I have complained for years about the bias I see in hospital trusts’ guidance on managing bigger pregnant women. A policy’s wording may not seem a big deal, but it provides insight into management attitudes. It may also influence how the staff we meet perceive and treat us. Their actions and recommendations can have knock on effects for our physical wellbeing and the progress of that labour. The impact of negativity on labour and birth is not to be underestimated.
Apart from alienating us, potentially reducing the chances of a trusting, co-operative relationship forming with our caregivers, the impact of negativity on labour and birth really can affect how our labour progresses.
Pregnancy Is Not An Illness!
Being pregnant is not a sickness; half 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 labour easiest when they feel comfortable, supported, and 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. Scans show the baby is growing normally, and she has happily gone into labour naturally around her due date. 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 high-risk we are.
The member of staff attending, having read the guidance about the increased risk of high BMI pregnancies; the increased likelihood of interventions; what a ‘problem’ obese pregnant women are, might be a little apprehensive if they’re not very 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. This will enable the staff member to check how labour is progressing and how the baby is responding to contractions. A perfectly sensible request, surely?
Ripples in a pond
A single drip can cause ripples reaching right across a pond, don’t forget! The impact of negativity on labour and birth can have very similar, wide-reaching consequences.
Normally this kind of monitoring utilises a hand-held doppler, as it was at midwife visits throughout the pregnancy. In a labour ward, labelled ‘high risk’ however, the preference (of staff) is often for a Cardiotocograph (CTG) printout. So the woman lies on the bed while straps hold pads on her belly, and the CTG does its thing.
Natural flow of labour interrupted
This lying-down position is uncomfortable for most labouring women. It is also counter productive, as lying down restricts space in the pelvis. Gravity, which was naturally helping the baby towards the exit, is now pulling the baby towards the woman’s back instead.
If the CTG isn’t giving a constant and reliable trace (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.
So already, we’ve interrupted the natural flow; the impact of negativity in labour and birth has begun, with one tiny procedure change, done with the best intentions. The woman is now more uncomfortable than she needs to be. She may also be getting concerned if there is a problem getting a continuous trace. If she’s been repeatedly told her pregnancy is likely to be problematic, she might already be losing faith.
Adrenaline is the saboteur of natural childbirth
Worry stimulates the body’s fight or flight mechanism, causing adrenaline to flow. Adrenaline stops the production of the hormone oxytocin, and oxytocin is what helps labour to progress. So adrenaline can slow down or even halt labour completely. There’s a very practical evolutionary reason for this; if in danger, it’s essential for the labouring mum to get to safety. Adrenaline stopping labour gives the woman time to get herself to safety. But she’s not in a life threatening situation right now, it’s merely fear tricking the body into fight/flight mode.
Sensing the woman’s pain and anxiety, the staff attending, in anticipation of that ‘difficult’ labour and birth, might start suggesting interventions rather than encouraging the woman to get back to as natural a birth process as possible. Perhaps attaching an electrode to baby’s head would give a reliable reading and provide reassurance? The CTG trace hasn’t shown any problems, but since it’s not reading half the time, we can’t be sure…
Continuous fetal monitoring
The mother agrees, of course! She is concerned for her baby, but what she doesn’t know and isn’t told until it is too late, because staff don’t always explain all the pros and cons of a procedure unless you ask, is that continuous fetal monitoring 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 lying on that bed even more.
(If you’re making decisions in pregnancy and labour, there’s a few things you might want to ask. There’s also a helpful acronym (BRAIN) to help you remember them, but that’s for another article. Click here if you’d like to read it…)
One domino pushes the next, and the next…
The woman is rapidly losing control of the situation and of faith in her own body’s natural abilities. Her hopes of a natural labour are drifting away. The bright lights, machines, and unfamiliar surroundings of a hospital are worlds apart from the environment most labouring mammals choose; dimly lit, quiet, private spaces, and so it will be difficult to regain the earlier momentum and sense of calm.
She may be worried for the baby, and concerned all her fears are coming to pass. If this is how she is feeling, adrenaline has probably taken over and all natural oxytocin is long gone. If progress continues to stall for a few hours, someone will likely say her labour is not progressing quickly enough.
Perhaps it’s time to suggest another intervention, a little cocktail of hormones to speed things along? If the woman’s tired, she may welcome this suggestion right now. Again, she doesn’t know all the implications however, not enough to make a fully informed choice. She doesn’t ask questions, she’s just grateful for any offers of help, and reassured that midwife knows best.
Bump-start in second gear
If you’ve ever bump-started a car with a flat battery, you’ll know you never do it in first gear, always a higher gear. It works, but means that when the engine jumps into life, it pulls away a bit more suddenly than expected. Artificial hormones used to bump-start labour are very similar.
Normal labour increases in intensity gradually, giving the body’s pain relief mechanisms a chance to adapt. Contractions brought on artificially tend to start in a higher gear than the body’s natural pain relief mechanisms were anticipating; this leaves many women ill-prepared to cope.
Given that the woman is tired, in pain (especially if she’s still led on the bed), and is probably feeling like childbirth is every bit as bad as many people say it is, she might feel now is a good time to request some pain relief. There are alternatives, but it’s likely she’ll be offered an epidural first because her caregivers are wary; with a bigger body it might be difficult to site and may not work first time. Best call the anaesthetist early if that’s where we’re headed.
Rather than 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 or ask questions. 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 its magical ability to enable you to move around more easily to stay comfortable.
Relief, but at a cost
Once the epidural is correctly sited, the woman is free from pain, but is now disconnected from the labour. She can no longer move around and keep active to give nature a helping hand. Gravity is working against her. Space in her pelvis is restricted because her coccyx is pushing into the birth canal. Not much, but enough when there’s not much room to begin with.
Eventually, she’s 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! Emergency! Whip the baby out with a c-section!
Everyone is OK. Mum and baby are both just fine. She’ll be off her feet for a while. She’ll need medication to thin her blood because she’s at risk of deep vein thrombosis from being immobile. She’ll likely have a longer recovery period than if she’d delivered vaginally. There’s the risk of problems with wound healing, and statistics show she might struggle more with initiating breastfeeding. On top of that, there’s a chance she’ll feel sad and disappointed and as if she failed (she hasn’t). Things didn’t go to plan, and if she feels (or anyone suggests) that this was due to her size, there might be feelings of guilt and regret. Hopefully these feelings aren’t deep enough to trigger a postnatal depression…
But as far as the medical team are concerned, all’s well that ends well. One healthy baby, one healthy mum. 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?
The evidence – a self-fulfilling prophecy?
A large Canadian study in 2011 looked at whether labour is managed differently in women with high BMI, and whether this might account for the higher caesarean rate.
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Their findings? Increased BMI was associated with increased use of artificial oxytocin and epidurals, and with earlier decisions to perform caesareans. 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. The impact of negativity on labour and birth on paper. It’s not always extreme, but if you can avoid toppling the first domino, you have a chance of avoiding the rest.
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. Using your BRAIN can help you make informed decisions (be that informed consent or informed refusal).
Being treated as high-risk might just be that self-fulfilling prophecy if we aren’t careful.