January 19, 2024 • 41 mins
Embark on a poignant exploration of a topic that's often cloaked in stigma yet crucial to maternal health: obesity and BMI during pregnancy. Join me, Florence, on the ObsPod, as we unravel the intertwined issues of weight management and prenatal care, delving into the NHS classifications that inform how expectant mothers with a BMI over 30 navigate their unique journey. This episode promises insightful discussions and a deeper understanding of the practical applications and limitations of BMI as a standard of health, particularly during such a life-changing period for women.
This candid discussion also brings to light the specific hurdles and advancements that shape the experiences of overweight women in pregnancy, from ultrasound imaging difficulties to anesthesia considerations during childbirth. We'll reflect on the latest innovations, such as the TraxiDrape and Alexis retractors, which have significantly improved caesarean section outcomes for both mothers and healthcare professionals. Throughout our conversation, the emphasis remains on fostering empathetic communication, empowering women to feel informed and supported—a commitment that transcends the clinical environment and touches the heart of human connection.
Want to know more?
https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/care-of-women-with-obesity-in-pregnancy-green-top-guideline-no-72/
https://www.nhs.uk/health-assessment-tools/calculate-your-body-mass-index/calculate-bmi-for-adults
https://www.youtube.com/watch?v=3Xus_vsiZ5c
https://www.youtube.com/watch?v=dgN_0iffzzI
Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
If you have found my ideas helpful whilst expecting your baby or working in maternity care please spread the word & help theobspod reach other parents or staff who may be interested in exploring all things pregnancy and birth.
Keeping my podcast running without ads or sponsorship is important to me. I want to keep it free and accessible to all but it costs me a small amount each month to maintain and keep the episodes live, if you wish to contribute anything to support theobspod please head over to my buy me a coffee page https://bmc.link/theobspodV any donation very gratefully received however small.
Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife, maybe birth fascinates
you, or you're simply curiousabout what exactly an
obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:56):
Today I'm going to tackle atopic for which I've had a lot
of requests.
Many people have got in touchand said Florence, can you do an
episode on obesity?
Or Florence, can you do anepisode on BMI body mass index?
And you'll be able to tell fromthe fact that I've called this
(01:22):
topic overweight, that I'm quiteconflicted about this topic.
I've thought long and hardabout what to call this episode,
and I think this is probablygoing to be one of a series of
episodes on this topic, becauseI've come across a few people
(01:42):
that are specialising in thisarea or doing research, and I'm
hoping to get them to come onthe podcast and talk to me soon.
In the meantime, I thought I'ddo a little bit of a kind of
nuts and bolts and my thoughts.
When I see a woman who'sclassified as overweight in the
(02:04):
antenatal clinic.
I think we should start bythinking what do we mean by
overweight?
And it's true, we do tend touse body mass index, or BMI, as
the best guide of that.
And in thinking about thistopic I've read a few papers
(02:26):
that dither a bit about is BMIactually the best way of
assessing obesity in apopulation?
And the answer is it's notgreat, but it's the simplest and
sort of best fit that we canuse.
But we do need to bear in mindit doesn't work for some
(02:49):
populations.
For example, there are someethnic differences in its
application.
There are some differences inage, so it's less good for the
very young or the very old.
And you could say well, thatdoesn't apply to an obstetric
(03:11):
population in the main, but itdoesn't really take account of
muscle mass, bone density andall sorts of other factors.
So the starting point is BMI isthe best thing we've got, but
(03:33):
we need to remember it's notgreat.
Then what do we classify asbeing overweight?
If you look at the NHS website,then there's some nice little
ranges.
So BMI of 20 to 25.
Yay, that's green, you're okay.
(03:56):
There's a BMI of 25 to 30.
You're considered overweightand that's where I sit, being
brutally honest.
And then you get above 30.
It starts to talk about obesity.
(04:16):
So, strictly speaking, if we'regoing with the general NHS
calculation, anyone with a bodymass index of over 30 is
overweight In pregnancy.
This can be complex because wealso need to think when are we
(04:40):
weighing people?
I mean, generally, a weight istaken at the beginning of
pregnancy, at bookingappointment, but people's weight
varies hugely during pregnancyand often when we're thinking
(05:00):
about weight and BMI inpregnancy, it might be at the
end of pregnancy when we'reperhaps on the labour ward and
thinking about whether or notthis woman needs to go to the
operating theatre, and we'lloften have a conversation about
the BMI.
Was this at booking?
But it's probably more likethat now, because women put on
(05:25):
an incredibly variable amount ofweight during pregnancy.
Right?
So you might think super simpleanyone over a BMI of 30 is
overweight and we need to dodifferent things for those women
, or do we?
Well, there are things that weknow are a bit more common in
(05:50):
women with a higher body massindex.
But if you look at the RCOGgreen top guideline on obesity.
That's what they call it.
You'll see that is veryconfusing for staff.
(06:10):
I've put a link in the shownotes and I'm not going to
comprehensively go through everysingle point on it now, but
it's 45 pages.
You need to do one set ofthings if a woman's BMI is over
30, needs to do another set ofthings if it's over 35, need to
(06:30):
do another set of things if it'sover 40, and another set of
things if it's over 50.
So this is very confusing forstaff, but equally it must be
very confusing for women.
One of the things I find mostdifficult is when a woman turns
(06:53):
up in obstetric clinic at 16weeks.
So she's had her booking, she'sseen her midwife and she's been
screened by all the questionsand things that have been asked
and deemed so-called high riskand I say so-called inverted
commas because I don't reallylike that terminology but she's
(07:14):
been deemed to need someobstetrician input.
That would be a better way ofdescribing it.
When I see a woman at thatpoint in clinic, I always look
at the kind of tick boxchecklist that the midwives
complete at booking, because Ineed to figure out why is this
(07:34):
woman in the obstetric clinicBecause hopefully, a totally
uncomplicated woman with nomedical problems and no problems
in her pregnancy wouldn't turnup in my clinic.
She would be being cared for byher midwife.
So in some situations I turn tothat tick box and I can see the
(07:55):
only thing ticked is BMI.
Now I don't know about you, butmany of us are quite sensitive
about our weight and our body.
We live in a society which isvery focused on diet culture and
there's a fantastic TEDx talkby a dietician, which I will
(08:16):
also include in the show notes,which discusses this.
So starting a conversation witha woman it has solely been sent
to see me because of her weightis a very sensitive topic and I
find it difficult.
Does she know why she's beensent to see me?
(08:39):
Is she aware that it's becauseof her weight?
Some women are very frank andopen and they understand and
they will open up theconversation and then we can
have a good conversation withoutme feeling that I'm insulting
and defending them.
