Posted by My OB said WHAT?!?.
Jun
21
Posted by My OB said WHAT?!?.
“Because Of Your Weight…We’re Going To …Schedule Your Cesarean.”
“Because of your weight, you’re just not a candidate for midwifery care, and we’re going to go ahead and get you to an OB to schedule your cesarean section.” – CNM to mother at 36 week appointment.
There are 41 comments to this post.
This is bull. The MEDwife is letting her incompetence show in a big way… there’s no proof that an overweight woman cannot birth a baby. I know scores of overweight and even morbidly obese women who have pushed baby after baby out with no complications.
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They fired her as a patient at 36 weeks? Good God.
(“Professional standards? What professional standards? We’ve already milked this one as much as we want, so let’s kick her to the curb and tell her it’s ‘For her own good’ and ‘All her fault for being fat.’ That’s our professional standards.” Bleh.)
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Kali Reply:
June 21st, 2011 at 7:12 pm (Quote)
Yes that’s the worst part of it I think. I mean, her weight isn’t just something that JUST then occurred at 36 weeks like other medical problems that ‘make” moms transfer care or have c-sections. The CNM knew her weight the entire time! Yes, the CNM had the right to refuse care due to weight, but she should have told her WAYYYY (like 30 weeks) before this. This is really inexcusable.
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Jessica had this to say,
Jun 21, 2011 @ 6:54 pm (Quote)
Yeah, it makes no sense that she wasn’t told this before 36 weeks. They cared for her for about 24 weeks previously without a problem? How much weight are we talking about?
This was my biggest fear when choosing a midwife and out of the three I interviewed not a one said it would be a problem, just that we’d have to work on my nutrition. And I actually am overweight, unlike some of the comments I’ve seen here where women who have no weight problem get called fat.
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August had this to say,
Jun 21, 2011 @ 7:02 pm (Quote)
Amazing how overweight women managed to give birth perfectly fine without medical help over the centuries.
I heard similar comments during my pregnancy, even though I have low blood pressure (112/72 is my highest), no diabetes, and no “weight-related complications”. Oh, and I have a perfectly healthy 7-month old sprawled across me. 
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Sarahred had this to say,
Jun 22, 2011 @ 2:16 am (Quote)
Okay, I know I’m going to be flamed here, but there is so much evidence that bariatric mothers have increased risks of various complications during labour- look on pubmed. And this doesn’t mean all larger mums must have a c-section, but the doctors can’t tell the future and see who will run into problems in this high risk group and who won’t. So, while I agree this was an inappropriate thing to say and the mother should have had the options and risks/ benefits explained, I also hope people can understand there are really good reasons for offering c-sections for larger mothers.
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Details Reply:
June 22nd, 2011 at 5:09 am (Quote)
No there really aren’t. The evidence is that overweight women have a higher incidence of problems, many doctor induced, not that they are ticking time bombs. There is a big jump from “you are not a good candidate for midwifery care” to you must schedule a c-section. Every woman even a high probablity of c-section woman should wait for her baby to signal that he/she is ready rather than schedule to the doctor’s convienece barring true medical indicator like P-E. Second, unless the woman gained most of the weight since the last appointment she deserved a heads up long ago and time to find a doctor she likes and trusts. And all of this is in addition to the rude “we have made the decision for you” attitude.
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sarahred Reply:
June 23rd, 2011 at 1:22 am (Quote)
Yes- I agree that ‘you can’t just schedule a c-section’. If you read my post you would see that I was pointing out there is a lot of good evidence that larger mothers have a higher risk of complications such as pre-eclampsia and gestational diabetes, which need to be taken seriously. I do not agree with the way the OP was told she ‘had to have a c-section’ but I was concerned about the amount of people on this site who seem to be minimising the very real risks. The difficulty is that doctors cannot tell who will develop these complications so they tend to weight up the risks and benefits for a population rather than the individual- unfortunately there’s no other evidence based way to do so.
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Heather Reply:
June 23rd, 2011 at 11:07 am (Quote)
http://musing-mommy.blogspot.com/2010/11/musing-on-gestational-diabetes.html
As a large mom, I find that offensive. I had no problems with either pregnancy, except a diagnosis of GD my first time which was basically bunk in the end. Both babies were the exact same weight and my cesarean was unnecessary.
The fact is that skinny moms get Pre-E and GD, too, but doctors don’t work at stressing them into the former and often allow them to skip testing for the latter.
It’s a case of looking for it equaling an increase, not an increase equaling correlation.
