Saturday, 12 January 2019

Induction: Don't Break The Waters Early

Amnihooks, which are used to artificially break a woman's waters

New research (Pasko 2018) suggests that when care providers induce high BMI women, they should NOT break the waters in early labor (early amniotomy), especially in first-time mothers.

Breaking the waters early is commonly done to speed up labor. Sometimes it is done to place an internal monitor to monitor the baby more easily, but usually it is used to intensify contractions and shorten labor. Caregivers assume that this will help obese women avoid a cesarean.

However, the results from this new study suggest that early amniotomy actually increases the risk for a cesarean instead.

Study Details

In this retrospective cohort study, women with Class III "obesity" (body mass index ≥40 kg/m2) who were being induced  (n=285) were placed into two groups.

The first group (n=107) received early amniotomy before 4 cm dilation, and the other group (n=178) received late amniotomy.

The group who received early amniotomy had double the cesarean risk of those who did received later amniotomy.

In first-time (nulliparous) mothers, the risk for cesarean was tripled with early amniotomy. 

The length of labor was not shortened in either group. So the whole justification for using early amniotomy (shorter labor, fewer cesareans) for obese women was irrelevant.

An older study (Sheiner 2000) which examined induction by early amniotomy concluded:
In order to decrease the CS rates, induction should probably start with cervical ripening techniques in order to improve the Bishop scores.
Bishop Scores are a measure of how ripe and ready for labor the cervix is. Inductions on an unripe cervix are more likely to fail and result in cesarean, especially in first-time moms. Bishop scores tend to be lower at the start of inductions in women of size, which is probably an important factor in higher weight women's induction failures. 

Women of size also tend to have longer labors and generally take longer in latent (early) labor before reaching active labor. Yet despite this, research shows that early amniotomy is used more often in higher weight women. This needs to change.

How can early amniotomy (also known as Artificial Rupture of Membranes or early AROM) affect labor? When the water is broken, the cushioning around the baby is removed. Labor becomes much more painful, and there is risk for infection. The baby may be more likely to experience an abnormal heart rate (distress). If the baby is not well-positioned when AROM occurs, then the baby can become stuck in that position and have difficult getting out (labor dystocia). These factors can add up and result in a cesarean.

The take-home message from this study on high BMI women is obvious: Avoid having your waters broken before active labor begins (now defined as at least 6 cm dilation). This is especially important if you are a first-time mother. 

Of course, parents have to remain flexible in labor; plans may need to change. For example, if baby may be in trouble and external monitoring is not working well, then breaking the water sooner to place an internal monitor may make sense. But most of the time, amniotomy should not be done early in labor, especially in obese first-time mothers.

Induction Hints

It is best to await spontaneous labor whenever possible, so always question whether an induction is truly necessary. However, it's a hard truth that sometimes induction of labor does become medically necessary. If so, there are some lessons from research that may lessen your risk for cesarean. Most apply to women of all sizes but may be particularly relevant for higher weight women.

Ask your provider about your Bishop Score; if your cervix isn't ripe (Bishop score <5), ask if the induction can be delayed. If it cannot be delayed, ask for techniques to help ripen the cervix before pitocin is started and realize that you may need more time to reach active labor. Some research suggests that Foley catheter or prostaglandin (PGE2) inductions may be more effective in women of size than misoprostol (Cytotec).

Women of size may also need a larger dose of pitocin to keep an induced labor going strong, but this must be done cautiously because too much pitocin can send the baby into fetal distress. Wait and see how you and baby respond before increasing the dosage and go slowly with any adjustments.

Be sure you have a care provider who understands that latent labor tends to take longer in higher weight women and will give you plenty of time. Many cesareans in women of size are done before active labor, and many could probably be prevented if caregivers were more patient and waited longer before moving to a cesarean.

Be sure your baby is in an optimal position for birth before the induction if possible. Chiropractic care may help align the pelvis and maximize the space for an easier birth. If the baby is posterior (facing your front) in labor, ask your caregiver for manual rotation, which clearly reduces the risk for cesarean in several studies.

Maintain your mobility as much as possible and don't get stuck in bed on your back. Make gravity work for you. Upright positions reduce the length of labor and the risk for cesarean. Special positions like hands and knees or an exaggerated Sims position may help malpositioned babies turn more easily. You can read more aboutvarious labor and birth positions here.

As discussed, don't let the caregivers break the waters until you are well into active labor. If possible, let the waters break on their own. Keeping the waters intact as long as possible can help a malpositioned baby turn more easily.

Hire a doula to give professional labor support. One study found a cesarean rate of 13.4% in a group of first-time mothers with doulas, whereas the cesarean rate in the group without doulas was 25%. The difference was even more marked in those whose labors were induced; the group with doulas had a cesarean rate of 12.5%, vs. a 58.8% rate in those without doulas.

