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Pregnancy & Birth

Women of Size and Cesarean Sections: Tips for Avoiding Unnecessary Surgery

Most articles about pregnancy in obese women, and even many childbirth providers, assume two things: that being fat interferes with a woman’s ability to give birth vaginally; and that the sky high cesarean rate among women of size is the logical outcome of obesity. 

Women of size do have very high cesarean rates today. But is this high rate really medically necessary?  Or is some of the increase caused by misguided assumptions about obesity and by unneeded interventions and protocols commonly used with women of size?  If so, what can a big mom do to lower her personal chances of having a cesarean?

Cesareans can be truly necessary and life-saving.  But nowadays, more and more women—especially obese women—are having cesareans that are not really needed. This puts them—and their babies—unnecessarily at risk. 

Women of size can give birth vaginally and safely, but to do so they have to be even more proactive about their childbirth choices than women of average size. 

CESAREANS ARE MORE RISKY FOR OBESE WOMEN

A cesarean is major abdominal surgery and as such poses risks for women of any size.  Women who undergo surgical births are more likely than women who have vaginal births to experience severe bleeding, infections, painful scarring, blood clots, bowel obstructions, readmissions to the hospital, and longer-lasting pain.1

In addition, having a cesarean birth increases a woman's chances of having future reproductive problems, including decreased fertility and an increased rate of placental problems. As the number of cesareans increases for a woman, the risk of complications in future pregnancies also increases.2

Cesareans are even more risky for big women. Obese women who have surgical births have higher rates of anesthesia problems, severe bleeding, wound problems, and infections than non-obese women who have surgical births.3  

Babies born via cesarean section also face more risks than babies born vaginally: they are more likely to have respiratory problems in the newborn period, more likely to have difficulties establish breastfeeding, and more likely to experience asthma in childhood and adulthood.4 (For more information, see "Comparing the Risks of Cesarean Births Versus Vaginal Births.")

Doctors should be doing everything in their power to lower the cesarean rate in obese women, but instead they are performing far more cesareans in this group than ever before, risking the health of both big moms and their babies.  This must change.

SKYROCKETING CESAREAN RATES IN WOMEN OF SIZE 

Just how high is the cesarean rate in big moms? Several recent studies found that nearly one-half of obese first-time mothers ended up with a cesarean.5, 6   The rate in “supersized” women is even higher.7  But it doesn’t have to be this way.

In the past, the cesarean rate among women of size was significantly lower than it is today. In fact, a 1978 article in the American Journal of Obstetrics and Gynecology noted:  

"In agreement with most other studies, no significant increase in Cesarean sections or operative forceps delivery was noted in [the obese group.]" 8
If the cesarean rate was significantly lower in the past for obese women, it means that most fat women can give birth vaginally under the right conditions, and that a high cesarean rate is not an inevitable outcome of obesity.

Many of the cesareans in women of size today may be “iatrogenic”—that is, caused by the attitudes and management protocols of the doctors, rather than by the woman’s size.  This echoes the real-life experience of many big moms, who have found that when they shift to a less-interventive care model, they experience fewer cesareans and their babies have better outcomes. 

The good news is that there are many things that a woman can do to lower her risk for a cesarean. The ones that are particularly important for women of size include:

  • Be proactive in your health habits

  • Choose truly size-friendly care

  • Avoid routine medical interventions during labor unless clearly needed

  • Do not intervene for a big baby


Be Proactive In Your Health Habits

  • Be proactive about your health before pregnancy
    Certain diseases can cause pregnancy complications, and heavy women have a higher risk of having some of these diseases.9   Before you get pregnant, check your blood sugar, blood pressure, and thyroid function, do what you can to stabilize them if needed, and address any other outstanding health concerns.

  • Get regular exercise and practice excellent nutrition
    Good nutrition and exercise can cut the risk for blood sugar and blood pressure problems during pregnancy significantly, by one-third to one-half.10  While weight itself is often blamed for many health problems, evidence shows that exercising and eating healthy foods – whether or not they lead to weight loss -- have clear positive benefits for women of all sizes and can improve pregnancy outcomes.  Eating well and getting sufficient exercise may also help you be more physically prepared to take on the work of labor and birth.

  • Pay careful attention to the baby’s position
    A baby in poor position may not fit through the pelvis as easily and can cause long, hard births.  Some research shows that obese women have a higher rate of malpositioned babies,11 so preventing a malposition is especially important in this group. Because obesity can be a strong mechanical stressor on the body, it can throw the pelvis out of alignment, which in turn may cause a fetal malposition.  One small study found that chiropractic care was able to lower the rate of malpresentations in women at term,12 and many women of size have found it helped them to have a more comfortable pregnancy.

Choose Truly Size-Friendly Care

  • Check for subtle size-bias in your care provider
    It’s not enough to find a provider that seems “nice” and doesn’t scold you about your weight. Being truly size-friendly means not using extra interventions simply because of size, and knowing to use size-appropriate equipment (like large blood pressure cuffs).  A truly size-friendly provider believes in your ability to give birth vaginally and knows that spontaneous natural labor is the best way to achieve this.  Ask your provider open-ended questions, like “What extra tests or interventions might I need as a large woman?” and then listen carefully. If she or he believes that lots of extra tests are needed, that labor will probably need to be induced early, that a cesarean is very likely, or if she or he recommends rigid nutrition/weight gain guidelines, this is not a size-friendly provider, no matter how “nice.”  Find a provider who is both “nice” and who truly believes that fat women can give birth normally, without intervention.

