Basingstoke and North Hampshire Hospital

Hampshire Hospitals NHS Foundation Trust (Basingstoke and North Hampshire Hospital)

Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Aldermaston Road, Basingstoke, Hampshire. RG24 9NA

Thanks to Stephanie for getting this one!

Date Obtained: September 2021

Observations:

Pleased to see they have renamed this from “Care of the Obese Pregnant Woman”.

Unfortunately, stigmatising and labelling language such as “women who are obese” and “obese women” remains throughout the document, apart from a few exceptions. Obesity Action Coalition and World Obesity advocate for People-First Language – where you talk about the person before their condition – e.g. person with obesity, woman who has obesity etc. My preference would be to skip the use of the word obese/obesity at all and just talk about BMI – so woman with a BMI >40, for example.

There’s some good stuff in there too.

“Many women do have non eventful pregnancies and births so it is important to bear this in mind. All l women must be treated as individuals and with respect; compassionate and respectful discussions should take place with all women”

Hampshire NHS Trust Obesity in Pregnancy Guidelines

Oversimplification of risks

However, the section “Risks associated with obesity in Pregnancy include.” just lists risks associated with pregnancy! Any pregnancy can experience these issues! Anyone reading this has no idea of what the actual statistical likelihood of any of the outcomes mentioned are, for people with a higher BMI, or in general!

There’s some hyperbole regarding “high risk of vitamin D deficiency”. When I looked for evidence for this I found that this study from 2008:

Who looked at the Vitamin D levels of 320 women, 43 of whom had BMI >30. 88% had ‘insufficient’ or ‘deficient’ levels of Vitamin D, so fair enough… except 82 % of women with a BMI <30 also had ‘insufficient’ or ‘deficient’ levels of Vitamin D.

Sounds to me like everyone is at high risk of Vitamin D deficiency!

Forgetting we have a choice

This is fairly standard, but needs to change.

Sentences like “All women should have their height and weight measured and BMI calculated at booking”, “Women who have a BMI of 30 or higher should be commenced on an increased dose of Folic acid”, “a referral should made to the obstetrician to arrange serialised USS [ultrasound scan] assessments of growth”.

Aside from the terrible grammar, saying “should be commenced on” and similar forgets that all interventions are an OFFER we can choose to accept or reject.

They do remember this later, however “All women with a booking BMI ≥30 should be offered referral to a weight management programme”. “Women should be recommended to have a GTT by 28 weeks and the rationale explained.”

Weighing and re-weighing

“All women should be re‐weighed in the third trimester, ideally at 34‐36 weeks; this should be clearly documented in the notes. It may be appropriate to offer re‐weighing earlier in pregnancy as part of an ongoing discussion regarding weight maintenance, diet and exercise.”

This is disappointing, firstly because it’s not worded as an offer, but secondly because weighing again in pregnancy is expressly discouraged by NICE Public Health Guidance 27 “Weight management before, during and after pregnancy”

Caveats by BMI category

BMI 30-34.9

If you have a BMI 30 – 34.9 and are otherwise low risk you ‘can receive midwife led care’.

Oddly, if you wish to use the pool you must have a gestational weight gain of “less than or equal to 12kg”, which is entirely without evidential basis as far as I am aware.

BMI 35+

If you have a BMI 35 and above you apparently ‘need’ referral to obstetric clinic for review (still an offer!)

They state that “Elective induction of labour at term in obese women may reduce the chance of caesarean birth without increasing the risk of adverse outcomes”, but the data on this is shaky.

This research study from 2019 shows a reduction of cesarean section of inductions at 39 weeks, but only of 39.1% vs 41.6% for those who’d never given birth before. (5.5% vs 10.1% for people who had given birth before).

That’s a significant intervention to reduce the risk of cesarean by a measly 2.5% (or 4.6%). And significantly, there were no lowered odds of cesarean for inductions in weeks 40 and 41.

“Women with a booking BMI of ≥35 should be advised to birth in an Obstetric unit.” But it goes on to say “For those women requesting birth at home or in a low risk birth centre a clinic appointment should be arranged to discuss the associated risks with a member of the senior midwifery or obstetric team…”

So MLU is not completely off the cards. Possibly.

But later in the document it recommends continuous fetal monitoring for anyone with a BMI 35+ . There’s no recognition of the fact that continuous fetal montioring is not without downsides. It restricts your options for movement and use of water, and has been shown to have limited benefits…

Fetal monitoring in labour: the challenge of balancing the benefits with harms

BMI 40+

If your BMI is above 40, Hampshire Hospitals NHS Foundation Trust guideline is worded as if you have no choice in anything at all. Spolier alert, you totally do.

“IOL [Induction of Labour] date should be arranged to maximise delivery on a weekday in daylight hours.” It’s not even being written as something to be considered, it’s a foregone conclusion with scheduling concerns… Well, yes, I’m concerned.

Referral to anaesthetist if BMI 40+ with co-morbidities or BMI 50+. Should be an offer of referral, of course.

“On admission to labour ward women with BMI ≥40 should have venous access established” again, this should be an offer with clear explanations of the pros and cons, not a foregone ‘we’re going to stick a needle in your arm because there’s no way you’re going to be able to do this without some sort of intervention…”

Postnatal

On the plus side it states: “Women with raised BMI have lower breastfeeding initiation and continuation rates” which is true, and “these women should be prioritised for support during the ante natal and post natal period both in hospital and community settings”.

But then goes on to say “During post‐operative recovery, care should be taken when the mother is breastfeeding or providing skin to skin contact in bed due to increased risk of airway obstruction of the infant”. WTAF? So provide us with support, but watch us like hawks in case we smother our babies with our flabby bodies?! Is there any evidence for this?

Uggh.

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