Facility and Equipment Concerns

by Kmom

Copyright 1996-2003 Kmom@Vireday.Com. All rights reserved.

This FAQ last updated: April 2003


DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.

CONTENTS

 

Introduction

Many big moms worry that their size will make things more difficult during their pregnancy and birth.  Among other things, big moms often wonder, Will the medical facilities have equipment that is big enough for me?  

The answer is Yes, they probably will have equipment that fits you, BUT on occasion you may have to educate them about the needs of larger people, or advocate to get the equipment you need. 

The most common equipment concerns of most big moms are blood pressure cuffs, scales, hospital/examining gowns, fetal monitors, stirrups, IV catheters, amniocentesis needles, and anesthesia equipment.

In most places, gowns, fetal monitors, IV catheters, and stirrups are not usually a problem, although of course that's not true everywhere. But unless you are quite supersized, most facilities will probably be able to accommodate you for these items.  In addition, those women who choose amniocentesis and epidurals are usually able to be accommodated without problems, although supersized women may sometimes need longer needles for these procedures.

On the other hand, blood pressure cuffs are a VERY important concern, and one that big women often have to fight about.   It is extremely important for the correct-sized cuff to be used on large people, since falsely high readings are very common with the wrong-sized cuff.  However, many doctors, nurses, and even midwives may not realize this, may not have the correct equipment, or may resist using it.  Big moms often have to really be assertive in order to get this important need taken care of properly.

Scales are another common concern for big moms, especially supersized ones.  Fat women often wonder whether the doctor or midwife will have a scale that will go up to their size.  This is a cause of great stress for many big women.  Most mid-sized women are able to weigh without problems; supersized women may be accommodated without special equipment, but sometimes an extra counterweight for the scale is needed.  

It is completely normal to feel anxious about whether your equipment needs will be met satisfactorily, and whether your requests will be met with dignity and understanding.  Considering how fat people have often been treated in the past, of course it's normal to worry about these things!  

However, learn to approach the problem proactively.  Actively discuss with your provider your equipment concerns, call ahead to see whether the doctor or midwife you are considering has large-sized cuffs, large examining gowns, a scale that can weigh you all through pregnancy, etc.  Ask the hospital if they have gowns in your size, fetal monitors that will fit you comfortably, and whether they will need to prepare special anesthesia needles should you need or chose to have regional anesthesia.  

If standing up for yourself is hard, consider taking along an advocate who can help you express your concerns without apology. This is a very effective technique that many supersized people have used in the past when facing medical care, and it is often very helpful both to client and provider.  Little by little, you will gain the assertiveness needed to stand up for yourself, express your equipment concerns, and advocate to have your needs met adequately and with dignity.  

You and your baby deserve no less.

 

Blood Pressure Cuffs

Big moms have larger arms.  Research CLEARLY shows that using a standard-sized blood pressure cuff on a larger arm can produce falsely high blood pressure readings.  Therefore, it is extremely important that large blood pressure cuffs be used on large women, especially in pregnancy when even small elevations in blood pressure are considered a major concern.

Unfortunately, it is quite routine for medical personnel to use the wrong-size blood pressure cuff on people of size ("undercuffing").  One classic study on blood pressure cuffs found that 37% of obese hypertensives were wrongly diagnosed with high blood pressure because a too-small blood pressure cuff was used (Maxwell, 1982).  Other studies since then confirm that undercuffing remains a common problem, despite education initiatives to raise awareness of this issue.   

Anecdotally, big moms often report that the wrong cuff was used on them.  Some big moms have almost been forced to have an unnecessary emergency cesarean because of falsely high blood pressure readings from the wrong cuff!  Using the correct cuff during pregnancy is especially important, as the threshold for intervention is very low in pregnancy with even slightly high blood pressure readings.   Blood pressure errors can lead to extreme interventions (like unnecessary cesareans) that are dangerous and harmful to both mother and child.

Sometimes, even when big moms point out that a  large cuff is needed, medical personnel have still pressured them to just use the regular cuff.   Big moms are often told the large cuff is "broken," "out for repair," "can't be found," or that using the large cuff doesn't make much difference.  But it does.  It can make a great deal of difference.

Big moms must not accept any excuses; they must DEMAND that the correct cuff for their arm size be used.  They must be vigilant to check that the correct cuff is being used EVERY time their blood pressure is taken.  They must train their labor support (husband/partner, relatives, doula) to double-check that the correct cuff is being used during labor, when the mother's attention may be elsewhere.  They must NEVER agree to a blood pressure reading with the wrong-sized cuff, no matter what excuse is given or what pressure applied.  And if they encounter resistance to using the correct cuff, it is important that big moms report the problem to medical supervisors. 

Knowing Which Cuff To Use

There are 3 main blood pressure cuff sizes for adults, "standard,"  "large,"  and "thigh cuff."  Most big women should use the "large" blood pressure cuff.  Supersized women and women with very heavy arms should probably use the "thigh cuff" to get the most accurate readings.  

Although those are general guidelines, blood pressure cuff sizes are not completely standardized, and you may or may not fit those guidelines.  So it is important for big moms to measure their arms to confirm the best cuff size for them.  Take a tape measure and measure the circumference of your arm at the midpoint between elbow and shoulder.  Write down your measurement so you will remember it.  Learn your measurement in both inches and centimeters, as cuff sizes are usually expressed in centimeters on BP cuffs. [Click here to see a conversion chart.]