  • Choose a doctor or midwife with low rates of intervention
    Some women of size assume that because of their weight, they should see an obstetrician or even a high-risk perinatologist.  However, unless you have a pre-existing disease like diabetes or uncontrolled high blood pressure, you can choose from the range of providers.

    Some caregivers have much lower rates of labor and birth interventions than others. While rates of intervention will vary depending on the population served, they also vary by the type of provider and the practice style. Although there are many exceptions, family physicians tend to have lower rates of intervention than obstetricians, and midwives generally have the lowest rate of all.13  

    While there are no randomized controlled studies that directly compare the safety and satisfaction of birth experiences among obese women attended by different kinds of providers, the best available research suggests that women cared for by midwives have fewer cesarean sections, lower rates of other birth interventions, and comparable and possibly better outcomes than women attended by obstetricians.14  Even women who have medical complications can often work with a midwife in collaboration with other specialists.

    Choosing a provider who follows a midwifery model of care (also known as a physiologic model) may be the most important step you can take to increase your chances of having a safe and satisfying vaginal birth. (For more information, see “Models of Maternity Care.”)

  • Consider non-traditional birthplaces
    Many studies have shown that low-risk women who give birth in a birthing center or at home have excellent outcomes and are much less likely to have a cesarean birth.15  Birthing at home or in a birth center is a reasonable choice for healthy women of size too, and many women of size have had satisfying and healthy experiences in these birth settings.

  • Date the pregnancy accurately
    Many women of size have longer menstrual cycles,16 but doctors rarely account for this, making the due date artificially early. This increases the chances of induction or cesarean for “overdue” pregnancy, and it can also throw off prenatal testing results.  If your cycles are longer, your due date should be adjusted accordingly.  If your provider will not adjust your due date, you need a new provider.  If your cycles are extremely long or irregular, it may be helpful to get an early transvaginal ultrasound in order to help date the pregnancy more accurately and reduce the rate of induction for “postdates.”  Charting your ovulation before you get pregnant can also help document the need to adjust a due date.

  • Understand the pros and cons of prenatal tests 
    Prenatal testing can be a double-edged sword; its benefits often come at a price of further invasive testing and interventions.17 Furthermore, tests tend to be less accurate in women of size18 and are often the first step on the slippery path that leads to cesareans in this group. Yet some providers require extra testing in women of size. Always learn exactly what the test is, the benefits and risks, the possible downstream outcomes, and whether there are any alternatives.  Remember also that you always have the right to decide about prenatal testing, regardless of your size. (For more information, see “Introduction to Prenatal Testing”)

  • Arrange for continuous labor support
    Arrange for a doula (a trained labor support companion) or a friend or family member who is experienced with birth to be with you throughout your labor and birth. Women who receive continuous, one-on-one support from a person who comes into the hospital for this purpose are less likely to have a cesarean section or "assisted" childbirth with vacuum extraction or forceps, have fewer complications, and greater satisfaction with their birth experiences.19  (For more information, see “Labor Support Doulas”)

  • Be an informed health-care consumer
    Because women of size are subject to a higher level of intervention, it is especially imperative that they understand the risk/benefit ratio of common obstetric procedures. An excellent introduction to these is Our Bodies, Ourselves: Pregnancy and Birth and The Thinking Woman’s Guide To A Better Birth by Henci Goer.20  Also, take a good non-hospital childbirth education class. 

Avoid routine medical interventions during labor unless clearly needed

  • Avoid routine induction of labor
    In first-time moms, women whose cervix is not yet soft and ready to open, or mothers who have not yet had a vaginal birth, induction of labor is one of the strongest risk factors for cesareans.21  Yet obese women are induced at very high rates;22  this is a major factor driving their high rate of cesareans. One study found a cesarean rate of 19% in obese women in spontaneous labor, versus 41% in those who were induced.23  Unless there is a clear medical reason to induce labor, let your baby choose its own birthday.

  • Don’t go to the hospital too early
    The cesarean rate is lowest in women who labor at home until labor is well-established and intense.24  This may be particularly important in women of size, because some research shows that these labors tend to take a little longer to get well-established.25  A supportive provider working with your doula can help you decide when it is time to go to the hospital if you are unsure, or you can give birth at home and not have to worry about when to leave at all.

  • Labor spontaneously
    Let your labor progress on its own timetable.  Rushing labor by augmenting with artificial drugs may increase the risk of cesarean.26  Similarly, breaking the bag of waters may increase the risk of cesarean.27 Unless there is a clear medical reason to perform an intervention, let labor progress naturally, at its own pace.