And I'm assuming that's becausethey're aware, but also because
(09:07):
the midwives had a conversationwith them about the fact that
there are some slightlydifferent things we might need
to offer them during thepregnancy.
But for some women.
I've got to start and broachthe conversation, and that can
be difficult.
(09:29):
If you look at the tick box inour notes and also at the RCOG
green top, on which it's based,much of what we're supposed to
discuss with women in thissituation is the risk of this,
the risk of that.
You've got a higher risk ofblood pressure problems.
You've got a higher risk ofgestational diabetes.
(09:50):
You've got a higher risk ofvenous thrombore embolism or
blood clots.
You've got a higher risk of abig baby and perhaps a more
difficult birth as a result.
Wow, I mean, put yourself inthe shoes of the pregnant women.
(10:11):
You're pregnant, you're excitedand you go and see the doctor
and all the doctor wants to talkabout, or the midwife, is the
risk of this, the risk of that?
You'd probably feel quitescared.
I distinctly remember aconsultation I had with a woman
in which she said to me I knowI'm at a higher risk of all
(10:39):
these things, all thesecomplications, but at this point
in time there's nothing I cando about it.
I'm already pregnant, I'm inthis situation and now the
maternity team are just makingme feel petrified.
I need help to get through thissafely, me and my baby and
(11:05):
telling me I have all thesedifferent risks really isn't
helpful.
And it wasn't like I hadn'tthought about it in that context
, but her talking to me likethat really made me think, and
so I really try and unpick andhelp women understand.
You've got a slightly higherchance of this, but therefore
(11:28):
we're going to offer you a testfor that.
You've got a slightly higherchance of that, but it's okay,
we can offer you this treatmentfor it.
And I do frequently tell womenthat the most likely outcome is
that you're not going to haveany of these things and
(11:48):
everything is going to becompletely fine, but you're
going to get to see me and themidwife and have a few extra
bits and bobs given to you.
And it's a tricky one becauseit's part of that paternalism or
not paternalism, isn't it?
Do we keep to ourselves thatthe woman has all these risks
and issues or do we share withher so that she's well informed
(12:12):
about her own health and that ofher baby?
And I think there's a goodargument for sharing all these
things, because she knows herbody best, she knows her baby
best, and if we can make heraware of all these issues in a
sensitive way, then she can bevigilant and be watching out for
any changes in how she feels orhow her baby is, so that we can
(12:36):
tweak things accordingly andpick things up early if they do
happen.
But it's got to be done in asensitive way.
So if you're overweightdepending on how overweight you
may be offered a glucosetolerance test to check for
(12:56):
gestational diabetes.
You may be offered some bloodthinning injections,
particularly in the throatthinning injections,
particularly in the thirdtrimester, from 28 weeks, to try
and reduce your chance ofgetting a blood clot in your
legs.
You're likely to be offered a36 week scan growth scan because
(13:17):
it's a little bit harder for usto assess the size of your baby
by measuring the fundal height,the top of the womb, in
centimeters, and we know thatwomen who are heavier are more
likely to have a macrosemic orbigger baby.
It may also be harder for us todetermine which way up your
(13:40):
baby is.
So doing a scan at 36 weeksmeans we can plan birth and talk
to you about your options ifthe baby happens to be in a
different position.
So we're checking the growthand size of the baby and its
presentation, what position it'sin, one of the other key things
(14:01):
we need to think about whenwe're thinking about blood
pressure and chance of bloodpressure issues is measuring the
blood pressure correctly.
The size of the blood pressurecuff depends on the
circumference of your upper arm.
So early on in pregnancy, staffshould be measuring and
(14:26):
checking your upper arm todecide which blood pressure cuff
you need, because if your armis bigger you need a large cuff,
not the standard cuff.
Otherwise we won't be able toget accurate readings of your
blood pressure.
So I've definitely hadsituations in which women have
(14:48):
been thought to have raisedblood pressure and then, when we
do it with the correct largecuff that fits their arm
appropriately, actually theirblood pressure is normal.
So something really importantyou can do as a pregnant woman
is, if you know you need a largecuff and the member of staff
(15:09):
tries to take your bloodpressure with the smaller cuff,
tell that member of staff.
Actually the midwife usuallyuses a large cuff.
I need a large cuff andsometimes we'll write on a
woman's notes large cuff so thatwe know what we're using, so
that we can get those accuratemeasurements.
(15:31):
There are some additional thingswe will suggest you might take
in early pregnancy.
Again, depending on your weight, we may recommend that you take
aspirin 150 milligrams once aday from 12 weeks and that's to
reduce your chances of growthrestriction in your baby and
blood pressure problems for you.
(15:52):
And we may also recommend ahigher dose of folic acid.
So you know, it's recommendedwomen take folic acid if they're
trying to conceive or in thefirst 12 weeks of pregnancy.
So women with a higher weightneed a higher dose of folic acid
(16:12):
five milligrams and also somevitamin D supplementation
because you're more likely to bevitamin D deficient.
So either we or your GP willsuggest that you're taking these
things from early on in thepregnancy.
So there you go.
(16:34):
You've booked in, you've seenyour midwife, you've been given
some extra supplements, you'vebeen told a bit about what to
expect during your pregnancy andwhat we're going to offer you.
Happy days.
Then you go for your scans.
Now I've already mentionedperhaps doing an extra 36-week
(16:54):
scan fantastic, but actuallyscanning through a bigger layer
of body fat is quite challengingand the images we get may not
be as clear and good as if youwere less heavy.
So in our guidance itrecommends that we talk to women
(17:20):
about the limitations ofultrasound and that the views of
the baby may be limited by theexcess tissue and it makes sense
that it's harder to see becauseyour ultrasound waves are
having to go through more layers, so there's a different depth
(17:43):
from the probe to the baby thanif the woman was thinner.
And we do need to accept thatultrasound for any woman is
never 100% accurate.
Some things are harder to seethan others on scan.
So there's always a bit of acaveat that we may or may not be
(18:05):
able to see all issues on scanantinatally for any woman.
So I'm not sure how helpful itis to tell a weight woman that
actually her scans are going tobe harder or we may be more
likely to make a mistake.
It feels a little bit like whenyou have those things on
(18:27):
television, particularly inAmerica, where they say, oh,
take this drug or buy this thing, and then they read out very,
very fast some terms andconditions about this investment
may go up or down and you mayor may not get all these side
effects or this, and that mayhappen.
It's kind of a bit of anembarrassing cover.
All Well, you're overweight, sowe might botch it up.
(18:51):
Well, that's not really verytrust inspiring or good at
building a relationship betweenthat woman and her maternity
care provider.