Although cuff sizes are not completely standardized, the most commonly accepted rule is that an arm above 13 inches (33 cm) in circumference absolutely should use a "large adult" blood pressure cuff.  Some research shows that arm sizes slightly below this (11-13 inches) may also need a larger cuff, so if you have an arm that is borderline in size, you might want to take your blood pressure with both cuffs and see if the results are comparable. If not, the measurement with the larger cuff may be the more accurate.  

When a "thigh" cuff is needed is much less clear.  Official resources recommend a thigh cuff starting at arm circumferences of 17 inches (43 cm), but many "large" cuffs these days are made to accommodate a wider range than that.  Some "large" cuffs state that they are appropriate for arms up to 18-19 inches.  

The only way to know for sure which cuff is right for you is to read the guidelines printed on the cuff and see if your own arm size fits within that range.  (This is why it's important to have measured your arm, and to know your arm size in both inches and cm.)

It is important to use the cuff size that is just right for your arm, neither too small nor too big.  A too big cuff (overcuffing) can sometimes underestimate blood pressure, which would also be problematic.  If you have high blood pressure, it is vitally important (especially in pregnancy) that this be known and treated.  Undercuffing is by far the most common scenario for women of size, but although unusual, overcuffing does occasionally happen and is not appropriate either.

Because cuff sizes can vary from practice to practice and because not all facilities carry a variety of cuffs, one option that works for many women is to buy their own blood pressure cuff.  Amplestuff ( www.amplestuff.com ) sells blood pressure cuffs for arms from 13 inches to 35 inches.  Women then take this cuff to all their appointments (and to the hospital) with them, so that the correct size is always available.  The cuff just screws into the blood pressure device that is already at the clinic or hospital.

If you are supersized or have arms above 18-20 inches in circumference, you should probably invest in your own blood pressure cuff, as it is likely you will encounter problems consistently finding the right cuff.  If you have borderline blood pressure and borderline arm sizes, you should also strongly consider buying your own BP cuff.

Many other errors in blood pressure measurement are commonly made by medical personnel.  Taking blood pressure with the back unsupported and the feet dangling, for example, can raise a person's blood pressure.  Talking to the patient before and during BP measurements can alter the results, as can having the arm level too low (it should be at heart level) or taking the pressure over a person's clothes.  Thus it is important to familiarize yourself with good blood pressure measurement technique in general so that you can be sure that the measurement done on you is as accurate as possible. Your providers need accurate data on which to base treatment, and it is your job to make sure they get it. 

To see the American Heart Association's Chart of Blood Pressure Cuff Sizes, click here.  For more extensive information about blood pressure technique, cuff sizes, and other blood pressure measurement issues for people of size, see the FAQ on The Importance of Large Blood Pressure Cuffs on this site.  

Summary

Miscuffing during blood pressure measurement is a chronic problem for women of size, even today.  Doctors who see hypertensive patients tend to be the most accurate in using blood pressure cuffs properly, but it is VERY common for providers in emergency medicine, general medicine, and obstetrics to use the wrong cuff size for big women.  

Although hospitals should certainly be aware of the importance of large cuffs, many women have found hospitals to be the least compliant of all regarding cuff size guidelines.  Therefore, be sure your labor support personnel know to check that nurses are using the correct cuff size when you are in labor at the hospital.  Your attention will be on your labor at that point; it is the job of your labor support team to be sure that the equipment used is appropriate for you.

Even when a person of size is well-educated about the importance of using the correct cuff size, many medical personnel strongly resist getting the correct cuff or do not have it available.  People of size may have to become quite assertive to be sure that the correct cuff size and blood pressure technique are being used, and at times may have to refuse blood pressure measurements if the correct equipment is not obtained or "is not available."

Remember that it is your RIGHT to refuse tests, and that no one can force you to have a test against your will.  Simply state calmly but assertively, "I do not consent to this procedure unless the proper equipment is used," and ask to speak to the doctor, head nurse, or office supervisor to help resolve the problem. If necessary, follow up with a written complaint.  Miscuffing is extremely common and will remain so until people of size begin to speak up and raise awareness about this problem.  

It is VITALLY important that the correct blood pressure cuff be used in people of size.  Treatment must be based on accurate data.  Using the wrong cuff often results in inappropriate treatment and intervention, especially during pregnancy.  NEVER let your pressure be taken with the wrong cuff! This is one of the MOST common equipment problems that women of size encounter in pregnancy; be on the lookout for it and be willing to speak up about it.

Women's Stories

L's Story: I came within an hour of having an emergency c/s at week 33 with my son.  They even went as far to have the surgical resident (who would be assisting my regular OB) and the anesthesiologist speak with me.  They were just waiting for my regular OB to get to the hospital and see me before they prepped me.  

When he did come in and see me, the first thing he did was take my BP.  When he reached for the BP cuff, he said, "Is this the cuff they're using to check your pressure with?"  I said yes, then he went out and yelled up one side and down the other to the nursing staff about jeopardizing his patient and baby because they didn't use the large cuff.  It made a huge difference!  The readings went from [about] 180/104 to [about] 114/63.  [Normal is <140/90.....Kmom]  Surgery cancelled!