  • Choose intermittent monitoring
    Many hospitals insist on continuous electronic fetal monitoring (EFM) of the baby.  This is necessary when labor is induced or drugs are used, but is usually not necessary with spontaneous, unmedicated labor.  EFM increases the likelihood of both cesarean sections and operative vaginal births (births in which forceps or a device known as a vacuum extractor are used to help pull the baby out of the birth canal).28  In addition, monitoring is more difficult in women of size because of extra tissue, so many larger women end up virtually motionless, or with an internal monitor instead (which increases the risk of infection).  Periodic monitoring tracks the baby’s condition adequately, allows more mobility, and lessens the chance of a misleading reading. (For more information, see "Fetal Monitoring.")

  • Avoid routine hospital protocols for women of size
    Some hospitals require that obese women have their waters broken on arrival to insert an internal monitor, or encourage all big moms to get an early epidural, “just in case.”  These set up a self-fulfilling prophecy for a cesarean.  Ask lots of questions about protocols, and choose the least interventive birthplace.  Also remember that you have the right to refuse interventions if you don’t want them.

  • Educate yourself about pain relief
    Because all pain-relieving medications can have adverse effects, it is generally best to approach labor with the idea of using no-risk or very low-risk pain relief strategies first, and then proceeding to the next higher level of intervention only if needed.   Epidurals are less effective and more difficult to place in women of size;29 use them only when truly needed. (For more information, see "Coping with Labor Pain: Introduction" and "Coping with Labor Pain: Epidurals and Spinals.")

  • Labor with full mobility and change positions often
    Moving around freely during labor is very helpful and can lessen labor pain.  Upright positions use gravity to help move the baby down, increase pelvic space, and help position babies better for birth.  Immersion in water can especially help increase mobility in women of size during labor, and many women of size absolutely love giving birth in water.

Do Not Intervene for a Big Baby

  • Choose a provider comfortable with the possibility of a big baby
    Although most big moms do not have big babies, statistically as a group they do have a higher rate.30  The fear of big babies is one of the strongest factors driving the high rate of cesareans in women of size; however, having a big baby is not in and of itself a valid medical reason for having a cesarean. Whether or not you actually have a big baby, your best bet is to find a provider who is comfortable with the possibility of a big baby and who will not intervene based on possible fetal size.

  • Do not be overly restrictive to get a smaller baby
    Many providers follow guidelines that restrict weight gain in obese women.  Some providers fear big babies so much they place women of size under draconian dietary restrictions or tell them not to gain any weight. However, the safety of these restrictive policies has not been well-established; some research shows that very low weight gain in obese women is harmful.31  It is unclear how much control we have over how much weight we gain in pregnancy. Instead of trying to manipulate weight gain and fetal size through caloric restriction, it makes more sense to focus on eating healthy and getting regular exercise and letting your baby be its intended genetic size.

  • Don’t estimate fetal weight
    Many care providers order ultrasounds to estimate the baby’s weight.  Research shows this is inaccurate at predicting big babies; simply the prediction of a big baby causes a strong increase in the cesarean rate, even if the baby was truly small instead.32 Choose a caregiver that does not do fetal weight estimates.

  • Labor spontaneously if a big baby is suspected
    If a big baby is suspected, many providers induce labor early, thinking it’s a good idea to start labor before baby gets “too big.” However, research clearly shows that this strongly increases the risk for cesareans instead.33  Other doctors insist on elective cesareans for big babies; research has also found this harmful.34  Big babies are more likely to be born safely if labor is spontaneous and if the mother can move around freely during labor and pushing.  Ask your provider if he or she would induce early or do a cesarean for a big baby, and if so, find another provider.

WHAT IF YOU HAVE A CESAREAN ANYHOW?

What if a cesarean becomes truly necessary during labor?  Adverse effects from anesthesia, blood clots, infections and wound complications are higher in women of size.  How can you lower your risks for these complications, should a cesarean be needed?

Before or During a Cesarean

  • Include guidelines for cesarean care in your birth plan
    Make a plan about cesarean care and discuss these requests ahead of time with your provider so everyone is in agreement on procedures, should a cesarean occur.

  • Use epidural or spinal anesthesia
    These are forms of regional anesthesia, which numb you from your ribs down. General anesthesia, which makes you unconscious, is far more risky for obese women, but sometimes hospitals do not have the longer needles needed for spinals and epidurals in very heavy women.  If you weigh significantly more than 300 pounds, request an anesthesia consult near the end of pregnancy and ask about needle sizes to be sure the correct equipment is available if you needed surgery.

  • Discuss the possibility of blood thinning medications
    Most women do not need special blood-thinners for cesareans but if you are supersized or have an inherited tendency towards blood clots, your doctor may wish to consider using an anti-coagulant preventively.

  • Insist that all personnel clean their hands before examining you
    Ask that your caregivers clean their hands before examining you during labor or after surgery.35  Gloves alone are not protective. You and any visitors should also clean hands frequently while in labor, post-surgically, or at home.  This is the first and most important step to prevent infections.

  • Insist on a low transverse (side-to-side) incision 
    Research shows that a low transverse incision offers the best outcome in women of size.36  In the past, many doctors were taught that a vertical (up-down) incision would avoid the hot, moist area under the belly and therefore decrease an obese woman’s chances of infection after surgery.  However, research shows that vertical incisions actually increase the chance of wound complications twelve-fold.37  Unfortunately, not all doctors are familiar with this research yet, so discuss the issue beforehand.  Having a low transverse incision will also decrease your chances of experiencing a uterine rupture in future pregnancies.