These ideas should improve your chances of a normal vaginal birth with an induction. Of course there are no guarantees, but rest assured that with enough time and patience, a reasonably ripe cervix, a well-positioned baby, and good support, many inductions in women of size can result in vaginal births.



Reference

Am J Perinatol. 2018 Nov 5. doi: 10.1055/s-0038-1675331. [Epub ahead of print] Pregnancy Outcomes after Early Amniotomy among Class III Obese Gravidas Undergoing Induction of Labor. Pasko DN, Miller KM, Jauk VC, Subramaniam A.  PMID: 30396229 
OBJECTIVE: We sought to evaluate differences in pregnancy outcomes following early amniotomy in women with class III obesity (body mass index ≥40 kg/m2) undergoing induction of labor. STUDY DESIGN: This is a retrospective cohort study of women with class III obesity undergoing term induction of labor from January 2007 to February 2013. Early amniotomy was defined as artificial membrane rupture at less than 4 cm cervical dilation. The primary outcome was cesarean delivery. Secondary outcomes included length of labor, a maternal morbidity composite, and a neonatal morbidity composite. A subgroup analysis examined the effect of parity. Multivariable logistic regression was used to adjust for covariates. RESULTS: Of 285 women meeting inclusion criteria, 107 (37.5%) underwent early amniotomy and 178 (62.5%) underwent late amniotomy. Early amniotomy was associated with cesarean delivery after multivariable adjustments (adjusted odds ratio [aOR], 2.05; 95% confidence interval [CI], 1.21-3.47). There were no significant differences in length of labor or maternal and neonatal morbidity between groups. When stratified by parity, early amniotomy was associated with increased cesarean delivery (aOR, 3.10; 95% CI, 1.47-6.58) only in nulliparous women. CONCLUSION: Early amniotomy among class III obese women, especially nulliparous women, undergoing labor induction may be associated with an increased risk of cesarean delivery.




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Wednesday, 9 January 2019

the HAES® files: To Be Seen

by Dawn Clark

When I came home from the ASDAH conference, I was repeatedly asked about my time there. How was it? Did you have fun? Did you learn anything? Who did you meet?

The simple answer to most of those people is; “I had a great time. I really enjoyed meeting everyone. I learned so much. And I learned that I have much to learn, especially regarding marginalized people.” But the deeper answer more confusing and difficult to understand. Deep down, when I reflect on that experience, I want to shout from the rooftops; “I WAS SEEN!!”

And this, for me, has been life-changing. For one of the few times in my life, I was seen for who I am, not what I weigh. Seen as someone who had stories of worth to tell, not someone to be ignored because of their size. Seen as having value, not someone who was lazy and a loser. I could commiserate with people about doctors and therapists. When I mentioned micro aggressions, people knew exactly what I was talking about. Smiles were met with genuine smiles. I wore a bathing suit in public for the first time in almost 25 years and it was greeted with cheers and clapping. When talking about accessibility, there was agreement, not argument.

It was amazing. It was also overwhelming. I didn’t want it to end. For the first time in what seems like forever, I felt safe. I felt as if I could be more of myself with no judgement.

But, like all conferences, the ASDAH conference did come to a close, and I did have to come home—and back to the “real world.” Within 24 hours, I was back to the good (or ill) intentioned weight-loss advice. I was back to the looks on the bus—to the world judging me by what I look like, not by who I am. Instead of health providers who were actively engaged in fighting fatphobia, I had to go to a doctor’s appointment where they insisted that they needed my weight in order to give me care (It was just a blood draw). I went back to a world where my body was once again under constant surveillance—a problem that everyone seems to need to fix.

But there is now a difference. Now, when I walk through this real, fatphobic world, I am less likely to apologize if I need accommodation. I am better equipped with how to talk to my doctor earnestly about my body and what I feel is appropriate. And I feel a little less alone when doing these small steps of self-advocacy. I have been seen. I have found community. I am not alone.

This sense of community has been a gift—and it’s one I want to share with other fat folks like myself. I recently attended a women’s retreat and had the chance to talk about HAES. Now I am still new to HAES, but I decided to take a chance. I got some skeptical looks, but some women really listened, hungry to hear that they didn’t need to destroy themselves for someone else’s ideal. Maybe they, like me, felt a little less alone.

In reflecting on all this, I think the biggest difference is that I have more hope now, something I did not have much of before.

Thank you for the gift of being seen.