Usually I'm much more alert than that and demand the large cuff.  I had requested it several times in the hospital and the nurses kept saying it didn't matter...[even after delivery] the jerks still wanted to use the small cuff!!!

Kmom's story:  When in the hospital laboring with my first baby, my BP was taken with what I assumed to be a large cuff, and it came back high (my pressure is usually fine). They started to get me ready for all kinds of invasive interventions.  I asked for a new reading with a large cuff.  However, I really had to be assertive; the nurse at first said a larger cuff wasn't important, then that they didn't have a large cuff, and then she told me it was lost. I had to really get insistent before she went and searched down the bigger cuff.  

When they did, to their surprise, the reading was quite a bit lower--back in a normal range. The interventions got cancelled and I went back to laboring. To think I almost didn't check on the cuff size because I was in the middle of labor and was concentrating on other things!  This shows how important it is to be aware of cuff size at all times!  (Or to have a doula or partner who can monitor cuff size for you.)

M.E.At the doctor's office, yes, all the time without being reminded.  At the hospital in [Labor and Delivery], no. The first nurse used the larger cuff and she even had to go search for one but did so.  Then she left it in my room for when she came back.  Sometime the next day someone removed it and the day nurse said she didn't need to use the large cuff.  (Too lazy to look for it in my opinion.)

Shari's Story: They used a large cuff.  Don't remember any problems with that.

C.M.'s Story: Yes, always without a problem.

D.K.: Not always.  I had to make sure each time that they were using the larger cuff.  If it was my 'regular' person taking BP, it would always be larger, but anyone else I'd check up on.

LJ:  Only after having to remind them several times.  Eventually they had the large cuff waiting for me in the exam room.

Scales

One concern that worries many heavy women is the weigh-in.  They worry whether there is a scale that will go up to their weight, how much they'll gain during pregnancy, and whether there is enough room on that scale for that gain.  They also worry whether they'll be treated with dignity and respect at weigh-ins.  Most larger women are apprehensive about this issue, but most of the time it works out just fine.

Outside of pregnancy, it is rarely necessary for patients to be weighed at every doctor visit and many fat people decline this as part of their size acceptance empowerment.  However, during pregnancy, most U.S. providers believe that pregnancy weight gain is important to keep track of, since a sudden sharp gain can indicate the possible onset of pre-eclampsia, a serious complication.  In addition, an accurate weight is important at the hospital in case medications are needed (so correct dosage can be used).  

Although there are some midwives  (and a few doctors) who will agree not to weigh a client as long as the client keeps track at home, most providers in the U.S. will insist on mothers being weighed.  Many providers outside of the U.S. are less insistent on weighing pregnant women, so it is not clear whether it is truly necessary practice, but at this time it seems to be the standard of care in the U.S.  If you have concerns about regular weigh-ins, you may be able to negotiate a compromise with your providers.  It can't hurt to ask.

Scale Capacity

Most doctors' scales go up to about 300-350 lbs. or so.  Few have scales that will go higher than that.  However, there are ways to weigh people larger than this.  There are digital scales available that weigh up to (or even over) 500 lbs.  These are available from www.amplestuff.com.  Other online companies also sometimes carry these types of scales.  

Even better, there is an adaptor/counterweight that can help convert a traditional beam balance scale to go into the supersizes.  Beam balance scales have a hook on the end of the beam from which you can hang a counterweight.  These usually allow a 350 lb. scale to be converted into a 450 lb. scale.

Sometimes these counterweights can be found in medical supply stores, but usually you have to special order them on the Web.  If you want your doctor or midwife to have one of these but he/she balks at the price of buying a counterweight (about $35-60, depending on the scale brand), you might want to offer to buy one for your doctor in exchange for a equivalent break in your bill.  Be sure to find out ahead of time what brand of scale they have so that you purchase the correct counterweight for it.  

Easing the Weighing-In Process

Weighing in is an activity fraught with emotional associations for large women.  For some it is no big deal, but for many it is a activity deeply associated with shame and condemnation from others.  It reminds some women too strongly of their dieting days, and may make them anxious over gaining even reasonable amounts of weight. A lot depends on the attitude of the person weighing you, and of course, upon your own attitude and personal 'hot buttons'.  

Big moms have reported a number of different ways of handling this problem.  Some confide to the nurse how emotional weighing in is for them, and ask them to be very non-judgmental about the results.  Some are more comfortable weighing in standing backwards on the scale.  This way they cannot see the number and the nurse knows not to say it out loud.   

Other women report that if THEY take control of the weighing process, it feels more empowering and less judgmental.  So they tell the nurse that they will do the measuring, and they move the scale balance themselves while the nurse watches and records the results.  Some nurses who are control freaks don't like this, but if you are assertive enough about, they back down.  This is about what makes YOU comfortable and better able to handle weighing in, and really, moving a scale balance does not take a nursing degree.  There is no legitimate reason why you should not be able to weigh yourself as long as you do so accurately.  