  • Request subcutaneous suturing of the fat layer
    Research clearly shows that closing the fat layers with extra sutures significantly lowers the chances for infection in women of size.38  On the other hand, some past research indicated that placing a drain in the area also lowered the risk for infection, but more recent research suggests that this actually increases the risk.39 Again, discuss the issue with your doctor beforehand to discuss the best protocol for you.

  • Ask about weight-based antibiotic dosing
    It seems intuitive that a larger person would require more antibiotics than a smaller one, yet weight-based dosing is often not practiced in adults.  Research is beginning to emerge about weight-based dosing,40 but many doctors are unfamiliar with the issue or simply discount its importance.  Discuss the issue with your doctor.

  • Get up and walk after surgery
    Walking soon after surgery can help lower the risk for blood clots significantly. If you find it difficult to get up, ask for help swinging your legs as a unit to the side, and ask for a stool at the side of the bed to help you get down more easily.  Don’t be afraid to ask for more personnel or an overhead trapeze grab bar if needed. Most women have trouble getting up after a cesarean, regardless of size; get the help you need to get moving.

  • Clean the area under the belly frequently at the end of pregnancy
    If you have any signs of a skin yeast infection (itching and redness in skin folds), be sure you treat these promptly at the end of pregnancy before any surgery might occur.  Many women wash the area under the belly with an antiseptic soap like Hibiclens to lower the risk for bacterial contamination,41 then use athlete’s foot spray, vaginal yeast cream, or medicated powders applied to the area. You may also wish to take probiotics (like acidophilus) to increase the number of “good” bacteria and help balance the “bad” flora, especially if you are given antibiotics in labor or have a cesarean.42 

Recovering from a cesarean

  • Keep the incision area dry and clean
    It is important to keep the incision area as dry as possible.  Lift your belly and use a blow-dyer (set on “cool”) on the incision area to accelerate the drying process.  If needed, a menstrual pad or a clean cloth diaper can be put under the belly folds, to help keep it drier.  It is not necessary to tape up the belly away from the incision; this advice is sometimes given to women of size but often results in painful skin damage instead.

  • Watch for infections, seromas, and wound separations carefully
    Women of size can experience more problems with wound healing, including infections, pockets of fluid under the skin (seromas), and wound separations.  Watch carefully for signs of problems with the wound, including redness, excessive swelling, tenderness, pus or watery discharge, foul odor, or generalized chills, sweats, or fever.  Report any problems promptly to your provider and be sure she or he takes your concerns seriously.  Be aggressive about asking for extra care if it is needed.

  • If infection develops, consider aggressive antibiotic treatment
    Some doctors inadvertently under-treat fat people when infection occurs.  Many people of size anecdotally report better outcomes with intravenous (instead of oral) antibiotics, or a more frequent dosing regimen, as well as with weight-based dosing.  Don’t be afraid to ask for an infection specialist to discuss aggressive treatment options if problems arise.

  • Ask about other infection treatment options
    If wound complications or infection occurs, some research shows that wound vacuum devices can be very effective in treating difficult-to-heal incisions.43 Other promising options may include the use of medical-grade honey, which has shown better outcomes than standard treatment in some studies.44  Daily wound care by a special nurse may also be helpful if problems develop.

  • Ensure excellent nutrition post-surgery in order to aid healing
    In the past, a liquid-only diet was imposed for several days after a cesarean, but recent research has shown better recovery with an earlier return to regular food.45 If you are diabetic or insulin-resistant, be sure to keep your blood sugar as stable as possible; high or unstable blood sugars can impede healing. Once home, emphasize excellent nutrition so the body has the nutrients it needs to repair tissue and rebuild your blood supply.  Vitamin C, folic acid, B12, iron, vitamin A and plenty of protein are particularly important during surgical recoveries.46

VAGINAL BIRTH AFTER CESAREAN FOR WOMEN OF SIZE 

If you have had a prior cesarean, must you always have cesareans?  Many doctors today strongly discourage women of size from trying for a Vaginal Birth After Cesarean (VBAC), and this plays a very significant role in the high cesarean rate in obese women.  Yet many women of size do have VBACs,47 given proper laboring conditions. The cesarean rate among women of size could be reduced significantly if more fat women were given a fair chance at giving birth vaginally after prior cesarean.  (For more information, see "Vaginal Birth After Cesarean (VBAC) or Repeat Cesarean Section?")

Remember, every cesarean puts a woman at more risk for future birth complications.  In addition, surgery is inherently more risky in obese people. Denying women of size the opportunity to VBAC puts them disproportionately at risk for these complications. Yet it can be hard to find a provider who will give a woman of size a real opportunity to VBAC.  Some practices outright forbid a trial of labor in obese women. 

Doctors often tell obese women that they have a low chance of success, an increased chance of infection, and that if an emergency were to occur, their obesity could impede the doctor getting to the baby in time.   Yet they often fail to tell women the significant risks of repeated surgeries.48

While obese women do have a lower success rate at VBAC than women of average size in some research, this is related to very high rates of induction and other interventions in those studies, just as it is with first-time obese moms.  Other research shows that the majority of women of size can have a VBAC, more than two-thirds in some studies.49  The problem is that few women of size are being given a fair chance at it. 