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Sheva Reply:
June 22nd, 2011 at 5:11 am (Quote)
I’m pretty sure the risks of major abdominal surgery on bariatric patients are much higher than they are for the smaller population as well. (And these issues refer to people who are more than just overweight.) Therefore, there are pros and cons to both choices, and all of them should be explained to the mom, who gets to make the final decision. Or, who should get to, in Jane’s happy orange place…
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Aron Reply:
June 22nd, 2011 at 6:42 am (Quote)
Agreeing with the above. Unfortunately, although being overweight is associated with an increased chance certain health risks, the risks of surgery on bariatric patients is dramatically higher. Their risks of hemmorhage, infection or adverse reaction to the anesthesia (namely respiratory depression) are particularly greatly increased. Also, studies comparing care of women who are overweight vs. those of standard weight have repeatedly demonstrated that doctor were far quicker to operate on overweight women regardless of whether actual complications were presenting, thus exposing those women to much higher risks.
Overweight patients need to be treated like every other patient by recognizing that there is a vast difference between “risk for future complication” and “complication currently in progress.” One requires action NOW and the other requires simple monitoring in case action may be required LATER. Unfortunately, too many care providers can’t see the difference and dive scalpel first into patient encounters like it’s a magic sword to ward off evil.
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sarahred Reply:
June 23rd, 2011 at 1:24 am (Quote)
totally agree with you here. Again though, while the risk of surgery is higher, it isn’t just the risk to the mother that is important- it is the risk to the mother and the baby.
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Aron Reply:
June 23rd, 2011 at 4:48 am (Quote)
That is true – the baby is definitely important, and I think one would be hard-pressed to find a mama who didn’t rate her baby’s safety quite highly indeed. It’s really not all about preserving some type of “experience”.
But like you mentioned, the primary increase in risks to larger women are pre-e, GD and PIH. All of those are illnesses that primarily effect the mother far faster than the baby. If a woman even developped one of those complications, a good doctor/midwife is going to want to deal with it well before it reached a point of being critical to the babe since the mother would already be quite sick herself. And again, all of that is assuming the overweight mother switched categories from “possible future risk” to “currently experiencing a complication.” Watchful waiting and solid patient education are still going to be the best ways to care for even those with inreased risks.
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Margaret Reply:
June 22nd, 2011 at 7:45 am (Quote)
Chiming in with the others to say that c-section would *also* be higher risk with larger patients.
And many of the “added risks” of pregnany have to do with lifestyle and/or genetics that is concurrent with obesity or a cause of obesity, rather than being directly caused by obesity. The numbers on the scale did not cause me to have high blood pressure, Gestational diabetes, or any other complication that is often related to obesity.
My risks may have been higher statistically, but I am an individual human being. And so is the woman in the OP. We deserve to be treated as individuals, not as potential statistics.
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The Deranged Housewife Reply:
June 22nd, 2011 at 12:17 pm (Quote)
I’ll have to agree with the doctor-induced complications, namely because whenever you hear about such and such having complications, it’s often because they were trying to head off other risks and ending up creating more problems than if they’d just left it alone. We can’t always say that’s the case, but neither can you just automatically treat an overweight patient with an immediate cesarean, as if it’s a foregone conclusion that she *will* have problems. It’s sort of like guilty until proven innocent.
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Debra Reply:
June 23rd, 2011 at 12:38 am (Quote)
I’m obese. When I was diagnosed with uterine cancer my gyn-oncologist wanted to do everything he could to avoid open abdominal surgery because of the risks. I can’t see how it would be any less risky to make a big incision to remove a baby than it would’ve been to remove my cancer.
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Sarahred Reply:
June 23rd, 2011 at 1:17 am (Quote)
Everyone here has pointed out the risks of surgery increase with obese patients. This is true. But during labour it isn’t just the risk to the mother that the doctors have to weight up- it’s the risk to the mother and her baby.
Women who are obese have a higher risk of gestational diabetes, pre-eclampsia and pregnancy induced hypertension, to name a few. I don’t agree that ‘every large woman needs a c-ssection’ and I don’t agree with how the OP was treated, but the plural of antedote is not data, which I think people on this website tend to forget.
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Jane Reply:
June 23rd, 2011 at 4:40 am (Quote)
GD, Pre-E and PIH can all be monitored for in a regular midwife visit, and none of those are prone to developing in the middle of labor. If the midwife was concerned about the OP’s weight for those reasons, then she needed to provide prenatal care, not go straight for the refer-out-C-section at 36 weeks.