So I think it is important thatwe're realistic with women,
that we may not be able to seeeverything on scan and that may
be a little bit harder for womento have more adipose tissue,
(19:14):
but actually the same is truefor any woman having an
ultrasound scan and I'm not suretelling people they've got a
higher chance of us missingsomething is necessarily helpful
.
Okay, so you've got threepregnancy.
Now we come to birth planning.
This is a minefield and I seequite a few women in my clinic
(19:44):
who want more personalized careplanning who fit into this
situation.
The guidance is that we shouldsuggest all obese women to give
birth on an obstetric unit.
There are rules and I'm callingthem rules because it is
(20:06):
guidance but people behave as ifthey're rules about not using
the birthing pool, which, let'sface it, there's no evidence for
this whatsoever.
It's sort of health and safetygone mad type situation in which
we're really worried.
What if the woman collapsed inthe pool and then it was really
(20:29):
difficult to get her out andwe'd need a hoist, and it's a
nightmare for the staff and wedon't want her to drown in the
pool if she collapses, butactually is she any more likely
to collapse than any other woman.
No, it's just a bit morelogistically difficult to get
her out.
So don't get me started on thatone.
(20:56):
Then we have the difficulty ofanesthetics.
Now it's true that giving ananesthetic to a pregnant woman a
general anesthetic that it isis very high risk For lots of
reasons.
Anesthetic is less safe inpregnancy.
A woman may have significantswelling around her throat, her
(21:20):
neck, which makes it harder forour colleagues to intubate.
They've also got more acidreflux coming back up their
gullet.
They've got a large pregnantuterus pressing up on their
lungs and compressing theirmajor blood vessels.
There are all sorts of concernsabout anesthetizing pregnant
(21:42):
women, and then that is evenworse if you're pregnant and
overweight.
The reason that this isrelevant is that regional bloc
such as spinal or epidural,which is what we would prefer to
use in labor, is much harderpotentially to cite in a woman
that's overweight, because youjust need to feel down her back
(22:06):
and between her vertebrae andnowhere to put their needle.
The needle's got to go muchdeeper and it's much harder to
identify the spaces between thevertebrae.
So, for many reasons andconcerns and fears from our
anesthetic colleagues, oftenwomen that are overweight are
(22:30):
recommended to have an epiduraljust in case.
Sometimes they're even toldhave an epidural.
You might not want an epidural,but if you have an epidural and
we cite it, even if we don't putanything down it, then if
there's an emergency you'realready.
We can top it up, we can use itin an emergency situation and
(22:53):
we're not struggling where wecan't get a spinal into your
back and therefore we're notthen increasing the chances of
you needing that more risky ordangerous general anesthetic.
And there is some rationale tothis, because if you're in an
(23:14):
emergency situation and you'vegot a distressed baby that's at
risk and you need to quicklydeliver the baby, then actually
the speed of anesthetic and theability to be able to give that
anesthetic is quite ahigh-pressurized situation.
So we don't want to be endingup in a situation where the
(23:36):
anesthetists can't get in anappropriate anesthetic, the
baby's at risk and, god forbid,something happens to the baby
because we're unable to safelyanesthetize the mother.
So that's how the thinking goes.
But if you have an epiduralcited, then that restricts you
(23:59):
immediately.
You can't use a birthing pooland I've already discussed why
we might be worried about youusing a birthing pool.
But is it right that we'rerestricting women's choices in
this way.
I had a situation in which awoman wanted a home birth.
She'd had a home birthpreviously, she was overweight
(24:21):
and actually the only reasonshe'd had a home birth
previously is the midwife doingher booking had made a mistake
in calculating her body massindex, so it looked like she was
lighter than she was.
So the woman was baffledbecause she came to us and said
I'm exactly the same weight as Iwas with my last baby.
You were perfectly happy for meto have that baby at home.
(24:43):
Why is there now an issue?
So we're really restrictingwomen who weigh more in their
choices around birth, birthplacepain relief options, and I
don't think that's right.
There's no evidence for it.
It's dealing with obstetric andanesthetic and midwifery
(25:08):
anxiety and fear about somethinggoing wrong, and it's
restricting women's choices in away that is probably not
rational and certainly is notevidence based.
Yes, we are the people thathave seen things when they go
badly wrong, and the womanhasn't, but should we be
(25:30):
pressing every woman who'soverweight into having an
epidural?
Then there's the business ofmonitoring the labor.
It's much harder to monitorsomeone with a continuous CTG
cardiotocular graph if they'reoverweight.
Again back to the ultrasoundthing.
(25:51):
There's a bigger layer of themom's body to go through before
those ultrasound waves hit thebaby's heartbeat and bounce back
so often.
It's harder for us.
So then we say we should put ona fetal scalp electrode.
We should attach a littleelectrode to the scalp of the
(26:14):
baby.
We can monitor the baby moreeffectively continuously and the
woman will be able to movearound.
And that's absolutely true andthat's great if you definitely
need continuous monitoring.
But do we have a question?
We recommend continuousmonitoring and if you go back
and listen to my excellentconversation with Dr Kirsten
(26:38):
Small in episode 157, you'll seethat there's no evidence that
actually we should becontinuously monitoring the
baby's heartbeat.
And actually for women that areoverweight, maybe listening in
intermittently would be easier,would be better for them, would
be better for us.
Actually, all that loss ofcontact that we're worrying
(27:02):
about on a continuous CTGwouldn't matter if we were
listening in every 15 minutes.
The woman might be morecomfortable, more able to move
around, therefore more able tohave the birth that she wants,
and we wouldn't be fussing aboutthe fact that we're not
continuously listening in to thebaby.
So the labour care of women whoare overweight, I feel is quite
(27:26):
messed up.
A lot of what we're suggestingis not evidence-based but more
anxiety-based.
It is true when you look atM-Base that obesity plays a role
(27:48):
.
It often crops up in reports asa risk factor for both women
and their babies.
So we need to be conscious ofthat.
But medicalising everything Idon't believe is necessarily the
answer.
And don't get me wrong choicegoes both ways.
(28:10):
I can clearly remember thefirst time a woman with a body
mass index of over 40 came andasked me for a maternal request
cesarean.
She felt for her that acesarean birth was what she
wanted and what she needed tomeet her baby in the best
possible way.
(28:30):
And I remember it because I washesitant.
I was thinking that you're moreat risk of complications,
you're more at risk of a woundinfection, you're more at risk
of blood clots in your legs.
I've seen some really nasty,difficult wound infections that
(28:55):
have taken weeks or even monthsto heal in women who are
overweight, not least becausethe panacea that sort of flap of
body fat, that kind of flopsover where we make the incisions
sometimes can make it verydifficult to keep that area
clean and dry while the wound ishealing.
(29:17):
So I really struggled in my mindwith this request, but I
rationalised it to myself thatBecause of her weight, why
should she have any less choicethan anyone else?