The tips for lowering the risk for cesarean in the first section of this article apply to women who are planning VBACs as well. The following tips may provide additional guidance for women of size who are planning VBACs:

  • Choose a provider who is truly supportive of VBAC
    Many providers pay lip service to VBAC in the beginning but change their tune as you near term.  If you start hearing negative comments from your provider about your chances at VBAC, this is a classic red flag indicating that this provider is not truly supportive of VBAC and doesn’t really believe in your body’s ability to give birth normally.  Remember, it’s far easier to switch providers early in pregnancy than later on.  Listen to your intuition and seek out another provider if your provider seems less than enthusiastic about your VBAC.  However, also remember that some women have switched providers successfully very late in pregnancy—even during labor! —and still gone on to have a VBAC.  Finding a truly VBAC-friendly provider is one of the most important things you can do in seeking a VBAC.

     
  • Avoid induction during your VBAC
    Research has found that induction lowers the chances for VBAC success substantially,50  while possibly also raising the risks for uterine rupture,51 especially in women who have never had a prior vaginal birth and have a cervix that is not soft and ready to dilate,52  or when multiple induction agents are used.53  Yet in the research, a third to half (or more!) of obese women are induced during their VBAC labors.54  It is small wonder, then, that their success rate is lower.  Yet when labor is not induced, the VBAC rates of obese women may improve.  One small study found that morbidly obese women who had a spontaneous trial of labor had a 63% VBAC rate, versus only a 45% VBAC rate in the morbidly obese group in which labor was induced.55  To raise your chances of a successful VBAC, do not induce labor unless it is clearly medically needed!  Instead, labor spontaneously and naturally on your body’s own timeline, with a provider who will not try to rush things.

  • Avoid vaginal exams, internal monitors, and breaking the waters
    Research shows that multiple vaginal exams, internal monitors, and breaking the waters increases the risk for infection.56  Because the risk for infection is increased in a larger woman with an unsuccessful VBAC,57  it is particularly important to keep your waters intact and keep foreign objects out.  Refuse those interventions as much as possible. Or, if your waters have been broken for a long time and you have had multiple vaginal exams, you may want to consider I.V. antibiotics during labor.  These things may help lower your chances for infection if you end up having another cesarean.

  • Pay attention to your baby’s position 
    If you were told that your baby was “too big” or your pelvis “too small,” you may have had an undiagnosed malposition instead. Pay extra close attention to your baby’s position and work with a care provider who knows how to help adjust baby’s position if needed during labor.58

  • Do not estimate fetal weight
    In VBACs in particular, many doctors want to estimate fetal weight, and will encourage women to have a repeat cesarean if the ultrasound suggests a big baby.  If your provider suggests your VBAC is dependent on having a small baby or wants to estimate fetal size, find another provider.

  • Don’t let your doctors scare you about “soft tissue dystocia”
    Some doctors tell women of size that there is too much fatty tissue padding the pelvis and therefore the baby can’t get out easily.  Doctors call this “soft tissue dystocia,” “fatty pelvis” or even “fat vagina.” However, little research supports the idea of a “fat vagina” preventing birth.  The one study on the topic did not find much fatty tissue in the pelvi of obese women and found no support for the common conclusion that soft tissue dystocia prevents babies from getting out.59  Many women of size who were told that they could never birth a baby normally because of a “fat vagina” have gone on to have successful VBACs.  The key is fetal position, not fetal size or maternal padding.
     
  • Accurate due dates are a must 
    Because obese women have longer menstrual cycles and tend to gestate longer, some doctors become especially nervous with a VBAC. Many require you to go into labor before 40 weeks or be forced into a repeat cesarean, but this is not necessary.60   It is very important to have an accurate due date, adjusted for the length of your cycle, and to select a care provider that does not interfere for “postdates” pregnancies, VBAC or not.

  • Space your pregnancies carefully after a cesarean
    The risk for uterine rupture may be increased in women with closely-spaced pregnancies; current research suggests allowing at least 19-25 months between deliveries after a cesarean.61  Although the length of time between pregnancies should not be used as an absolute contraindication to labor, having a longer space between pregnancies may make it easier to find a care provider supportive of VBAC.

  • Maintain full mobility in labor
    Many doctors want especially close fetal monitoring during a VBAC labor, but this tends to immobilize women and make it harder for the baby to get out easily.  Choose a provider comfortable with allowing you more freedom of movement, who promotes alternate birthing positions, and who is flexible about monitoring choices during labor.

  • Seek out emotional support for your VBAC
    Many women find that seeking out support from others who are also considering a VBAC is helpful. Organizations such as the International Cesarean Awareness Network provide valuable online and in-person support and information to women considering a VBAC.  In addition, some women may wish to consider one-on-one counseling with a therapist who specializes in birth-related issues.  This may help women deal with difficult lingering feelings from past births or fears about an upcoming birth. Many women find that emotional support of some sort is very important in helping them prepare for a VBAC.

CONCLUSION 

Articles that offer only scare tactics about pregnancy at larger sizes emphasize how high the cesarean rate is in women of size.  And it is true that the rate is high-----far too high.  But it doesn’t have to be that way.