If you receive any hassle from medical personnel about your weight or the amount you've gained in pregnancy, don't accept it in silence.  Tell them to mind their own business.  Tell them it's a matter between you and your doctor/midwife, and you don't appreciate their comments.  Ask to speak to their supervisors if they become rude about it.  If needed, request that a different nurse attend you for prenatal weigh-ins.  

If it is your doctor or midwife that is hassling you about your weight or weight gain, you should seriously consider whether or not to stay with this provider.  Any provider that would make comments like that is NOT a size-friendly provider, and will likely cause you problems in other areas as well because of your size.  If the provider is part of a practice, complain to the other medical providers in the practice, and see if you can avoid having this person on call for your labor.  Or better yet, find a NEW practice entirely.

Many women mistakenly believe that once they have started going to a certain provider during pregnancy, they cannot switch providers, but this is rarely true.  It is almost NEVER too late to switch providers in pregnancy.  Women have switched providers even in the middle of labor!  If your provider makes remarks about your size, you should strongly consider switching providers.  Chances are it is but the tip of the iceberg of fat-phobic behavior.  

Summary

Women whose weight is not likely to exceed 300 lbs. during pregnancy are not likely to have a problem with scales at the doctor's office.  Women whose weight is above 300 lbs. pre-pregnancy (or who may go above this level during pregnancy) should call ahead to the doctor or midwife's office and check to see if there is a scale that will accommodate them.   

If they do not have the correct scale for you, either find a new provider that has a scale that goes up high enough (they'll probably be more size-friendly anyhow), request that they (or you) buy a scale or scale counterweight adaptor to accommodate you, or find out if they feel it's really necessary to weigh you.  Some supersized women report that their providers were fine with not weighing them as long as they ate very nutritiously and were watched carefully for other signs of pre-eclampsia.  

If you are anxious about being weighed, communicate that to your health care workers. Be proactive; tell them how they can best help you feel more at ease with the process.  Most will be happy to help you in any way possible.  However, if you encounter an insensitive health care worker, be sure to call them on inappropriate or insensitive remarks. Tell them you will not tolerate such treatment. If necessary, complain to their supervisors, request a different nurse, or whatever you need to do to feel comfortable again.  

If it is the doctor or midwife that is making sizist or insensitive remarks about your weight or weight gain, seriously consider switching providers.  Such remarks are often a strong marker for more extensive size bias that will show up down the road in much more harmful ways.  How your providers and their staff handle weigh-ins and weight gain discussions often form an "early warning system" for size bias later on.  Listen between the lines for what they are really saying and how they are saying it, and then act as needed.  Better to switch providers unnecessarily than to stick with a bad provider and end up with an unnecessary cesarean.

Although scales and weigh-ins are one of the things big women obsess about the most before their first prenatal appointment, a little calling around ahead of time can save a lot of embarrassment and hassle later on.  In most cases, scales and weigh-ins do not turn out to be as big a deal as we fear they might be. But if there are problems, there ARE alternatives you can utilize. Don't be afraid to.  Claim your space as a big woman and make sure your needs are met, with dignity and with respect.

Women's Stories

Aramanth's Story: Both scales in the Doc's office went to much higher than I needed.  I weighed about 115 kg (250 lb.) and the scales went to 200 kg (440 lbs.).  In the hospitals the scales were not so generous, though.

D.K.'s Story: The scale went at least to 350.  I never got higher than 317 during my pregnancy. 

C.M.'s Story: They have scales that go up to 400 pounds so it wasn't a problem for me.

 

Hospital Maternity Gowns

Many big moms worry about whether the doctor and hospital will have gowns that fit.  Because many of us have experienced the frustration of a too-small gown in the past, we worry that the same thing will happen when we are pregnant and even bigger.  

However, usually this is not a problem for most plus-sized women these days.  Gowns have to be quite roomy in maternity units so as to provide coverage for all sizes of women with all manners of  pregnancies (including high order multiples), so usually there is not a problem with getting a gown that is big enough for you.  

If you are really supersized, you can call ahead to the hospital to ask if they have gowns that will fit you.  The nurses on the obstetrics floor will be able to answer you; they have almost certainly have had large women there before you, so they should know (or be able to find out) if gowns will be a problem.  Most hospitals have gowns that go to 4x easily; many have gowns that go to 6x or larger.  They may not be very attractive, but they do fit most big moms.

Occasionally, big moms have found that health care workers were unwilling to get the correct gown size for them, even though the hospital almost certainly carried larger sizes.  In this case, it helps to have brought your own t-shirt or gown for laboring in (see below), or to have your partner or labor support person advocate strongly for you to get the gown size that you need.  Having someone to advocate for your needs is extremely helpful in birth, and especially so for big moms.  You might want to seriously consider professional labor support (a "doula") in addition to your partner/husband.  

Many big women worry about being too exposed in hospital gowns.  They don't want to worry about their behinds hanging out for all to see if they go for a walk during labor!  One good strategy to preserve your modesty is to wear two gowns, one with the opening in the back in the traditional manner, and another over top of the first, worn like a robe (opening in front). This provides good coverage.  Or you can wear a gown and bring your own robe from home to wear over it.

