Bordesley Green East, Birmingham, England, B9 5SS
Tel: 0121 424 2000
Rectory Road, Sutton Coldfield, England, B75 7RR
Tel: 0121 378 2211
Lode Lane, Solihull, England, B91 2JL
Tel: 0121 424 2000
Heart of England’s clinical guideline is hot off the press, having only been released in January 2013.
Its intentions seem good. It states early in the document; “Women affected by maternal obesity need to be treated with dignity and respect. Their needs should be openly discussed regarding their care and regarding any identified risks involved during pregnancy.”
Later it says “The aim is to provide accurate and accessible information sensitively, which empowers the woman to actively engage with health professionals and the services available to her“.
It states that the aim of the guideline “is to ensure that women receive appropriate, individualised care based on contemporary evidence and best practice to manage the risks associated with obesity in pregnancy.”
The trouble is I can’t find much evidence of the care being individualised, BMI seems to rule over all considerations. I can report, however, that BMI is not mentioned as a specific exclusion in the waterbirth policy. It states that to be automatically allowed to use the pool the pregnancy needs to be ‘uncomplicated’. Whether a high BMI with no other complications is classed as uncomplicated is unclear, however, the alternative pathway allows for an individualised plan of care for women who do not fit the ‘uncomplicated’ model, so use of a pool should be possible, depending on your circumstances.
The stats for women attending the three hospitals with a BMI over 30 from 01/04/2012 to 07/02/2013 are as follows:
Birmingham Heartlands = 1172 women with BMI 30+ out of 5675 women = 20.65%
Good Hope Hospital = 457 women with BMI 30+ out of 3307 women = 13.8%
Solihull Hospital = 30 women with BMI 30+ out of 294 women = 10.2%
What you can expect:
If your BMI is between 30 and 35, you will be booked under the care of a consultant. You can expect the usual ‘here’s all the things that are more likely to go wrong with your pregnancy because you’re fat’ conversation but at least it should come with the aside “and here’s what you can do to minimise the risks”. You’ll be advised NOT to diet, and to take 5mg folic acid daily (instead of 400μg) because of your BMI, and be considered for daily aspirin if you’re at additional risk of pre-eclampsia.
You’ll be booked for a glucose tolerance test (GTT) at 26-28 weeks if you’re at Good Hope Hospital, but due to a lack of facilities at Solihull and Heartlands you will instead have a random blood glucose test at booking and at 28 weeks, and if any issues identified you then go on to have a GTT. You will have your risk of DVT (deep vein thrombosis) assessed at every stage. You may be sent for extra growth scans if previous scans have been difficult. You should receive advice on starting and maintaining breastfeeding before you go into labour and again after delivery. You should have an individual risk assessment to plan your place of birth. You seem to be herded towards delivering at either Good Hope Hospital or Heartlands Hospital, not Solihull, but 30 women (10% of the total number of deliveries) have delivered at Solihull with a BMI over 30, so it appears to be possible, somehow.
So long as there are no concerns when you present in labour, you should not be continuously hooked up to a fetal heart rate monitor (important for active birth). They will recommended that you have an ‘active management’ of the third stage of labour rather than a natural management. You should be given medication to help prevent DVT if you have an additional risk factor for DVT (as well as being overweight). You may have your ‘manual handling needs’ assessed (usually, can you get yourself out of a chair, can you wash yourself etc.), if the health care professional thinks it necessary. You’ll likely be referred for ongoing “dietetic & lifestyle advice” after the birth.
If your BMI is between 35 and 40, you can expect the above, but you’ll be advised to give birth in the consultant-led obstetric unit (not woman-led or baby-led?).
You’ll be monitored more closely for pre-eclampsia, especially in the third trimester. Interestingly, they ‘consider referral for smoking cessation’ if woman has BMI 35+… I’d have hoped they’d offer a smoking cessation referral to all women who smoke, not just obese ones?!
If your BMI is between 40 and 45, you can expect the above, but they’ll weigh you again in the third trimester to check the appropriate equipment is being used for your weight. They also may want to establish access to a vein early in labour in case you need to be given medication later and access is difficult. They also suggest you consider early use of an epidural. You’re also likely to be offered medication to help prevent DVT, even if you have no other risk factors for DVT, and you’ll automatically have your ‘manual handling needs’ assessed to see if you need help to get off of a bed, go to the toilet etc.
If your BMI is 45 or greater or you weigh more than 130kg on booking, you can expect the above, but you also get an anaesthesia consultation in your third trimester, unless you’ve previously had an uncomplicated vaginal delivery and expect to do the same again, or you’ve previously had a consultation and no concerns were identified.
To be considered for IVF your BMI needs to be below 30.