Research from the past proves that the cesarean rate was not always so high in women of size, and that in some studies, it was no higher for larger women than for average-sized women.  That means the cesarean rate does NOT have to be so high in women of size, and we can all help normalize that rate. 

The first step belongs to consumers.  Women of size must take responsibility for their health by doing what they can to stay healthy before pregnancy, being proactive about nutrition and exercise during pregnancy, and educating themselves about the benefits and risks of labor and birth interventions.  They can benefit from using a less-interventive model of care and from choosing their care provider and birthplace wisely. 

The second step belongs to healthcare providers.  They must recognize that modern practice patterns and biases may have raised the cesarean rates much more than obesity itself.  They must stop inducing labor at such high rates, they must stop intervening for “big babies,” they must stop pressuring women of size into having unnecessary and debatable tests and procedures, and they must become more vigorous in their promotion of spontaneous natural labor for women of size.

When allowed to labor naturally and with excellent support, women of even very large sizes have given birth vaginally, with very good outcomes.   But until healthcare providers recognize the harm caused by routine interventions, the cesarean rate in this group will only continue to climb.  Women of size must demand truly size-friendly care, and that means care that does not add to their risk for unnecessary surgery.

REFERENCES

 1. Childbirth Connection. What Every Pregnant Woman Needs to Know About Cesarean Birth.  2nd Revised Edition. New York: Childbirth Connection, December 2006.  [Return to text]

 2. Ibid.  [Return to text]

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

 4. Childbirth Connection. What Every Pregnant Woman Needs to Know About Cesarean Birth.  Rev. ed. 2006.  [Return to text

 5.  Weiss JL et al.  "Obesity, obstetric complications and cesarean delivery rate---A population-based screening study."  American Journal of Obstetrics and Gynecology  April 2004.  190(4):1091-7.  [Return to text

 6. Dietz PM et al.  "Population-based assessment of the risk of primary cesarean delivery due to excess prepregnancy weight among nulliparous women delivering term infants." Maternal and Child Health Journal  2005 Sep;9(3):237-44.  [Return to text

 7. Hood DD, Dewan DM.  "Anesthetic and obstetric outcome in morbidly obese parturients."  Anesthesiology  1993 Dec;79(6):1210-8.  [Return to text]                

 8. Edwards LE et al. "Pregnancy in the massively obese: Course, outcome, and obesity prognosis of the infant."  American Journal of Obstetrics and Gynecology  1978. 131(5):479-83.  [Return to text

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

 10. Dye TD et al. "Physical activity, obesity, and diabetes in pregnancy." American Journal of Epidemiology  1997 Dec 1;146(11):961-5.  See also Oken E et al. "Associations of physical activity and inactivity before and during pregnancy with glucose tolerance."  Obstetrics and Gynecology 2006 Nov;108(5):1200-7 and Sorensen TK et al. "Recreational physical activity during pregnancy and risk of pre-eclampsia." Hypertension 2003 Jun;41(6):1273-80.  [Return to text

 11. Jensen H et al.  "The influence of prepregnancy body mass index on labor complications."  Acta Obstet Gynecol Scand  1999.  78:799-802.  [Return to text

 12.  Pistolese RA.  "The Webster Technique: A chiropractic technique with obstetric implications."  Journal of Manipulative and Physiological Therapeutics 2002 (July);25(6):E1-9.  [Return to text

 13. Childbirth Connection, “Choosing a Caregiver: Best Evidence.”  Accessed at http://www.childbirthconnection.org/article.asp?ck=10155&ClickedLink=247&area=27 on Feb 22, 2008.  [Return to text

 14. Ibid.  [Return to text

 15. Johnson KC and Daviss B. "Outcomes of planned home births with certified professional midwives: large prospective study in North America."  BMJ   (18 June) 2005;330:1416  (abstract available online at http://bmj.bmjjournals.com/cgi/content/abstract/330/7505/1416 )  [Return to text

 16. Symons JP et al. "Relationship of body composition measures and menstrual cycle length." Annals of Human Biology 1997 Mar-Apr;24(2):107-16.  [Return to text

 17. Katz Rothman, Barbara. The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood. New York: W.W. Norton & Company, 1993.  [Return to text

 18. Drugan A et al. "The inadequacy of the current correction for maternal weight in maternal serum alpha-feto-protein interpretation."  Obstetrics and Gynecology 1989 Nov;74(5):698-701 .and "Prenatal screening for fetal aneuploidy.  Clinical Practice Guideline from the Society of Obstetricians and Gynaecologists of Canada."  Journal of Obstetrics and Gynaecology of Canada  Feb 2007;187:146-61.  See Appendix B.  [Return to text

 19.  E. D. Hodnett, S. Gates, G. J. Hofmeyr, and C. Sakala, “Continuous Support for Women During Childbirth,” Cochrane Database of Systematic Reviews 2007 Jul 18;(3):CD003766  [Return to text

 20. Goer, Henci.  The Thinking Woman’s Guide to a Better Birth.  New York: The Berkeley Publishing Group, 1999.  [Return to text