Another option is to bring your own hospital gown,  especially if you are super-sized.  There are several resources that carry hospital gowns in larger sizes, or will custom-make one for you, including www.naafa.org, or www.exami-gowns.com.  These gowns can also be taken to the doctor's office if you are not sure they will have a gown in your size.  Then take them home afterwards and wash them so they will be ready for the next time they are needed.  You might want to have 2 or more so that you would have a change available in the hospital if one gets stained.  

Although properly fitting gowns used to be a real problem for women of size, it is much less of a problem these days.  More doctors and hospitals have invested in a wider range of gown sizes and more nurses are willing to get these for you when in the hospital, although sometimes problems are still encountered.  Truly supersized women may need to bring their own gown or advocate strongly for the correct size, but most of the time, gowns are not the problem they used to be.

Other Options: Bringing Your Own Labor Shirt

Is a hospital gown really necessary?  Actually, no, it is not.  Your best bet may be to bring a favorite old ratty "comfort shirt," comfy sports bra, or old sleep shirt to labor in. Since it is important to be as relaxed and calm as possible in labor, using a favorite shirt or gown is quite comforting to birthing women. Often, bringing your own labor clothes is the best choice. 

Sometimes wearing your own clothes makes the nurses uneasy, and they may get insistent that you 'need' a hospital gown in labor.  This is rarely true.  You should of course be aware that in an emergency your shirt may have to be cut off of you, or that it could get quite messy during birth.   However, clothes wash or can be thrown away.  Take an old shirt that is super-comfy but which you wouldn't be heartbroken about losing if it became necessary. Many women find that the emotional benefits of having an old 'comfort shirt' with them in labor are so great it is well worth the small risk of losing the shirt. 

Of course, not everyone chooses to labor and give birth in a hospital.  If you choose to labor in a birth center or at home, you can wear whatever clothes you feel like (or don't feel like!) wearing.  This is a subtle but telling difference between birthplace choices.  If you feel strongly about not wearing a standard hospital gown, you might want to consider that you may feel more comfortable in a birthing center or in a home birth.  Or you may wish to find a hospital that is not so tied up in stringent regulations about gowns.  

The decision to use your own labor shirt may have deeper implications than simple comfort.  Robbie Davis-Floyd, an anthropologist who studies childbirth cultural traditions all over the world, notes that Western nurses and doctors may get unconsciously nervous about not using hospital gowns for cultural reasons instead of medical ones.  Taking a woman's clothes away and replacing it with a hospital 'uniform' becomes an important part of her socialization into medicalization.  It strips away the mother's power and individual identity and makes her 'part of the system.'  Women tend to be more compliant in hospital gowns, and less likely to question their doctor's advice.  It takes a birthing woman and makes her a patient.  

Thus, using your own comfort shirt for labor may be an important way to resist the taking away of a woman's birthing power and independence, of withstanding the medicalization of birth.  It's a subtle point, but a fascinating one.  Many women just feel more relaxed and empowered wearing their own clothes during labor, and that psychological benefit should not be underestimated.

Don't let anyone dictate to you what you must or must not be wearing during labor.  The important thing is not their rules and regulations, but YOUR comfort and convenience.  Ask your provider to sign a waiver "permitting" you to wear your own shirt in labor, and prepare your labor support persons to help you withstand pressure to change to a hospital gown if you don't want that.  If you are prepared and firm about your wishes, you can usually find a way around standard "rules" and hospital pressure.

[You can read more about how Western medical traditions around birth actually fulfill the need for rituals of the providers more than the clients at the following URL: www.birthpsychology.com/messages/contents.html.  This is an excerpt from Davis-Floyd's book, and is truly fascinating reading.  Kmom highly recommends it!]

Other Options: Laboring In the Buff!

Although you may not believe that YOU would do this, many women of all sizes choose to labor in the buff when things get intense.  Even women who are normally extremely modest can become remarkably uninhibited once they become internally focused.  Labor has a wonderful way of focusing your attention only on the really important stuff!  

Really, doctors, midwives, and nurses have seen it ALL before, in ALL sizes of women, and they are going to see your most intimate parts soon enough anyhow!  They already know what fat pregnant women look like.  It's not a big deal to them if you don't have a lot of clothes on---it's amazingly common!  

Don't feel that you have to labor naked, of course, but don't rule it out either.  Many women who would normally never consider such a thing end up laboring totally in the buff.  If you are very modest or uncomfortable with being completely naked in front of hospital personnel or family members, you can compromise and labor with a bra on only, or a bra and t-shirt that you can take off if you feel you want to.  

Be flexible, and go with what you feel like doing once you are in labor.  If being naked makes you nervous, plan ahead on using a long nightshirt or something in labor.  But don't get too wrapped up in modesty worries---be able to go with the flow if you get too hot or too constricted by gowns, and only keep on what you consider to be comfortable.  Moral of the story: do what feels right to you while you are in labor!

Clear Your Choice Ahead of Time

Whatever your choice, be sure to write it into your birth plan and have your doctor sign off on it ahead of time so that if hospital personnel resist, you have a way around the rules. Requiring you to labor in a hospital gown is old-fashioned and silly, but it is still standard procedure in some places and you may have to be assertive in order to labor in clothing of your choice. 