If I explain the risks to herand that her personal risks are
(29:38):
perhaps a bit different fromsomeone else's personal risks,
then she has the right to choosejust as anyone else does.
If a woman can come in and askfor a caesarean birth, then that
should be true of every woman.
It shouldn't be that if you'rethinner, yes, you can choose a
(29:58):
caesarean.
If you're more overweight, no,you can't.
That's discrimination.
And that brings me on togadgets.
I'm not a big fan of gadgets ingeneral, but there have been
some fantastic advances inthings we use to operate.
(30:21):
We do caesareans for people whoare more overweight, and this
has made a big difference to me.
It used to be, if we had a womanwho was very overweight, that
rather than having a surgeon andan assistant, we would need a
surgeon and two assistants.
Like I said, there's often somebody fat that needs holding
(30:46):
back so we can get in to theabdomen, get in to see where the
womb is.
So you need someone whose jobit is to do that, and it's
physically very demanding joboperating on someone who's
overweight.
You've got to go through asignificantly thicker layer of
(31:07):
tissue before you reach therectus sheath the muscles that
hold the abdomen together andthen get in to the abdomen and
be able to see the womb.
Getting a baby out through thatdepth of tissue is difficult.
You need space and it'schallenging.
(31:28):
You'll come out of that surgeryphysically exhausted from what
you're doing, as well asmentally, because you've got to
concentrate.
And that sounds bad.
Like we don't concentrate whenwe're operating.
Yes, we do, but it's a morechallenging operation than if
the woman had less body fat.
(31:51):
But now we have some newinventions.
So there's a great thing calleda traxidrape.
It's like a giant sticky thingand you place it on before you
clean the woman's abdomen andstart your cesarean.
So she's had her anaesthetic,she's lying on the table and you
put on the traxidrape and it'sthis massively sticky thing and
(32:14):
it pulls everything up out ofthe way.
So you no longer need thatsecond assistant, that person
whose entire job is to pull backthat body fat, because this
traxidrape, this sticky thing,does it for you.
It's a little bit fiddly toapply the first time you do it
(32:36):
and you might think that youcould only use this for a
planned cesarean birth, but Ihave done a category one
cesarean where I've beenincredibly worried about the
baby, where I have used the timewe've been waiting for the
anaesthetic to work, which it'sonly a few minutes to get the
midwives to apply the traxidrape.
(32:57):
And at the time the midwiveswere like, why are we faffling
around with this?
It's a massive emergency.
But I've explained to them thatknife to skin from when I start
the operation to when I get thebaby out will be significantly
quicker if we spend this timewhile we're waiting for the
(33:18):
anaesthetic to be effective,applying that traxidrape.
And indeed it enabled me to doknife to skin to baby out in one
or two minutes.
It's genius invention.
The other thing we have that'snew is called an alexis
retractor.
It's like a giant ring or tworings joined together with
(33:45):
basically what looks like aplastic bag, and once you've
opened the abdomen you pop thatin and again it holds everything
back and everything open sothat you can clearly see the
womb and get your hand in todeliver the baby without having
multiple assistants having tohold everything back for you
(34:06):
Again, genius.
So now when I do a caesarean fora woman who's significantly
overweight.
I can use the Traxidrape, I canuse the Alexis.
It makes my operation much lesschallenging and it makes it
safer, because it's easier forme to get in focus on what I
(34:27):
need to do and get that baby outsafely.
At the end of the surgery wecan apply my final favourite
gadget, the Pico dressing.
And the Pico dressing is aspecially designed dressing that
has negative pressure.
So it's a dressing that you puton over the caesarean wound and
(34:50):
you seal it on with lots ofstrips of sticky stuff, a bit
like cellotape, and then it hasa little battery pack which you
activate and it creates negativepressure which makes it a bit
harder for the bacteria to grow.
That means that when the womanstands up and that excess body
fat flops over the wound, thewound is protected, it's clean,
(35:14):
it's covered and there'sevidence that you're less likely
to get a wound infection andit's more likely to heal better.
So when we're doing our who, oursafety briefing that I
discussed in episode 104, wewill discuss this woman.
She's got a raised BMI.
(35:35):
These are the issues and theseare the pieces of equipment we
want the theatre staff to getready.
We'll discuss whether we'regoing to use the Traxy Drape,
the Alexis and the Pico dressingand in that way, hopefully, we
can offer women who areoverweight, who either want or
need a caesarean birth, thesafest possible way of having
(35:59):
that birth with hopefully lesschance of complications.
And for me, this isrevolutionised how easy or
difficult it is to operatesuccessfully on these women, and
it's important because thereare increasing rates of obesity
(36:24):
and weight issues in ourpopulation.
When I started out inobstetrics, I remember we were
shocked if we saw a woman whosebody mass index was over 40.
And those women had to go andsee an anesthetist and have
special care.
Now we're in a situation wherethe goalposts have moved and now
(36:45):
this applies to women whosebody mass index is over 50.
So, whilst weight is asensitive issue, it is also a
health, population issue, and soit's really important to have
these tools at our fingertipsand have the experience of
(37:08):
operating on women of all shapesand sizes so that, in an
emergency situation, you knowexactly what you can do to
minimise the risk for mother andbaby, make it as safe as you
possibly can.
So that's my little whistle stoptour of overweight.
As I've said, it's a topic I'mprobably going to come back to,
(37:35):
and I haven't given you acomprehensive guide.
I've just given you my thoughtsand experiences.
So, from my zesty bit, I thinkthe key thing is, when you're
talking to women who areoverweight, think about what
your biases are.
(37:55):
Think about how much of whatyou're telling them is because
we, as health professionals, areanxious and fearful.
And remember that actually thecare we're offering should be
for her, not because of us, andtry and have really good but
(38:18):
sensitive conversations so thatshe knows what our anxieties are
but doesn't feel helpless.
Make her feel that she iscentral to that team that are
monitoring the health of her andher baby and that we're there
as a supporting act, rather thanmaking her feel guilty and
(38:39):
ashamed just because she is theshape and size she is.
And if you're pregnant andexpecting a baby and you're on
the slightly bigger side, don'tbe frightened to have
conversations with your healthprofessionals.
Give them the advice they'regiving you and make sure you're
(39:04):
making the right choices, foryou Know that we really are
trying to have your bestinterests at heart, but it
doesn't always come out theright way.
I hope this has given you foodfor thought that might help you
with some of these conversations.
Thanks for listening.
(39:25):
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it'd be fantasticif you could subscribe, rate and
review, on whatever platformyou find, your podcasts, as well
as recommending the OBS pod toanyone you think might find it
(39:45):
interesting.