 21.  Grobman WA.  "Elective induction: When? Ever?" Clinical Obstetrics and Gynecology  2007 Jun;50(2):537-46. See also: Glantz JC.  "Elective induction vs. spontaneous labor associations and outcomes." Journal of Reproductive Medicine.  2005 Apr;50(4):235-40.  [Return to text

 22. Michlin R et al. "Maternal obesity and pregnancy outcome." The Israel Medical Association Journal  2000 Jan;2(1):10-3. See also: Graves, B et al. Maternal body mass index, delivery route, and induction of labor in a midwifery caseload.  J Midwifery Women’s Health 2006;51(4):254-259.  [Return to text

 23. Usha Kiran TS et al. "Outcome of pregnancy in a woman with increased body mass index."  BJOG 2005 Jun;112(6):768-72.  [Return to text

 24.  Jackson DJ et al, "Impact of collaborative management and early admission in labor on method of delivery."  Journal of Obstetric, Gynecologic & Neonatal Nursing  2003 Mar;32(2):147-157. http://www.ncbi.nlm.nih.gov/pubmed/12685666  [Return to text]

 25. Vahratian A, et al. "Maternal prepregnancy overweight and obesity and the pattern of labor progression in term nulliparous women."  Obstetrics and Gynecology 2004 Nov;104(5 Pt 1):943-51.  [Return to text

26.  Bugg GJ et al. "Outcomes of labours augmented with oxytocin." European Journal of Obstetrics, Gynecology, and Reproductive Biology  2006 Jan1;124(1)37-41.  [Return to text

27.  Smyth RM et al. "Amniotomy for shortening spontaneous labour."  Cochrane Database Systematic Reviews.  2007 Oct 17;(4):CD006167.  [Return to text

28.  Z. Alfi revic, D. Devane, and G.M.L. Gyte, “Continuous Cardiotocography (CTG) as a Form of Electronic Fetal Monitoring (EFM) for Fetal Assessment During Labour,” Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066.  [Return to text

29.  Vallejo MC. "Anesthetic management of the morbidly obese parturient." Current Opinion in Anaesthesiology  2007 Jun;20(3):175-80.  [Return to text

30.  Michlin R et al. "Maternal obesity and pregnancy outcome." The Israel Medical Association Journal  2000 Jan;2(1):10-3.  [Return to text

31.  Edwards LE et at. "Pregnancy complications and birth outcomes in obese and normal-weight women: effects of gestational weight change." Obstetrics and Gynecology  1996 Mar;87(3):389-94.  [Return to text

32.  Parry S  "Ultrasonographic prediction of fetal macrosomia.  Association with cesarean delivery."  Journal of Reproductive Medicine  2000 Jan;45(1):17-22.  See also: Weiner Z et al. "Clinical and ultrasonographic weight estimation in large for gestational age fetus." European Journal of Obstetrics, Gynecology, and Reproductive Biology  2002 Oct 10;105(1):20-4.  [Return to text

33.  Zamorski MA and Biggs WS. "Management of suspected fetal macrosomia." American Family Physician 2001;63:302-6.   Free full-text article available at http://www.aafp.org/afp/2001/0115/p302.html. See also: Combs CA et al. "Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia."  Obstetrics and Gynecology 1993 Apr;81(4):492-6.  [Return to text

34.  Rouse DJ and Owen J.  "Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography—A Faustian bargain?"  American Journal of Obstetrics and Gynecology  1999 Aug;181(2):332-8.  [Return to text

35.  Committee to Reduce Infection Deaths, http://www.hospitalinfection.org/. “15 Steps You Can Take To Reduce Your Risk of a Hospital Infection,” accessed at http://www.pall.com/pdf/RID_protect_yourself.pdf on February 6, 2008.  [Return to text

36.  D’Heureux-Jones AM.  "Incision Choice for Cesarean Delivery in Obese Patients:  Experience in a University Hospital."  American Journal of Obstetrics and Gynecology  April 2001.  97(4):62S-63S.  [Return to text

37.  Wall PD et al.  "Vertical skin incisions and wound complications in the obese parturient."  Obstetrics and Gynecology 2003;102:952-6.  [Return to text

38.  Chelmow D et al.  "Suture closure of subcutaneous fat and wound disruption after cesarean delivery: a meta-analysis."  Obstetrics and Gynecology  2004 May;103(5 Pt 1):974-80.  [Return to text

39.  Ramsey PS et al. "Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery."  Obstetrics and Gynecology  2005 May;105(5 Pt 1):967-73.  [Return to text

40.  Bearden DT and Rodvold KA.  "Dosage adjustments for antibacterials in obese patients: applying clinical pharmacokinetics."  Clinical Pharmacokinetics  2000 May;38(5):415-26.  [Return to text

41. Committee to Reduce Infection Deaths, http://www.hospitalinfection.org/. “15 Steps You Can Take To Reduce Your Risk of a Hospital Infection,” accessed at http://www.pall.com/pdf/RID_protect_yourself.pdf on February 6, 2008.  [Return to text

42.  Pham M et al. "Probiotics: sorting the evidence from the myths." The Medical Journal of Australia.  2008 Mar 3;188(5):304-8.  [Return to text

43.  Sarsam SE, et al. "Management of Wound Complications From Cesarean Delivery." Obstetrical and Gynecological Survey 2005;60(7):462-73.  [Return to text