Medical concerns about quick access in an emergency are legitimate, so it’s important to plan on something that’s accessible or that you would not mind having destroyed in an emergency.   But an emergency such as this is highly unlikely, and the comfort and relaxation factor is so strong in wearing your own clothes that it's worth pursuing.  Just have it in writing that it's okay with your provider, so that any potential hassle can be avoided.

If you have an epidural or cesarean, however, you should probably choose to use the hospital's gowns because an IV will be required.  Dealing with IV lines is very awkward and you need to have gowns that can be fastened and unfastened easily to work around these lines.   Ask for the kind that open at the shoulder.  These work well for dealing with IVs and also are convenient for breastfeeding.  Once your IV is out, you can choose to wear your own shirt or gown again whenever you are ready.  

Other Clothing Supplies To Bring To The Hospital

If you choose to give birth in a hospital, it’s also a good idea to be prepared with other clothing items in your size.  Bring your own slippers, socks, robe, nursing bras, and old underwear, as well as extra comfy shirts and shorts/pants (6 month pregnancy size). The postpartum panties and other materials provided by the hospital are supposed to be one-size-fits-all, but they rarely are. Be prepared with your own stuff, just in case.  

Bring old ratty underwear in your size, since women bleed quite a bit after childbirth and things are sometimes very messy in the first few days.  The hospital will provide you with postpartum sanitary pads, but it's not unusual for underwear to get stained anyway.  If the postpartum panties the hospital gives you don't fit well and you just use old ratty underwear, you won't have to clean them or worry about stains.  You can just throw them away afterwards without feeling guilty. 

Packing your own clothes and underwear in your own size is important, just in case hospital-provided materials don't fit well or are not comfortable.  You may or may not use them, but it's best to be prepared in case you want them.

Summary

Although many big women worry a lot about whether their doctor or hospital will have gowns that fit them, this is not usually a problem for most plus-sized women.  However, if you are truly supersized or know that your hospital does not provide gowns in your size, you may want to purchase your own gowns ahead of time.  

Other options include bringing your own super-comfy shirt or gown to labor in, wearing only a sports bra, or laboring in the buff.  Although many big women think they would not be comfortable with these options, they are often surprised at their willingness to explore these options once they are in labor! Don't rule any option out, no matter how modest you normally are. Go with the flow in labor, and follow your body's needs.

Many birthing women have commented how wonderful it was to slip on their own soft shirt during labor, and how much comfort it brought to them to wear their own clothes.  While you must be prepared to lose these clothes if an emergency occurs, and while you may have to be assertive about using your own clothes in some hospitals, many women have found that this is a comfort well worth advocating for.  

In addition to your own shirt for labor, it is often a good idea to bring postpartum clothes and underwear in your size from home for after the baby is born.  Although hospitals purport to carry postpartum items that fit all women, in reality most large women find it easier to use their own clothing. Bringing your own gives you options in case the materials provided by the hospital do not work well for you.

Women's Stories

Aramanth's Story: The doc's office didn't provide gowns to anyone, regardless of size, so this wasn't an issue.  In the hospitals (I was in 2 different ones), they had gowns of several different sizes available, some of them bigger than I needed.

D.K.'s Story: The gowns fit fine and were even a bit too big...the one-size-fits-all panties they give you really DO fit all!

Shari's Story: They told me they did not have any large gowns, which I did not believe, but was too preoccupied to argue. I think they just did not have any large gowns on their unit, and did not make an effort to find one.  I'm not super-sized, either.  But I had to undo the first snaps on either side to avoid feeling choked by the gown.  

Lj's Story: Yup [I had trouble getting gowns of the right size], so I brought my own to wear.  The nurses tried to discourage me from wearing them.  The problem I found with the hospital gowns is that while they were big enough to cover my body, the arm holes were not big enough for my arms.  

M.E.'s Story:  They just gave me two regular size gowns to wear, one on the front, one on the back, but it wasn't really uncomfortable.

Mina's Story: The gown was okay, but didn't really fit all that well.  After the actual labor, I spent my time in my own nightgown...The only thing I couldn't use at the hospital was the mesh panties they have to hold the pad after you give birth so you don't get blood all over your own panties.  It wasn't really a big deal---I didn't mind wearing my own. 

C.M.'s Story: I had my own gown, but I never wore any gown.  I wore my own tank top from home and was much more comfortable. 

 

Fetal Monitors

Fetal Monitors keep track of the baby's heartbeat during labor and birth.  There are two main types of fetal monitors--those that are used externally (from the outside) and those that are used internally (from the inside).  

The External Fetal Monitor (EFM) uses continuous ultrasound to track the baby's heart rate.  It is put on a belt that goes around the mother's abdomen.  Also on this belt is the Tocodynamometer (Tocometer), which measures the strength of the mother's contractions through the surface tension produced by contractions.  

At times, an Internal Fetal Monitor (IFM) is used instead of the external one.  This is a small electrode-like device that is inserted into the mother's vagina and then screwed into the baby's head.  To measure the strength of the mother's contractions internally, an Intra Uterine Pressure Catheter (IUPC) is often used with the IFM.  