There's also tons of episodesto explore in my back catalogue
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(40:10):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(40:33):
the programme notes, where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email metheobspod at gmailcom.
(40:54):
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and by chance, you do
(41:16):
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it free,via my link, to buy me a coffee,
don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
Hello, my name is Florence.
Welcome to the ObsPod.
I'm an NHS obstetrician hopingto share some thoughts and
experiences about my workinglife.
Perhaps you enjoy Call theMidwife, maybe birth fascinates
you, or you're simply curiousabout what exactly an
obstetrician is.
You might be pregnant andpreparing for birth.
(00:21):
Perhaps you work in maternityand want to know what makes your
obstetric colleagues tick, oryou want some fresh ideas and
inspiration.
Whichever of these is the caseand, for that matter, anyone
else that's interested, theObsPod is for you.
(00:56):
Today I'm going to tackle atopic for which I've had a lot
of requests.
Many people have got in touchand said Florence, can you do an
episode on obesity?
Or Florence, can you do anepisode on BMI body mass index?
And you'll be able to tell fromthe fact that I've called this
(01:22):
topic overweight, that I'm quiteconflicted about this topic.
I've thought long and hardabout what to call this episode,
and I think this is probablygoing to be one of a series of
episodes on this topic, becauseI've come across a few people
(01:42):
that are specialising in thisarea or doing research, and I'm
hoping to get them to come onthe podcast and talk to me soon.
In the meantime, I thought I'ddo a little bit of a kind of
nuts and bolts and my thoughts.
When I see a woman who'sclassified as overweight in the
(02:04):
antenatal clinic.
I think we should start bythinking what do we mean by
overweight?
And it's true, we do tend touse body mass index, or BMI, as
the best guide of that.
And in thinking about thistopic I've read a few papers
(02:26):
that dither a bit about is BMIactually the best way of
assessing obesity in apopulation?
And the answer is it's notgreat, but it's the simplest and
sort of best fit that we canuse.
But we do need to bear in mindit doesn't work for some
(02:49):
populations.
For example, there are someethnic differences in its
application.
There are some differences inage, so it's less good for the
very young or the very old.
And you could say well, thatdoesn't apply to an obstetric
(03:11):
population in the main, but itdoesn't really take account of
muscle mass, bone density andall sorts of other factors.
So the starting point is BMI isthe best thing we've got, but
(03:33):
we need to remember it's notgreat.
Then what do we classify asbeing overweight?
If you look at the NHS website,then there's some nice little
ranges.
So BMI of 20 to 25.
Yay, that's green, you're okay.
(03:56):
There's a BMI of 25 to 30.
You're considered overweightand that's where I sit, being
brutally honest.
And then you get above 30.
It starts to talk about obesity.
(04:16):
So, strictly speaking, if we'regoing with the general NHS
calculation, anyone with a bodymass index of over 30 is
overweight In pregnancy.
This can be complex because wealso need to think when are we
(04:40):
weighing people?
I mean, generally, a weight istaken at the beginning of
pregnancy, at bookingappointment, but people's weight
varies hugely during pregnancyand often when we're thinking
(05:00):
about weight and BMI inpregnancy, it might be at the
end of pregnancy when we'reperhaps on the labour ward and
thinking about whether or notthis woman needs to go to the
operating theatre, and we'lloften have a conversation about
the BMI.
Was this at booking?
But it's probably more likethat now, because women put on
(05:25):
an incredibly variable amount ofweight during pregnancy.
Right?
So you might think super simpleanyone over a BMI of 30 is
overweight and we need to dodifferent things for those women
, or do we?
Well, there are things that weknow are a bit more common in
(05:50):
women with a higher body massindex.
But if you look at the RCOGgreen top guideline on obesity.
That's what they call it.
You'll see that is veryconfusing for staff.
(06:10):
I've put a link in the shownotes and I'm not going to
comprehensively go through everysingle point on it now, but
it's 45 pages.
You need to do one set ofthings if a woman's BMI is over
30, needs to do another set ofthings if it's over 35, need to
(06:30):
do another set of things if it'sover 40, and another set of
things if it's over 50.
So this is very confusing forstaff, but equally it must be
very confusing for women.
One of the things I find mostdifficult is when a woman turns
(06:53):
up in obstetric clinic at 16weeks.
So she's had her booking, she'sseen her midwife and she's been
screened by all the questionsand things that have been asked
and deemed so-called high riskand I say so-called inverted
commas because I don't reallylike that terminology but she's
(07:14):
been deemed to need someobstetrician input.
That would be a better way ofdescribing it.
When I see a woman at thatpoint in clinic, I always look
at the kind of tick boxchecklist that the midwives
complete at booking, because Ineed to figure out why is this
(07:34):
woman in the obstetric clinicBecause hopefully, a totally
uncomplicated woman with nomedical problems and no problems
in her pregnancy wouldn't turnup in my clinic.
She would be being cared for byher midwife.
So in some situations I turn tothat tick box and I can see the
(07:55):
only thing ticked is BMI.
Now I don't know about you, butmany of us are quite sensitive
about our weight and our body.
We live in a society which isvery focused on diet culture and
there's a fantastic TEDx talkby a dietician, which I will
(08:16):
also include in the show notes,which discusses this.
So starting a conversation witha woman it has solely been sent
to see me because of her weightis a very sensitive topic and I
find it difficult.
Does she know why she's beensent to see me?
(08:39):
Is she aware that it's becauseof her weight?
Some women are very frank andopen and they understand and
they will open up theconversation and then we can
have a good conversation withoutme feeling that I'm insulting
and defending them.
And I'm assuming that's becausethey're aware, but also because
(09:07):
the midwives had a conversationwith them about the fact that
there are some slightlydifferent things we might need
to offer them during thepregnancy.
But for some women.
I've got to start and broachthe conversation, and that can
be difficult.
(09:29):
If you look at the tick box inour notes and also at the RCOG
green top, on which it's based,much of what we're supposed to
discuss with women in thissituation is the risk of this,
the risk of that.
You've got a higher risk ofblood pressure problems.
You've got a higher risk ofgestational diabetes.
(09:50):
You've got a higher risk ofvenous thrombore embolism or
blood clots.
You've got a higher risk of abig baby and perhaps a more
difficult birth as a result.
Wow, I mean, put yourself inthe shoes of the pregnant women.
(10:11):
You're pregnant, you're excitedand you go and see the doctor
and all the doctor wants to talkabout, or the midwife, is the
risk of this, the risk of that?
You'd probably feel quitescared.
I distinctly remember aconsultation I had with a woman
in which she said to me I knowI'm at a higher risk of all
(10:39):
these things, all thesecomplications, but at this point
in time there's nothing I cando about it.
I'm already pregnant, I'm inthis situation and now the
maternity team are just makingme feel petrified.
