Big can be Beautiful and Normal Plus plus size Pregnancy ... · sizes including plus size women ....
Transcript of Big can be Beautiful and Normal Plus plus size Pregnancy ... · sizes including plus size women ....
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Big can be Beautiful and Normal
Plus plus size Pregnancy
Are we serving women well?
Maggie Davies Consultant Midwife
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Too hot to handle
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Pregnant for the first time why shouldn’t they be excited?
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What information will the women find on the internet?
They google everything
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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
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They then google increased BMI in pregnancy and what do they find
line?
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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
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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
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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
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So what are these messages saying to women
Hardly
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Do plus size women have the same human rights as others ?
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Or they have no choices when labour begins
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Not allowed to mobilise
Can’t go in the ‘pool’
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We come in all shape and sizes including plus size women
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Are all obese pregnant women ‘grouped’ together,
Is this right?
Overweight teenager
Older overweight woman
having her first baby
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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
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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
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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
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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
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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
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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
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Neath Port Talbot Birth Centre
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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
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• 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
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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
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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
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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
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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%
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So are we serving the plus plus women well?
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To serve them well perhaps we do need to review the place of
birth
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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
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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
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Perhaps then we will be serving the plus plus women well and big can be beautiful and normal.