 


Dawn Clark was born in Iowa but has spent most of her life in beautiful western Washington. After high school (where the band uniforms never fit), she moved to Alberta,Canada to attend college. You don’t understand the meaning of cold until you have spent it in the prairies. She now lives back in western Washington and works for a major travel company. She loves to fish, cruise, crochet, cook, and is very active in her church. Through her best friend, she is learning about HAES and has started down the road of being a advocate for herself and others. She attended the International Weight Stigma conference last year in Prague and had the tremendous honor of being one of the speakers at a workshop at the ASDAH conference in Portland in August.

 



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Monday, 7 January 2019

Before You Call A Fat Person at the Gym “Brave”

Bullshit FairyThere is a concept in Fat Activism called the “Good Fatty Bad Fatty Dichotomy.” coined by Kate Harding. Basically, it’s the idea that fat people should be treated differently based on health status or performance of “health” (foods eaten, exercise undertaken etc.)

There is a more complete discussion here. The end result of this is to create hoops that fat people have to jump through in order to be treated with basic human respect by the person who is creating the hoops and judging how well fat people are jumping through them.  It’s bullshit, of course, but it’s ingrained in our culture and it comes out often in memes that are well meaning, but messed up.  Here are some that I’ve corrected:

why-would-you-make-fun-of-a-fat-person

And while we’re on the subject –  fat people’s bodies are not “problems” to be “fixed.” Extra shame on the person who created this for besmirching the good named of Captain Picard.

Original pictures is a fat person on a machine at the gym, photographed from behind with the caption "Making fun of a fat person at the gym is like making fun of a homeless person at a job fair." This image and caption are crossed out, the image is copied on the right with the new caption "Making fun of a fat person or a homeless person is a shitty thing to do no matter where they are. Don't be an asshole."

Another version of this compares fat people in the gym to sick people at the hospital, which is ridiculous since it pathologizes fat bodies and suggests that they have some special need to go to the gym to “fix” themselves that thinner people don’t. Super extra shame on the person who created this for using homeless people as a tool in their bullshit good fatty argument.

goals-based-on-size

This person took the popular meme “confession bear” and turned him into “stereotyping, patronizing bear.” As Fat Activists and Health at Every Size practitioners who have been asked intrusive and clueless questions by perfect strangers at the gym (like “how much weight have you lost?”) can attest, this is crap. Don’t make assumptions about people based on their size – not at the gym, not anywhere else.

run-or-dont

Ugh.  People who are running are not morally better than people who are sitting on the couch. People who run faster are not morally better than people who run more slowly. We do not have to be “better” than someone else in order to be happy with ourselves.  I blogged more about this one here.

Or maybe you’ve seen the letter written to a fat person who was, one might assume, just trying to run around a track and not trying to be a muse for someone who wants a medal for not being as shitty and fatphobic as they possibly could.

As always, think before you meme and when you see memes that put some people down as a way to prop other people up you can remind the people who post it that it’s not necessary and, in fact, it’s extremely harmful. No more good fatty bad fatty BS please.

Did you like this post? If you appreciate the work I do, you can support my ability to do more of it with a one-time contribution or by becoming a member.

Like this blog?  Here’s more cool stuff:

The New Year Sale is on! – Give the gift of body love and/or get your own year off to a Size Acceptance and Health at Every Size start with discounts on books, online programs, and DVDs to get your year (or the year of the people you’re gifting them to) off to a great start, and save you some money! (Dances With Fat Members get even bigger discounts, so make sure to use your link on the member page.)

Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members – register on the member page)

Non-Members click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m (still!) training for an IRONMAN! You can follow my journey at www.IronFat.com or on Instagram.

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Thursday, 3 January 2019

Three Easy Ways to Know If A Diet Study Sucks

LiesOne of the most frustrating things about weight loss (so-called) research, is that the media often covers any weight-loss study as if the conclusions they claim have been proven beyond a shadow of a doubt when, in fact, much of the research is embarrassingly poor – often for profit by the weight loss industry. I get a lot of questions about how to evaluate studies, and it’s a topic that can get complicated fast, but here are some easy ways to evaluate a study about a purported weight loss technique

1. Did they take their time?

This is covered in greater detail here, but basically almost everyone can lose weight short term, but almost everyone gains it back within five years. So if a study doesn’t follow subjects for at least 5 years then it’s not a valid look at whether a weight loss method works for anything more than the short term.  (This is especially important with diet companies like Noom which both claims to be a “brand new” way to diet, and simultaneously claims that they offer “permanent” weight loss. Where are they getting their long-term data? If they are “brand new,” how many people who lost weight on their program could have died having kept it off?

2. Are these people?

When it comes to the study subjects, you might think that you should start with questions like “were the study participants diverse?” But you actually need to start with the question “were the study participants human?”