I need help to get through thissafely, me and my baby and
(11:05):
telling me I have all thesedifferent risks really isn't
helpful.
And it wasn't like I hadn'tthought about it in that context
, but her talking to me likethat really made me think, and
so I really try and unpick andhelp women understand.
You've got a slightly higherchance of this, but therefore
(11:28):
we're going to offer you a testfor that.
You've got a slightly higherchance of that, but it's okay,
we can offer you this treatmentfor it.
And I do frequently tell womenthat the most likely outcome is
that you're not going to haveany of these things and
(11:48):
everything is going to becompletely fine, but you're
going to get to see me and themidwife and have a few extra
bits and bobs given to you.
And it's a tricky one becauseit's part of that paternalism or
not paternalism, isn't it?
Do we keep to ourselves thatthe woman has all these risks
and issues or do we share withher so that she's well informed
(12:12):
about her own health and that ofher baby?
And I think there's a goodargument for sharing all these
things, because she knows herbody best, she knows her baby
best, and if we can make heraware of all these issues in a
sensitive way, then she can bevigilant and be watching out for
any changes in how she feels orhow her baby is, so that we can
(12:36):
tweak things accordingly andpick things up early if they do
happen.
But it's got to be done in asensitive way.
So if you're overweightdepending on how overweight you
may be offered a glucosetolerance test to check for
(12:56):
gestational diabetes.
You may be offered some bloodthinning injections,
particularly in the throatthinning injections,
particularly in the thirdtrimester, from 28 weeks, to try
and reduce your chance ofgetting a blood clot in your
legs.
You're likely to be offered a36 week scan growth scan because
(13:17):
it's a little bit harder for usto assess the size of your baby
by measuring the fundal height,the top of the womb, in
centimeters, and we know thatwomen who are heavier are more
likely to have a macrosemic orbigger baby.
It may also be harder for us todetermine which way up your
(13:40):
baby is.
So doing a scan at 36 weeksmeans we can plan birth and talk
to you about your options ifthe baby happens to be in a
different position.
So we're checking the growthand size of the baby and its
presentation, what position it'sin, one of the other key things
(14:01):
we need to think about whenwe're thinking about blood
pressure and chance of bloodpressure issues is measuring the
blood pressure correctly.
The size of the blood pressurecuff depends on the
circumference of your upper arm.
So early on in pregnancy, staffshould be measuring and
(14:26):
checking your upper arm todecide which blood pressure cuff
you need, because if your armis bigger you need a large cuff,
not the standard cuff.
Otherwise we won't be able toget accurate readings of your
blood pressure.
So I've definitely hadsituations in which women have
(14:48):
been thought to have raisedblood pressure and then, when we
do it with the correct largecuff that fits their arm
appropriately, actually theirblood pressure is normal.
So something really importantyou can do as a pregnant woman
is, if you know you need a largecuff and the member of staff
(15:09):
tries to take your bloodpressure with the smaller cuff,
tell that member of staff.
Actually the midwife usuallyuses a large cuff.
I need a large cuff andsometimes we'll write on a
woman's notes large cuff so thatwe know what we're using, so
that we can get those accuratemeasurements.
(15:31):
There are some additional thingswe will suggest you might take
in early pregnancy.
Again, depending on your weight, we may recommend that you take
aspirin 150 milligrams once aday from 12 weeks and that's to
reduce your chances of growthrestriction in your baby and
blood pressure problems for you.
(15:52):
And we may also recommend ahigher dose of folic acid.
So you know, it's recommendedwomen take folic acid if they're
trying to conceive or in thefirst 12 weeks of pregnancy.
So women with a higher weightneed a higher dose of folic acid
(16:12):
five milligrams and also somevitamin D supplementation
because you're more likely to bevitamin D deficient.
So either we or your GP willsuggest that you're taking these
things from early on in thepregnancy.
So there you go.
(16:34):
You've booked in, you've seenyour midwife, you've been given
some extra supplements, you'vebeen told a bit about what to
expect during your pregnancy andwhat we're going to offer you.
Happy days.
Then you go for your scans.
Now I've already mentionedperhaps doing an extra 36-week
(16:54):
scan fantastic, but actuallyscanning through a bigger layer
of body fat is quite challengingand the images we get may not
be as clear and good as if youwere less heavy.
So in our guidance itrecommends that we talk to women
(17:20):
about the limitations ofultrasound and that the views of
the baby may be limited by theexcess tissue and it makes sense
that it's harder to see becauseyour ultrasound waves are
having to go through more layers, so there's a different depth
(17:43):
from the probe to the baby thanif the woman was thinner.
And we do need to accept thatultrasound for any woman is
never 100% accurate.
Some things are harder to seethan others on scan.
So there's always a bit of acaveat that we may or may not be
(18:05):
able to see all issues on scanantinatally for any woman.
So I'm not sure how helpful itis to tell a weight woman that
actually her scans are going tobe harder or we may be more
likely to make a mistake.
It feels a little bit like whenyou have those things on
(18:27):
television, particularly inAmerica, where they say, oh,
take this drug or buy this thing, and then they read out very,
very fast some terms andconditions about this investment
may go up or down and you mayor may not get all these side
effects or this, and that mayhappen.
It's kind of a bit of anembarrassing cover.
All Well, you're overweight, sowe might botch it up.
(18:51):
Well, that's not really verytrust inspiring or good at
building a relationship betweenthat woman and her maternity
care provider.
So I think it is important thatwe're realistic with women,
that we may not be able to seeeverything on scan and that may
be a little bit harder for womento have more adipose tissue,
(19:14):
but actually the same is truefor any woman having an
ultrasound scan and I'm not suretelling people they've got a
higher chance of us missingsomething is necessarily helpful
.
Okay, so you've got threepregnancy.
Now we come to birth planning.
This is a minefield and I seequite a few women in my clinic
(19:44):
who want more personalized careplanning who fit into this
situation.
The guidance is that we shouldsuggest all obese women to give
birth on an obstetric unit.
There are rules and I'm callingthem rules because it is
(20:06):
guidance but people behave as ifthey're rules about not using
the birthing pool, which, let'sface it, there's no evidence for
this whatsoever.
It's sort of health and safetygone mad type situation in which
we're really worried.
What if the woman collapsed inthe pool and then it was really
(20:29):
difficult to get her out andwe'd need a hoist, and it's a
nightmare for the staff and wedon't want her to drown in the
pool if she collapses, butactually is she any more likely
to collapse than any other woman.
No, it's just a bit morelogistically difficult to get
her out.
So don't get me started on thatone.
(20:56):
Then we have the difficulty ofanesthetics.
Now it's true that giving ananesthetic to a pregnant woman a
general anesthetic that it isis very high risk For lots of
reasons.