Although it sounds like a good idea to monitor the baby's heartrate at all times, "just in case," research has found that continuous fetal monitoring actually does more harm than good. Continuous monitoring has been shown to strongly increase the cesarean rate without also improving outcomes for babies, and the loss of mobility and increased pain levels associated with immobility extract a steep price from birthing women, whatever their size.

Although many hospitals push women to have continuous fetal monitoring because of their fear of lawsuits, continuous monitoring is rarely necessary.  Intermittent fetal monitoring is usually all that's necessary if labor is spontaneous.  Don't let the hospital's legal worries come before your own need to have an easier and better birth.  Put your own needs (and your baby's needs) first. 

However, if induction or pain medications are being used, then continuous monitoring does become necessary because of the risks involved with these drugs.  Because spontaneous labor usually results in much better outcomes for women and babies, women of all sizes should aim for spontaneous, natural labor whenever possible, making the question of continuous monitoring moot in most cases, and also decreasing the likelihood of an unnecessary cesarean. 

Fetal Monitoring and Plus-Size Women: General Issues

Some women of size are told they must have constant monitoring because of their size.  While it is important to periodically track the baby's well-being, it is rarely necessary to use continuous fetal monitoring in women of any size.  Unless there are other medical concerns necessitating continuous monitoring (like high blood pressure or diabetes), women of size should not be required to use continuous monitoring simply because of their size.  

Some hospitals tell all large women (especially supersized ones) that they will be required to have an internal monitor.  Unfortunately, internal monitors have risks as well as benefits and should not be used lightly.  Although they can be a useful tool at times for women of size, they can also cause problems and should not be automatically required for women of size.  If your hospital strongly encourages you to have an internal monitor simply because of your size, you may want to strongly consider changing your place of birth instead.

As noted, continuous monitoring of the baby will be required if induction or pain medications are used, due to the risks associated with these drugs.  Research shows that women of size are induced at a much higher rate than other women, even when there are no medical indications for induction.  Many doctors assume (wrongly) that if the baby is delivered when it is smaller, there will be fewer problems and a decreased risk for cesarean.  However, research clearly shows the opposite---when labor is induced to get a smaller baby, the cesarean and complication rate actually increases quite strongly.  So the common practice of inducing big moms early probably actually increases the cesarean and complication rate, rather than decreasing it.  Thus it is important to consider any proposed induction carefully.

Spontaneous labor with full mobility and no medications is greatly advantageous to the mother and baby in many ways; avoiding continuous fetal monitoring is one of those ways.  Strongly consider a normal, spontaneous labor without interventions, if possible, in order to minimize the risks associated with fetal monitoring. If your doctor suggests induction, carefully question the doctor to see if there truly is a medical indication for early induction of labor, or whether the doctor is doing it because of your size, under the theory that "it will help because the baby will be smaller."  Remember that you always have the right to refuse any medical procedure, and the right to switch providers, even very late in pregnancy.

Also remember that continuous monitoring clearly increases the cesarean rate, reduces your mobility, and increases your pain levels.  An induction or epidural requires continuous monitoring because of the risks associated with these drugs.  Don't let yourself be put into the position of requiring continuous monitoring by agreeing to an unnecessary induction or an early epidural (see below), just because of your size. 

External Fetal Monitoring and the Plus-Sized Mother

The mechanism for attaching EFM to the mom differs somewhat from hospital to hospital, but most of the time it involves a belt strapped around the mother's belly with Velcro to help adjust the belt's size.  In some hospitals, it may involve a band of elasticized cloth that goes around the mother's tummy.  Some hospitals have both types of EFM, or may use one type in the Prenatal Screening Unit, and a different type in the Labor and Delivery.

Many plus-sized mothers fear that they will have problems with fetal monitor equipment.  However, EFM belts fit most mid-sized and mid-to-supersized women without a problem, although they may feel a little snug.  In supersized women, fetal monitors can be more challenging and don't always fit well.  Even so, most hospitals have dealt with supersized women before and have found ways to get around this.  

If you are unsure whether the EFM belt will fit you, simply discuss the issue ahead of time with your provider or with the hospital.  They may have larger EFM belts available, or have ways to adapt their usual equipment.  Some big moms have had luck going to the Prenatal Screening Unit and using the EFM belts available there during labor and birth.  

Some bigger women find that it is difficult to find the baby's heartbeat steadily when they are on EFM.  This may be partially due to size (more fat between the transducer and the baby can make it harder to track the heartbeat), but it often is due to other factors like the baby's position as well. Many women who have trouble tracking the baby's heartbeat actually have babies that are malpositioned or are moving in response to the ultrasound in the EFM.  If you have trouble finding your baby's heartbeat and keeping it on the monitor, you might want to consider the possibility that your baby may not be well-positioned for birth.

One strategy that works well for big moms is to have the nurse use a hand-held Doppler device on the belly for monitoring.  They hold this in place for the amount of time they need an intermittent monitoring strip.  If they are too busy to hold the Doptone in place, you or your labor support team can do it instead.  Because the Doppler is hand-held, its position can be changed more subtly in response to the baby's movements, and results are often better.  This is also a good strategy to use if the belts are uncomfortably tight on you or hinder your mobility during contractions too much. 