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Sheva Reply:
June 23rd, 2011 at 7:24 am (Quote)
It’s more than a little bit insulting that you make an assumption that while the doctor is considering the benefit/risks of both choices for both mom *and* baby, the mother is not.
Also, it is well known that a cesarean carries its own set of risks to the baby, as well. Even allowing the mother to go into labor naturally, and then doing a cesarean, is healthier than a scheduled surgery. But that would mean the doctor has to go by the mother’s and baby’s schedule, not his.
Which is what obstetricians should all be prepared for and willing to do.
And also, GD, Pre-e, and high BP are all issues that creep up slowly, and can be prevented or treated. And if they can’t be, surgery may be warranted. But scheduling surgery because these issues *may* come up is just bad medicine.
Unless you think that all retirees should have pacemakers installed “just in case”.
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Margaret Reply:
June 23rd, 2011 at 1:08 pm (Quote)
But once again, those things don’t just magically appear for the sole reason that a woman is obese. I’m very, very fat. I had not a single one of the complications you mention. My vaginally born children are healthy as horses.
So a c-section-for-being-fat would have been damaging to me, and putting them at unnecessary risk.
And taking into account *possible* risks is a far cry from what this doctor actually did, which involved not weighing the risks *at all* and jumping to conclusions.
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Bear with me here. What if this mother suddenly gained, oh, twenty pounds between her 34 week appt and her 36 week appt.
Then the midwife looks at her and thinks, “Water weight gain.” She tests her urine and blood pressure and thinks, “Pre-eclampsia.” She looks at the mom, who’s jittery and knows something wrong.
She calls her back up OB and says, “Dude, we need to transfer.”
The doctor says, “Send her over. She’s 36 weeks? If it’s dangerous, we’ll section her today if need be.”
The midwife comes back to the mom, who’s really nervous now, and she knows it’s not good for the mom to be nervous, so instead of saying, “You have pre-E,” she just blames the mom’s weight, that way the mom won’t feel there’s danger to her baby or that her body is out of control or doing something dangerous.
I like that scenario because it’s clueless rather than malicious and it explains why someone would wait until 36 weeks to notice the numbers on the chart. And because I’m pre-coffee right now, I’ll go live in my happy orange place where this isn’t one evil midwife in a practice of five nice ones, and the OP didn’t ahve to call her insurance company or an attorney and file complaints with every medical board she could after this appointment was done.
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Debra Reply:
June 23rd, 2011 at 12:44 am (Quote)
I can see what you’re saying but I would be just as nervous at suddenly being told I had to have a c/s for being fat as I would for being told I had pre-E. And the idea that the midwife wouldn’t tell the mother the truth – what if mom walks out of the office not knowing she has pre-E. She doesn’t want a c/s so she doesn’t go to see the OB. Instead, she goes home and starts shopping for another midwife. Then she strokes out.
Like you said, there are plenty of professionals who are that clueless but that’s almost as scary as the ones who are malicious.
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What a load of hooey.
I’ve never been under 250 lb at any of my deliveries.
And actually, I don’t like to think of the mess and complication that would be a c-section, given the amount of fat and loose skin they’d be working with. My babies will take Nature’s way out, thankyouverymuch.
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Nica Reply:
June 22nd, 2011 at 7:08 am (Quote)
Same here. I was 223 lbs on a 5′ 6″ frame when I had an uneventful, uncomplicated vaginal birth of a 9 lb, 12 oz baby after a completely uneventful, uncomplicated pregnancy…
All my OB ever said about my weight (I was about 200 lbs when I got pregnant) was “Make good food choices” and that was it.
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Mama Wrench Reply:
June 24th, 2011 at 2:54 am (Quote)
I gained 40lbs with my 1st baby, who was 6lb 7oz, and then lost it all within 3 months after birth, so I figured, not a big deal.
THIS time around my midwife gave me a 20 minute lecture on weight management and making good food choices and proper pregnancy diet. How much do I weigh now? 105 at 5’0″ — oh, and did I mention I’m in school to be a dietitian? *facepalm*
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Yes, natural birth has more risks/complications with a heavier woman, but so does a c-section. There’s more to cut through, more to suture, a much higher risk of infection, etc.
With MOST surgeries it’s hard to get the go-ahead if you’re too heavy because it increases your risks. But not with c-sections. Why?
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sarahred Reply:
June 23rd, 2011 at 1:28 am (Quote)
With most surgeries there is only one person to weigh up the risks and beenfits for- that is the patient. With a c-section the safety of the baby comes into play as well. If a large mother suffers a complication during labour its a lot harder to do an emergency c-section on an obese patient than it is to do a planned c-section. Therefore, the doctors put the combined health of the mother and the baby first.