Anesthetic is less safe inpregnancy.
A woman may have significantswelling around her throat, her
(21:20):
neck, which makes it harder forour colleagues to intubate.
They've also got more acidreflux coming back up their
gullet.
They've got a large pregnantuterus pressing up on their
lungs and compressing theirmajor blood vessels.
There are all sorts of concernsabout anesthetizing pregnant
(21:42):
women, and then that is evenworse if you're pregnant and
overweight.
The reason that this isrelevant is that regional bloc
such as spinal or epidural,which is what we would prefer to
use in labor, is much harderpotentially to cite in a woman
that's overweight, because youjust need to feel down her back
(22:06):
and between her vertebrae andnowhere to put their needle.
The needle's got to go muchdeeper and it's much harder to
identify the spaces between thevertebrae.
So, for many reasons andconcerns and fears from our
anesthetic colleagues, oftenwomen that are overweight are
(22:30):
recommended to have an epiduraljust in case.
Sometimes they're even toldhave an epidural.
You might not want an epidural,but if you have an epidural and
we cite it, even if we don't putanything down it, then if
there's an emergency you'realready.
We can top it up, we can use itin an emergency situation and
(22:53):
we're not struggling where wecan't get a spinal into your
back and therefore we're notthen increasing the chances of
you needing that more risky ordangerous general anesthetic.
And there is some rationale tothis, because if you're in an
(23:14):
emergency situation and you'vegot a distressed baby that's at
risk and you need to quicklydeliver the baby, then actually
the speed of anesthetic and theability to be able to give that
anesthetic is quite ahigh-pressurized situation.
So we don't want to be endingup in a situation where the
(23:36):
anesthetists can't get in anappropriate anesthetic, the
baby's at risk and, god forbid,something happens to the baby
because we're unable to safelyanesthetize the mother.
So that's how the thinking goes.
But if you have an epiduralcited, then that restricts you
(23:59):
immediately.
You can't use a birthing pooland I've already discussed why
we might be worried about youusing a birthing pool.
But is it right that we'rerestricting women's choices in
this way.
I had a situation in which awoman wanted a home birth.
She'd had a home birthpreviously, she was overweight
(24:21):
and actually the only reasonshe'd had a home birth
previously is the midwife doingher booking had made a mistake
in calculating her body massindex, so it looked like she was
lighter than she was.
So the woman was baffledbecause she came to us and said
I'm exactly the same weight as Iwas with my last baby.
You were perfectly happy for meto have that baby at home.
(24:43):
Why is there now an issue?
So we're really restrictingwomen who weigh more in their
choices around birth, birthplacepain relief options, and I
don't think that's right.
There's no evidence for it.
It's dealing with obstetric andanesthetic and midwifery
(25:08):
anxiety and fear about somethinggoing wrong, and it's
restricting women's choices in away that is probably not
rational and certainly is notevidence based.
Yes, we are the people thathave seen things when they go
badly wrong, and the womanhasn't, but should we be
(25:30):
pressing every woman who'soverweight into having an
epidural?
Then there's the business ofmonitoring the labor.
It's much harder to monitorsomeone with a continuous CTG
cardiotocular graph if they'reoverweight.
Again back to the ultrasoundthing.
(25:51):
There's a bigger layer of themom's body to go through before
those ultrasound waves hit thebaby's heartbeat and bounce back
so often.
It's harder for us.
So then we say we should put ona fetal scalp electrode.
We should attach a littleelectrode to the scalp of the
(26:14):
baby.
We can monitor the baby moreeffectively continuously and the
woman will be able to movearound.
And that's absolutely true andthat's great if you definitely
need continuous monitoring.
But do we have a question?
We recommend continuousmonitoring and if you go back
and listen to my excellentconversation with Dr Kirsten
(26:38):
Small in episode 157, you'll seethat there's no evidence that
actually we should becontinuously monitoring the
baby's heartbeat.
And actually for women that areoverweight, maybe listening in
intermittently would be easier,would be better for them, would
be better for us.
Actually, all that loss ofcontact that we're worrying
(27:02):
about on a continuous CTGwouldn't matter if we were
listening in every 15 minutes.
The woman might be morecomfortable, more able to move
around, therefore more able tohave the birth that she wants,
and we wouldn't be fussing aboutthe fact that we're not
continuously listening in to thebaby.
So the labour care of women whoare overweight, I feel is quite
(27:26):
messed up.
A lot of what we're suggestingis not evidence-based but more
anxiety-based.
It is true when you look atM-Base that obesity plays a role
(27:48):
.
It often crops up in reports asa risk factor for both women
and their babies.
So we need to be conscious ofthat.
But medicalising everything Idon't believe is necessarily the
answer.
And don't get me wrong choicegoes both ways.
(28:10):
I can clearly remember thefirst time a woman with a body
mass index of over 40 came andasked me for a maternal request
cesarean.
She felt for her that acesarean birth was what she
wanted and what she needed tomeet her baby in the best
possible way.
(28:30):
And I remember it because I washesitant.
I was thinking that you're moreat risk of complications,
you're more at risk of a woundinfection, you're more at risk
of blood clots in your legs.
I've seen some really nasty,difficult wound infections that
(28:55):
have taken weeks or even monthsto heal in women who are
overweight, not least becausethe panacea that sort of flap of
body fat, that kind of flopsover where we make the incisions
sometimes can make it verydifficult to keep that area
clean and dry while the wound ishealing.
(29:17):
So I really struggled in my mindwith this request, but I
rationalised it to myself thatBecause of her weight, why
should she have any less choicethan anyone else?
If I explain the risks to herand that her personal risks are
(29:38):
perhaps a bit different fromsomeone else's personal risks,
then she has the right to choosejust as anyone else does.
If a woman can come in and askfor a caesarean birth, then that
should be true of every woman.
It shouldn't be that if you'rethinner, yes, you can choose a
(29:58):
caesarean.
If you're more overweight, no,you can't.
That's discrimination.
And that brings me on togadgets.
I'm not a big fan of gadgets ingeneral, but there have been
some fantastic advances inthings we use to operate.
(30:21):
We do caesareans for people whoare more overweight, and this
has made a big difference to me.
It used to be, if we had a womanwho was very overweight, that
rather than having a surgeon andan assistant, we would need a
surgeon and two assistants.
Like I said, there's often somebody fat that needs holding
(30:46):
back so we can get in to theabdomen, get in to see where the
womb is.
So you need someone whose jobit is to do that, and it's
physically very demanding joboperating on someone who's
overweight.
You've got to go through asignificantly thicker layer of
(31:07):
tissue before you reach therectus sheath the muscles that
hold the abdomen together andthen get in to the abdomen and
be able to see the womb.
