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    Questions? Ask Henci!


    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

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    Archived User


    Dear Henci,

    I am 40 weeks and 6 days and my midwife is pressuring me to get an induction ASAP. Her reasoning is that my BMI is 30 and she says many times a woman with a high BMI will not experience cervical ripening on her own. I am quite healthy--and I have had a wonderfully pleasant and uneventful pregnancy (it is my first).  Me and my baby are fine--no gestational diabetes, no high blood pressure, passed 2 BPs and non-stress tests, positive for group b strep, the baby's estimated size is 7.5 lbs.

    I have put off induction until after the weekend, giving me 4 days to ripen on my own.  My midwife also wants me to have a Misoprostil induction, because she doesn't think any other method will work for me. Any thoughts on this matter? I have been walking, having sex, eating pineapple and eggplant, taking rasberry leaf capsules, evening primrose oil and black cohosh.  Today I had a session of acupuncture to get labor going. I really want to trust my body to do what it was designed to do, but it is hard when my midwife has no faith in me. It seems like for some doctors, a high maternal weight is a deal breaker for a no-or low intervention birth.

    Thanks for any advice you may have,

    Jenne

    Henci Goer

     

    Jenne --
     
    To begin with, I met Kmom a couple of years ago when she was speaking at a conference, and I was impressed with her knowledge. A plus-sized woman herself, she has written an article with helpful information on how big women can minimize their likelihood of cesarean.
     
    In the second place, while I rarely come out and say to do or not do something (my mantra is helping women make informed decisions based on the best evidence), I make an exception for misoprostol (aka "miso"; trade name Cytotec). Do not agree to a Cytotec induction. Here is what the FDA has to say about this drug:

    "Cytotec can induce or augment uterine contractions. Vaginal administration of Cytotec, outside of its approved indication, has been used as a cervical ripening agent, for the induction of labor and for treatment of serious postpartum hemorrhage in the presence of uterine atony. A major adverse effect of the obstetrical use of Cytotec is hyperstimulation of the uterus which may progress to uterine tetany [uterus contracts and doesn't let go] with marked impairment of uteroplacental blood flow, uterine rupture (requiring surgical repair, hysterectomy, and/or salpingo-oophorectomy), or amniotic fluid embolism [maternal and infant mortality rate is very high from this]. Pelvic pain, retained placenta, severe genital bleeding, shock, fetal bradycardia [profound slowing of the baby's heart], and fetal and maternal death have been reported.

    "There may be an increased risk of uterine tachysystole [contractions coming too fast], uterine rupture, meconium passage, meconium staining of amniotic fluid, and Cesarean delivery due to uterine hyperstimulation with the use of higher doses of Cytotec; including the manufactured 100 mcg tablet. The risk of uterine rupture increases with advancing gestational ages and with prior uterine surgery, including Cesarean delivery. Grand multiparity [usually defined as more than four births] also appears to be a risk factor for uterine rupture.

    "The effect of Cytotec on the later growth, development, and functional maturation of the child when Cytotec is used for cervical ripening or induction of labor have not been established. Information on Cytotec’s effect on the need for forceps delivery or other intervention is unknown."

    In cases where induction is truly warranted and the cervix is not ready to labor, prostaglandin E2 (aka dinoprostone; trade names Cervidil, Prepidil and probably others) works just as well at ripening the cervix, although not as quickly, and prostaglandin E2 is FDA approved for the purpose. Whenever possible, though, even when induction is indicated, it is much more likely to work when the cervix is ripe. 

    I'm afraid, though, you have even bigger problems than the soundness of your midwife's recommendations, although those are problems enough. As you have realized, you have a midwife who almost certainly thinks you will not be able to birth your baby unless you follow her recommendations and probably not even then. Her lack of faith in you is likely to affect her judgment, which means you will not be able to trust her judgment in labor, not to mention how vulnerable laboring women and their partners can be to a negative atmosphere. Is there any chance of finding another care provider? I assume this midwife is hospital-based. Have you considered a home birth? Home birth midwives are much less likely to be biased against plus-sized women. If you can't change providers, do you have a doula? She can give you the support and encouragement you will need to counteract your midwife's pessimism. Here, too, are some ideas of mine to help you avoid an avoidable cesarean:

    • Begin labor spontaneously.
    • Stay home until in active, progressive labor. If you go into the hospital and it turns out you are still in early labor, go back home. 
    • Stay active in labor.
    • Push in an upright position so that gravity is working for you.
    • Use pain coping techniques other than an epidural so that you can stay active and push effectively.
    • Refuse a cesarean based on arbitrary time limits for making progress.
    -- Henci
    Archived User

    Dear Henci,

    Your advice was very helpful. Holding off on the induction at least through the weekend, I went into labor spontaneously on May 2nd--in the early morning hours. The two days prior I had tried numerous techniques to ripen the cervix/get labor going, including acupuncture--which I think did the trick.  You were right in saying my biggest problem was having a midwife who did not believe in my body's ability to birth. Luckily, I had the support of a wonderful doula who encouraged me to wait it out--reminding me that most first time moms average a gestation of 41 weeks and a day. May 2nd marked that average--I was pregnant 41 weeks and a day!  My doula stayed with me as I labored at home through the morning, helping me through hours of contractions.