I can’t even count how many times that I’ve read an article about a study and asked myself “Wait – was this rats?” and then looked it up to find that it was, in fact, done with rats as subjects. And the reporter didn’t bother to mention that while droning on about how effective this new diet is.

3. Who are these people?

If the researchers did study humans, we then have to ask how representative the sample  (the group of people who participated in the study) is. Which is to say that who they study determines to whom the study results can be appropriately extrapolated. So if they only studied white cisgender dudes, that’s the only group we can expect the results to apply to (and that’s only if they had a large enough sample – included enough white cisgender dudes – to rule out individual differences.)

A number of assumptions in medicine that have been proven false (like the idea that heart attacks have the same symptoms regardless of gender) were based on researchers’ habit of studying 150-pound cisgender white men and then extrapolating those results to literally everyone. Many studies (not just weight loss, but all studies) under-represent People of Color and completely fail to represent Trans and Non-Binary people at all. Representative samples are a huge issue, and that’s not even getting into the variables they don’t control for. So you are looking for a study with a large, diverse sample.

To date, there is not a single study where more than a tiny fraction of people were able to maintain significant weight loss long-term, so don’t be suprised if you find the weight loss studies you are analyzing are lacking in study methodology, and subject success.

If you are interested in checking out an exhaustively researched paper supporting a departure from diet culture, I recommend you head over here.

Did you like this post? If you appreciate the work I do, you can support my ability to do more of it with a one-time contribution or by becoming a member.

Like this blog?  Here’s more cool stuff:

The New Year Sale is on! – Give the gift of body love and/or get your own year off to a Size Acceptance and Health at Every Size start with discounts on books, online programs, and DVDs to get your year (or the year of the people you’re gifting them to) off to a great start, and save you some money! (Dances With Fat Members get even bigger discounts, so make sure to use your link on the member page.)

Wellness for All Bodies ProgramA simple, step-by-step, super efficient guide to setting and reaching your health goals from a weight-neutral perspective.  This program can be used by individuals, or by groups, including as a workplace wellness program!
Price: $25.00 ($10 for DancesWithFat members – register on the member page)

Non-Members click here for all the details and to register!

Book and Dance Class Sale!  I’m on a journey to complete an IRONMAN triathlon, and I’m having a sale on all my books, DVDs, and digital downloads to help pay for it. You get books and dance classes, I get spandex clothes and bike parts. Everybody wins! If you want, you can check it out here!

Book Me!  I’d love to speak to your organization. You can get more information here or just e-mail me at ragen at danceswithfat dot org!

I’m (still!) training for an IRONMAN! You can follow my journey at www.IronFat.com or on Instagram.

If you are uncomfortable with my offering things for sale on this site, you are invited to check out this post.



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Wednesday, 2 January 2019

Hospitals with Midwives on Staff Have Better Outcomes


Here are two recent studies showing that hospitals with midwives and doctors practicing together ("interprofessional" centers) have better outcomes than hospitals with only doctors. One study is on first-time mothers (nulliparous), and the other study is on women who have given birth before (multiparous), to separate out the possible effects of parity.

In first-time mothers, women were much less likely to be induced or have oxytocin augmentation of labor in interprofessional/collaborative centers. The cesarean rate was 12% lower in interprofessional centers too.

For multiparous mothers (multips), women were again much less likely to be induced or have augmentation of labor in interprofessional centers. The first-time cesarean rate was 36% lower, and the Vaginal Birth After Cesarean (VBAC) rate was 31% higher than in institutions with only doctors. Neonatal outcomes were similar between the two types of centers.

The implication here is that not only do midwives lower the rates of interventions without endangering outcomes, they also influence the hospital culture in a positive way. Doctors who work with midwives tend to be more flexible about interventions, less likely to push a cesarean without need, and more likely to support VBACs.

If you are considering a hospital birth, try to choose a hospital with both doctors and midwives on staff, one with low overall cesarean rates, and strongly consider hiring a doula for professional labor support. Most women can safely be attended by a midwife, so make that your first choice if you can. If a risk comes up that means that you need to see an OB or high-risk maternal fetal medicine (MFM) specialist, the midwife will refer you to one, probably one that is supportive of the parents' birth wishes whenever conditions allow.



References

Birth. 2018 Nov 11. doi: 10.1111/birt.12407. [Epub ahead of print] Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study. Neal JL, Carlson NS, Phillippi JC, Tilden EL, Smith DC, Breman RB, Dietrich MS, Lowe NK. PMID: 30417436
...Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). .. women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.
Birth. 2018 Nov 9. doi: 10.1111/birt.12405. [Epub ahead of print] Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study. Carlson NS, Neal JL, Tilden EL, Smith DC, Breman RB, Lowe NK, Dietrich MS, Phillippi JC. PMID: 30414200
...We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). .. women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.


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