Having said this, I absolutely believe mums should be fully informed instead of just being told ‘they’ll be scheduled in’- thats awful and demeaning.
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Details Reply:
June 23rd, 2011 at 6:04 am (Quote)
Please stop using the term “weigh up.” It must be slang for some part of the world. The word you are looking for is consider. “weigh up” sounds a lot like exaggerate to me. You weigh it and then you up it. Not right in my mind. Plus there is the FACT that a planned c-section carries more risks than a Trial of Labor because the baby is almost always slightly premature and studies have shown the hormones of labor are good for the baby’s lungs. The only thing safer about scheduling is that the doctor is less likely to be sued. It is not a lot harder to do an unplanned c-section. And unplanned does not equal emergency. There is a whole big group of c-sections that fall into failure to progress, opps we didn’t know he was breech and other non-emergency make a rational decision, take your time and do it right situations. You don’t have to make everything into a big drame in order to avoid a big drama. Waiting to see what happens is a much better approach than assuming there will be complications and risking major surgery to avoid what? major surgery?
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Not a good alternative (for the mom), but maybe the CNM is in a state where they have to operate under “supervision” of an OB. If so, the OB may impose limits where the CNM has to transfer care. For job security – CNMs in this scenario may just take the blame. This isn’t more appealing to the mom – but, it may change where the responsibility for the comment lies.
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Details Reply:
June 22nd, 2011 at 7:04 am (Quote)
I didn’t see where you addressed the difference between “you are not a good candidate for midwifery care” vs. Scheduling a c-section. A responsible midwife operating under supervision would have refered this woman to her back up at first visit and given her the opportunity to switch to a better OB if she choose. This would be a bait-and-switch where the midwife waits until finding a new care provider would be extremely difficult specifically for the purpose of making sure the money stays in the group practise. She could even be getting kick back from the doctor for this technique of retaining patients. I find this disgusting!
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I don’t know what state the OP delivered in, but I know in my state MW’s are very limited as to the kinds of pregnancies they can attend. And I think it is possible to “risk out” of a MW delivery by being too overweight at the beginning of pregnancy or gaining too much weight during pregnancy. That may not be the case here, but food for thought.
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Lil had this to say,
Jun 22, 2011 @ 3:06 pm (Quote)
After birth (or C-section) over-weight and obese women are routinely told at our hospital, the huge risks of being fat and having a c-section. Some OBs even warn the mums that obese and morbidly obese women will be more likely to have a c-section that a vaginal birth…I notice that they NEVER pass on the little gem of knowledge that our hospital (considered better than average in official reports) had a 35% c-section rate 4 years ago, and has managed to claw it down to 21%, and the majority of those figures are over weight women. When an anonymous survey was conducted 100% of the OBs at this hospital (yes, every last blinkin’ one of them) admitted that they would schedule a c-section automatically if a woman’s BMI was over 30, and there were any other risk factors or BMI over 40 with no other problems!!!
Add that to the fact that BMIs don’t give a ‘full story’ for a person’s fitness, let alone ability to give birth…and also doctors don’t work them out right! Mine was 52 during my last pregnancy, which I am embarrassed about, and wish it was the other way round (25!), but I was horrified to find my OB had written ‘BMI >60′ on the front of my notes! I pointed out that she was wrong, she looked at the calculations and ‘hmmmed’ a bit, I said ‘I’m closer to 50 than 60′ and she shook her said ‘no, in your case 52 is closer to 60 than 50′…WHAT?! I wish someone had told me at school that I was special enough to change mathematical values, it would have helped at lot when I was doing sin, cos and tan!!!
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The Well-Rounded Mama had this to say,
Jun 22, 2011 @ 6:34 pm (Quote)
Yes, women of size have a higher rate of complications as a GROUP but that doesn’t mean they should all be sectioned pre-emptorily. That’s a ridiculous premise because the risks of surgery in women of size are higher too.
Unfortunately, many doctors have taken the position that it’s better to do a planned cesarean in a high-BMI woman than to risk trying to do a cesarean during labor (which they think will surely happen anyhow, since they don’t believe that women of size CAN give birth vaginally).
However, there was a study done recently on “super obese” women (BMI greater than 50) to see whether planned vaginal births or planned cesareans were associated with better outcomes with this group. The study is Homer 2011, BJOG, PMID: 21244616
They found that 70% of the “super obese” women in the study WERE able to give birth vaginally if given an actual chance to. And if you look closely at the stats, the infection/complications rate was lower in the planned vaginal group (the abstract doesn’t show this, but if you crunch the numbers in the full text, it does).