Getting a baby out through thatdepth of tissue is difficult.
You need space and it'schallenging.
(31:28):
You'll come out of that surgeryphysically exhausted from what
you're doing, as well asmentally, because you've got to
concentrate.
And that sounds bad.
Like we don't concentrate whenwe're operating.
Yes, we do, but it's a morechallenging operation than if
the woman had less body fat.
(31:51):
But now we have some newinventions.
So there's a great thing calleda traxidrape.
It's like a giant sticky thingand you place it on before you
clean the woman's abdomen andstart your cesarean.
So she's had her anaesthetic,she's lying on the table and you
put on the traxidrape and it'sthis massively sticky thing and
(32:14):
it pulls everything up out ofthe way.
So you no longer need thatsecond assistant, that person
whose entire job is to pull backthat body fat, because this
traxidrape, this sticky thing,does it for you.
It's a little bit fiddly toapply the first time you do it
(32:36):
and you might think that youcould only use this for a
planned cesarean birth, but Ihave done a category one
cesarean where I've beenincredibly worried about the
baby, where I have used the timewe've been waiting for the
anaesthetic to work, which it'sonly a few minutes to get the
midwives to apply the traxidrape.
(32:57):
And at the time the midwiveswere like, why are we faffling
around with this?
It's a massive emergency.
But I've explained to them thatknife to skin from when I start
the operation to when I get thebaby out will be significantly
quicker if we spend this timewhile we're waiting for the
(33:18):
anaesthetic to be effective,applying that traxidrape.
And indeed it enabled me to doknife to skin to baby out in one
or two minutes.
It's genius invention.
The other thing we have that'snew is called an alexis
retractor.
It's like a giant ring or tworings joined together with
(33:45):
basically what looks like aplastic bag, and once you've
opened the abdomen you pop thatin and again it holds everything
back and everything open sothat you can clearly see the
womb and get your hand in todeliver the baby without having
multiple assistants having tohold everything back for you
(34:06):
Again, genius.
So now when I do a caesarean fora woman who's significantly
overweight.
I can use the Traxidrape, I canuse the Alexis.
It makes my operation much lesschallenging and it makes it
safer, because it's easier forme to get in focus on what I
(34:27):
need to do and get that baby outsafely.
At the end of the surgery wecan apply my final favourite
gadget, the Pico dressing.
And the Pico dressing is aspecially designed dressing that
has negative pressure.
So it's a dressing that you puton over the caesarean wound and
(34:50):
you seal it on with lots ofstrips of sticky stuff, a bit
like cellotape, and then it hasa little battery pack which you
activate and it creates negativepressure which makes it a bit
harder for the bacteria to grow.
That means that when the womanstands up and that excess body
fat flops over the wound, thewound is protected, it's clean,
(35:14):
it's covered and there'sevidence that you're less likely
to get a wound infection andit's more likely to heal better.
So when we're doing our who, oursafety briefing that I
discussed in episode 104, wewill discuss this woman.
She's got a raised BMI.
(35:35):
These are the issues and theseare the pieces of equipment we
want the theatre staff to getready.
We'll discuss whether we'regoing to use the Traxy Drape,
the Alexis and the Pico dressingand in that way, hopefully, we
can offer women who areoverweight, who either want or
need a caesarean birth, thesafest possible way of having
(35:59):
that birth with hopefully lesschance of complications.
And for me, this isrevolutionised how easy or
difficult it is to operatesuccessfully on these women, and
it's important because thereare increasing rates of obesity
(36:24):
and weight issues in ourpopulation.
When I started out inobstetrics, I remember we were
shocked if we saw a woman whosebody mass index was over 40.
And those women had to go andsee an anesthetist and have
special care.
Now we're in a situation wherethe goalposts have moved and now
(36:45):
this applies to women whosebody mass index is over 50.
So, whilst weight is asensitive issue, it is also a
health, population issue, and soit's really important to have
these tools at our fingertipsand have the experience of
(37:08):
operating on women of all shapesand sizes so that, in an
emergency situation, you knowexactly what you can do to
minimise the risk for mother andbaby, make it as safe as you
possibly can.
So that's my little whistle stoptour of overweight.
As I've said, it's a topic I'mprobably going to come back to,
(37:35):
and I haven't given you acomprehensive guide.
I've just given you my thoughtsand experiences.
So, from my zesty bit, I thinkthe key thing is, when you're
talking to women who areoverweight, think about what
your biases are.
(37:55):
Think about how much of whatyou're telling them is because
we, as health professionals, areanxious and fearful.
And remember that actually thecare we're offering should be
for her, not because of us, andtry and have really good but
(38:18):
sensitive conversations so thatshe knows what our anxieties are
but doesn't feel helpless.
Make her feel that she iscentral to that team that are
monitoring the health of her andher baby and that we're there
as a supporting act, rather thanmaking her feel guilty and
(38:39):
ashamed just because she is theshape and size she is.
And if you're pregnant andexpecting a baby and you're on
the slightly bigger side, don'tbe frightened to have
conversations with your healthprofessionals.
Give them the advice they'regiving you and make sure you're
(39:04):
making the right choices, foryou Know that we really are
trying to have your bestinterests at heart, but it
doesn't always come out theright way.
I hope this has given you foodfor thought that might help you
with some of these conversations.
Thanks for listening.
(39:25):
I very much hope you found thisepisode of the OBS pod
interesting.
If you have, it'd be fantasticif you could subscribe, rate and
review, on whatever platformyou find, your podcasts, as well
as recommending the OBS pod toanyone you think might find it
(39:45):
interesting.
There's also tons of episodesto explore in my back catalogue
from clinical topics, my careerand journey as an obstetrician
and life in the NHS moregenerally.
I'd like to assure women I carefor that I take confidentiality
very seriously and take greatcare not to use any patient
(40:10):
identifiable information unlessI have expressly asked the
permission of the personinvolved on that rare occasion
when it's been absolutelynecessary.
If you found this episodeinteresting and want to explore
the subject a little more deeply, don't forget to take a look at
(40:33):
the programme notes, where I'veattached some links.
If you want to get in touch tosuggest topics for future
episodes, you can find me at theOBS pod on Twitter and
Instagram and you can email metheobspod at gmailcom.
(40:54):
Finally, it's very important tome to keep the OBS pod free and
accessible to as many people aspossible, but it does cost me a
very small amount to keep itgoing and keep it live on the
internet.
So if you've enjoyed myepisodes and by chance, you do
(41:16):
have a tiny bit to spare, youcan now contribute to keep the
podcast going and keep it free,via my link, to buy me a coffee,
don't feel under any obligation, but if you'd like to
contribute, you now can.
Thank you for listening.
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