    We went to the hospital only when I felt it was absolutely time to have my baby.   When I went into the hospital, I was 8cm dilated, and had a different midwife deliver me. She and the team of nurses were kind, encouraging, and simply wonderful. I was not offered any drugs at any point during the birth.  I went to the hospital at 2:00 pm and my son Nathaniel was placed in my arms at 4:27pm.  I had a beautiful and merciful birth that I probably would not have realized if I had listened to the first midwife who said I would not go into labor spontaneously because of my high BMI.  I hope that this story helps encourage other curvy women to trust their bodies and not accept interventions that may be unnecessary and harmful.

     

    Thank you so much!

    Jenne Hayden

    Henci Goer

    I am thrilled for you! And I am so glad you posted your story for others to see and be inspired. I'm also glad to have been able to help you on your journey.

    -- Henci

    Archived User

    Is there any evidence-based info that induction for BMI of 30 or above is warranted or not?  We have a new doc in our area who is pushing for induction at 40 weeks if BMI is 30 or more.  I am searching for info about this to present, although my gut says it's not right!

    Henci Goer

    I would trust your gut on this one. Presumably, he is pushing for induction in the belief that it averts cesareans by keeping the baby from getting too big since plus-sized women tend to have bigger babies, but the research is rock solid that inducing for suspected big baby has no advantages while increasing likelihood of c/sec. In fact, I would consider this a red flag for this doc in general. There are also a bunch of studies consistently finding that when the ob believes the baby to be big (8 lb 13 oz or more) but is wrong, cesarean rates are much higher than when the baby actually is that big but the doctor didn't suspect it. In other words, the ob's belief in the woman's ability to birth vaginally is a crucial factor in whether she actually does. 

    Earlier in this thread, I referred a woman to an article by KMom, a plus-sized woman herself who specializes in the research regarding what best promotes safe, healthy birth in women of size, and I'm going to repeat the link here in case you haven't already read it. It is about miminizing the likelihood of cesarean and includes the recommendation not to induce. 

    -- Henci

    Archived User

    Actually, the "he" is a "she", and when I mentioned ACOG's stance on inducing for suspected macrosomia, I was told "She's not worried about the baby being too big, she is worried about complications in a larger woman."  I think the two are still linked.  This isn't for me, I was the one put on the job to see if we could find evidence-based research info to present (this doc is now overseeing hospital midwives). 

     

    I will check out the linked site you mentioned.  I just wondered if there was anything out there where BMI and outcomes were looked at?

    Henci Goer

    Sorry it has taken a while to get back to you. I was away, and when I came back, I was pushing to finish a chapter in the manuscript of the new edition of my book, Obstetric Myths Vs. Research Realities. You might want to find out more about what complications she's referring to and ask for the evidence on the issue. It will be interesting to see if she has any, and if she does, its quality. 

    In answer to your question, I searched the Well Rounded Mama, on cesarean complications, which led me to a blog post with a link to an Our Bodies Ourselves webpage discussing Pregnancy and Birth in Women of Size. It notes that high BMI women are at higher risk of complications with cesarean surgery than women who are not and sources ACOG (see below), so it would make sense to give them the best possible shot at vaginal birth, which would not be inducing labor.

    -- Henci

    ACOG Committee Opinion. "Obesity in pregnancy."  Obstetrics and Gynecology  2005 Sep;106(3):671-5.

    Archived User

    It must have worked out because I haven't been able to get back here until today :). I just got my copies of the Journal of Perinatal Education and I enjoyed your piece.  I am so excited for the revised book, as well!

    I will see what I can find out about what this doctor says the risks are.  I am not personally in a position to ask her myself, and I have a feeling the midwives won't be eager to ask her to cite her sources...

    I thought I had heard before that cesarean births do hold more risks for women who are obese than those who are not.  It certainly is an interesting shift to see on a local level if she insists on induction at 40 weeks for "qualifying" women :(.

    Henci Goer

    If the midwives are interested but don't want to get the ob's back up, I suggest they approach it as asking this ob to help them learn more on this issue, in other words, educational rather than confrontational. One of three things will happen: 1) She will have the data, and it is compelling; 2) She has the data, and it is weak; or 3) She has no data beyond opinion. In the latter two cases, this opens the door on grounds of "we all want to practice according to the best evidence" of proposing a joint MW and OB task force to research optimal care (care that produces the best outcomes with the least use of intervention given the individual case) in high BMI women.

    ~ Henci  


    All Times America/New_York

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