Too many doctors are willing to jump straight to a c-section with a woman of size, but outcomes are NOT better on average. Women of size CAN give birth vaginally if they are just given the chance to do so (spontaneous labor is vital!).
And women of size should NOT be denied access to midwifery care. There is NO proof that a high-intervention model of care improves outcomes. Unless a woman of size has major complications taht necessitates an OB’s care, she has just as much right to midwifery care as any other woman.
You can read my articles on this on Science and Sensibility’s blog. And you can find a lot more information on pregnancy in women of size at my blog, http://www.wellroundedmama.blogspot.com.
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This infuriates me at every level.
And pre-E? Got a friend with early symptoms right now, 36 weeks, hasn’t been transferred care and under the midwife’s care, her symptoms have been GOING DOWN. None of the things she has been doing to do that (aside from resting and reducing salt intake) would have even been suggested by an OB.
And this garbage is self-fulfilling prophesy. I was dumped at 38 weeks by my midwife because she “had a bad feeling.” I ended up with a cesarean 4 weeks later because the nurses gave up on me when pushing for an hour and a half before I had the urge didn’t produce a baby. I was already so defeated and beaten down between the midwife and my control-freak OB, I couldn’t fight for myself anymore. I’d been fighting for months.
However, with my VBAC, I had an honestly supportive OB who was reassuring, positive and I got my VBAC.
Look for a problem hard enough, you’ll find it or cause it.
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I was told something similar, first at 36 weeks the midwife said I needed to induce at 37 weeks, and then when I didn’t immediately agree to it, she said I wasn’t a good candidate for midwifery and needed to transfer to an OB because of my weight, my VBAC status, and the likelihood of having a big baby. I found a new midwife. But my issue with the first midwife was, all of those conditions had existed from DAY 1 of my pregnancy. So why weren’t they brought up as concerns from DAY 1, if they were true concerns? To go from “Wow, you’re looking great, best pregnancy ever” to “you need an OB and possibly a c/s” at 36 weeks, for conditions that had existed from the very beginning, just didn’t make any sense to me and I rejected the idea completely. Spent 3 weeks searching for a new midwife and did find one, had a fantastic home birth with a perfectly healthy baby. I still hold that if these issues had been real concerns, they would have come up earlier in my prenatal care, and any decent maternity caregiver should discuss any issue like that at the very beginning of pregnancy (even if it’s just “Because of your weight or your history, these issues might come into play and we need to be prepared to consider them”).
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OH Boy had this to say,
Jul 7, 2011 @ 4:45 am (Quote)
Hi. I’m the OP. My scenario was pretty much exactly what mama wrench describes. And this was a VBAC after a horrible and traumamtizing “emergency” c/s for “failure to progress” 18 months before this appointment. I sought out this midwife because I’d heard she was both fat- and VBAC-friendly. Actually, the worst part about this story is that the midwife I’d been seeing for a year and a half (I went to her for postpartum care after baby 1, and got pregnant when baby 1 was 11 months old) wasn’t even the one to tell me that this was the practice groups policy. Te CNM who fired me was the second in the group who MY CNM wanted me to meet just in case I went in to labor while she was off duty or on vacation, etc. It was literally the first time I met the woman! And it turns out that my original CNM has a reputation for just keeping people who the OBs would otherwise harass under the radar and hope for the best outcome. My friend who was pregnant at the same time with same CNM had GD. She came to the attention of the OBs and was bullied into inducing at 38 weeks to “avoid the serious risk of a macrocosmic baby.” after a torturous induction, 40 hours of pit labor, etc., her baby emerged at a whopping 5 lb 11 oz. And had to be NICUd for jaundice. Anyway, I came to the attention of the OBs at 33 weeks because in was in a car accident and had to be monitored afterwards. When the chief OB got my file, apparently he was pissed that my CNM was breaking their BMI rule and that was that. According to my CNM all along, I was a perfect VBAC candidate and my pregnancy was textbook uneventful.
I had to find another midwife at a different hospital. Not too many providers will take a fat, 36 week, VBAC so I didn’t have a ton of options. I ended up with a c/s at 43 weeks because my bishops were low and I didn’t want to go through a failed induction. Baby girl 2 is perfect at 9 months old, but I do wish I got my VBAC.
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Wow, could have possibly told the patient this oh, 36 weeks ago maybe? Were they going by the Holy BMI, perhaps?
I hope this mama didn’t get railroaded into a cesarean, or was at least able to have a VBAC.
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