44.  Al-Waili NS and Saloom KY.  "Effects of topical honey on post-operative wound infections due to gram positive and gram negative bacteria following caesarean sections and hysterectomies." Journal of Medical Research  1999 Mar 26;4(3):126-30.  See also: Phuapradit W and Saropala N.  "Topical application of honey in treatment of abdominal wound disruption."  The Australian and New Zealand Journal of Obstetrics and Gynaecology  1992 Nov:32(4):381-4.  [Return to text

45.  Patolia DS et al. "Early feeding after cesarean: randomized trial."  Obstetrics and Gynecology 2001 Jul;98(1):113-6.  [Return to text

46.  Sarsam SE, et al. "Management of Wound Complications From Cesarean Delivery." Obstetrical and Gynecological Survey 2005;60(7):462-73.  [Return to text

47.  Goodall PT et al. "Obesity as a risk factor for a failed trial of labor in patients with previous cesarean delivery."  American Journal of Obstetrics and Gynecology 2005 May;192(5):1423-6.  [Return to text

48.  Silver RM et al. "Maternal morbidity associated with multiple repeat cesarean deliveries."  Obstetrics and Gynecology  2006 Jun;107(6):1226-32.  [Return to text

49.  Juhasz G et al. "Effect of body mass index and excessive weight gain on success of vaginal birth after cesarean delivery." Obstetrics and Gynecology 2005 Oct;106(4):741-6. See also: Goodall PT et al. "Obesity as a risk factor for a failed trial of labor in patients with previous cesarean delivery."  American Journal of Obstetrics and Gynecology 2005 May;192(5):1423-6.  [Return to text


50. Grobman WA, et al. "Outcomes of induction of labor after one prior cesarean." Obstetrics and Gynecology 2007 Feb;109(2 Pt 1):262-9.  See also: Rageth JC, Juzi C, Grossenbacher H.  "Delivery after previous cesarean: a risk evaluation." Obstetrics and Gynecology 1999 Mar;93(3):332-7; and McDonagh MS et al.  "The benefits and risks of inducing labour in patients with prior caesarean delivery: a systematic review."  BJOG 2005 Aug;112(8):1007-15.  [Return to text

 51. Ravasia DJ et al. "Uterine rupture during induced trial of labor among women with previous cesarean delivery."  American Journal of Obstetrics and Gynecology  2000 Nov;183(5):1176-9.  [Return to text

52.  Grobman WA, et al. "Outcomes of induction of labor after one prior cesarean." Obstetrics and Gynecology 2007 Feb;109(2 Pt 1):262-9.  [Return to text

53. Macones GA et al. "Maternal complications with vaginal birth after cesarean delivery: A multicenter study."  American Journal of Obstetrics and Gynecology  2005 Nov;193(5):1656-62.  [Return to text

54.  Chauhan SP et al.  "Mode of delivery for the morbidly obese with prior cesarean delivery: Vaginal versus repeat cesarean section."  American Journal of Obstetrics and Gynecology 2001;185:349-54. See also: Hibbard JU et al. "Trial of labor or repeat cesarean delivery in women with morbid obesity and previous cesarean delivery."  Obstetrics and Gynecology  July 2006;108(1):125-133.  [Return to text

55.  Edwards RK et al. "Deciding on route of delivery for obese women with a prior cesarean delivery." American Journal of Obstetrics and Gynecology 2003 Aug;189(2):385-9.  [Return to text

56.  Jazayeri A et al.  "Is meconium passage a risk factor for maternal infection in term pregnancies?"  Obstetrics and Gynecology  2002 Apr:99(4):548-52.  See also: Martens MG, Kolrud BL, Faro S, Maccato M, Hammill H. "Development of wound infection or separation after cesarean delivery. Prospective evaluation of 2,431 cases." The Journal of Reproductive Medicine  1995;40:171–5.  [Return to text

57. Edwards RK et al. "Deciding on route of delivery for obese women with a prior cesarean delivery."  American Journal of Obstetrics and Gynecology 2003;189:385-90.  [Return to text

58.  Shaffer BL et al. "Manual rotation of the fetal occiput: predictors of success and delivery." American Journal of Obstetrics and Gynecology 2006 May;194(5):e7-9.  See also: Reichman O et al. "Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section."  European Journal of Obstetrics and Gynecology and Reproductive Biology  2008 Jan;136(1):25-8.  [Return to text

59.  Wischnik A et al. "Does the "fatty pelvis" exist? Quantitative computer tomography studies." Zeitschrift fur Geburtshilfe und Perinatologie  1992 Nov-Dec;196(6):247-52.  [Return to text

60.  Coassolo KM et al. "Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation."  Obstetrics and Gynecology  2005 Oct;106(4):700-6.  [Return to text

61.  Bujold E et al.  "Interdelivery interval and uterine rupture."  American Journal of Obstetrics and Gynecology  2002 Nov;187(5):1199-202.[Return to text

Written by: Pamela Vireday. Thanks to: Neal Devitt, Joan Robillard, Carol Sakala, Kimberley Schmidt, and Cornelia Van Der Ziel.
Last revised: March 2008

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