode to the baby’s head would give a more reliable reading of the baby’s condition? The CTG trace hasn’t shown any problems, but since it’s not reading half the time, we can’t be sure… The mother agrees, of course, she is concerned for the baby, but what she doesn’t know and isn’t told until it is too late is that this will require her waters to be artificially broken, will restrict her movements and options further, she won’t be allowed to have a bath to soothe her contractions (probably isn’t allowed to use a hospital birth pool anyway due to a blanket BMI exclusion), won’t be allowed to use a TENS machine, and will be restricted in her movement, possibly stuck led on a bed even more.
The woman is rapidly losing control of the situation and of faith in her own body’s natural abilities. Any hope of a natural labour is drifting away. Adrenaline has probably taken over and all natural oxytocin is long gone. It’s been a few hours, and now she’s told her labour is not progressing quickly enough.
Time to suggest another intervention, a little cocktail of hormones to speed things along… The artificial hormones kick start labour back up, but unlike normal labour which increases in intensity gradually, the contractions have advanced too quickly for the body’s natural pain relieving chemicals to cope. The woman is tired and in pain and asks for some relief. She is offered an epidural as a first option because her caregivers know it might be difficult to site, and may not work first time, so best start early if that’s where we’re headed…
Rather than think back to those antenatal classes and asking to try less severe options first; paracetamol, gas and air, etc, she gratefully accepts the first suggestion. She’s in pain and it’s difficult to think straight. She’s not allowed to use a birth pool – so she is denied one of the simplest yet very effective form of pain relief and relaxation, along with it’s magical ability to enable you to move around more easily to stay comfortable.
So, the epidural is sited and the woman is no longer in pain, but she is disconnected from her body and the labouring process. She can no longer move around and keep active to give nature a helping hand. Gravity is working against her and space in her pelvis is restricted because the weight of her body is pushing her coccyx into the birth canal. Not much, but enough. There’s not a lot of room in there anyway…
Eventually she is told it is time to push, not by her body, but by a machine and the professionals reading it. She pushes and pushes, but nothing seems to be happening. After an exhausting few hours with nothing to show it’s time to ‘help’ again; maybe an episiotomy, ventouse, now forceps. Oh gosh, the monitor is recording that the baby is in distress (surprise!?!)! Quick! Into theatre! Whip the baby out with a c-section! Phew! Everyone is OK. The woman is going to be off her feet for a while, she’ll need medication to thin her blood because she’s at risk of deep vein thrombosis (even though her weight puts her at higher risk of bleeding out from post-partum hemmorhage?). She’s also more likely to experience problems with the wound healing. See, these obese pregnant women, so problematic, such difficult labours, such a drain on resources…
Does it seem implausible that tiny shifts in attitude could lead to such a cascade of intervention?
A large Canadian study in 2011 looked into whether labour is managed differently in women with high BMI, and whether this might account for the higher caesarean rate.
Their findings? After adjustment for pregnancies where there was known to be a problem, increased BMI category was associated with an increase in the use of artificial oxytocin and epidurals, and with earlier decisions to perform caesarean sections. When the researchers adjusted for these differences in the management of labour, guess what? The rate of Caesarean section did not increase with increased BMI.
I’ve said it before and I’ll say it again. We need to do our own research. We need to know our options, and the potential consequences of any interventions offered. Being treated as high-risk might just be that self-fulfilling prophecy if we aren’t careful.