Again, it helps to avoid inductions, pain medications, and other interventions so that continuous fetal monitoring is not required.   Intermittent monitoring gives you so much more flexibility that many of the EFM issues for plus-size women become irrelevant.  However, if you must be induced or choose to have an epidural, rest assured that most hospitals have ways to do continuous EFM on women of size, though they may not always be totally comfortable.  

Internal Fetal Monitors and the Plus-Sized Mother

An internal fetal monitor tracks the baby's heartbeat from within the womb instead of from without.  It is inserted into the mother's vagina, and then screwed into the top of the baby's scalp. A cord leads down from the internal monitor to the recording machine, so the cord must be taped to the mother's leg to keep it from being pulled out inadvertently.  

Some hospitals tell large women that it is too hard to use external fetal monitoring on them, and that they will be required to have internal fetal monitoring.  However, this is probably an overreaction and not truly necessary.  If your hospital tells you that you MUST have internal monitoring because of your size, you should strongly consider changing your place of birth, as this one is not likely to be size-friendly at all.  An internal monitor can sometimes be useful in some situations, but its use should NOT be required simply because of size.

An internal monitor has advantages and disadvantages.  The advantages of IFM include: 

However, the internal monitor comes with a price.  The disadvantages of IFM include: 

Obviously, putting in an internal fetal monitor is not without risks.  It should NOT be automatically required of all heavy women but it does remain an option should intermittent or continuous external fetal monitoring not prove effective.  

Sometimes, IFM can be an advantage for big moms, giving them more mobility, comfort, and position flexibility than EFM.  In an induction when continuous monitoring becomes necessary, internal monitoring may offer the best compromise for tracking the baby's heartrate without tying the mother down excessively.

If it is considered, IFM should preferably be done only after the woman's waters break naturally in labor, as artificially rupturing the mother's membranes carries too many risks to justify doing it simply for fetal monitoring.  However, once the waters have broken on their own, an internal monitor can free the mother to be a bit more mobile while still keeping track of the baby's heartbeat.  In some very heavy women (or women whose babies are shifting position), internal monitoring may be the only way to reliably track the baby's heartrate.  

Internal Fetal Monitoring can have its uses, but it DOES have risks and should not be done lightly. It should never be required simply because of a woman's size.

Tocodynamometers and the Plus-Sized Mother

Fetal monitors also often include a device that measures the strength of the mother's contractions as felt on her belly.  This is called the tocodynamometer, or "tocometer" for short.

If contractions do not measure as "strong enough" on the tocometer, artificial drugs are often added to make the woman's labor stronger.  However, many large women report that the tocometer did not fully register the strength of their contractions, probably due to their size.  Intervening fat layers may "muffle" the contraction and make it "feel" less strong to the tocometer.  In some women it may register the contraction as being 'weak' or not register it at all!  

Some big moms report their nurses looking at the machines, telling them that their contractions were not strong enough to be effective (even though the mom assured the nurse that the contractions were QUITE strong!), and then adding pitocin to their labor, which then made labor extremely painful and hard to manage without drugs.  And of course, once pitocin is added to labor, continuous monitoring becomes required, with all its disadvantages. 

Other big moms report that the nurses told them that they were not in labor at all (based on tocometer readings), even when the mother protested that in fact birth was imminent!  The fact is that medical personnel are much more likely to believe the machines than the mother, and do not generally recognize that their machines underestimate the strength of the large mother's contractions, leading to a high rate of labor augmentation. 

Shari's Story: They couldn't pick up any of my contractions on their monitor, either.  Never did, even when the contractions were severe.  All of my contractions were very low, though; it felt like they were all around my pelvic floor/hips, and a little in my lower back.  

Veronica's Story: The monitor wasn't picking up anything substantial so the nurses kept increasing the pitocin every 20 minutes until I was writhing in pain. I was screaming that the contractions were too intense and it felt like my uterus was being torn in half, but they hushed me and pointed to the monitors that were showing nothing. Finally I convinced them that my padded tummy was causing the monitor to fail. They inserted an internal monitor and found my contractions were off the charts at only 4 cm. All I could do was scream. That breathing stuff was useless at this point. Finally, at 5 cm I was told I could have an epidural. I was so relieved at the mere thought of it. My pitocin had been turned down but it was too late at that point. The contractions stayed unnaturally strong the remainder of the time.

Tocometers work just fine on some women of size and not on others.  It is not clear why.  It may have to do with the amount of adiposity (fatness) in the belly area, it may have to do with the baby's position and where labor is the strongest, or it may simply have to do with differences between tocometers.  Some equipment may just be more sensitive than others.

Make sure your labor support and labor nurse are aware that tocometers may or may not accurately measure the strength of contractions in heavy women.   If you feel your contractions are adequately strong, be hesitant to add pitocin augmentation simply because your contractions are not measuring as "strong enough" on the tocometer.  Remember how much risk is added to the baby by use of pitocin, and remember that you would then be required to have continuous monitoring and be immobile in labor.  

If your water is already broken and medical personnel are hassling you about whether your contractions are "strong enough," another option is to use the Intra Uterine Pressure Catheter (IUPC), as in Veronica's Story above.  This is like an internal tocometer, and it may measure contraction strength more accurately.   Its use is not risk-free; sometimes injuries result from insertion of this device into the womb.  However, most of the time, its use is not associated with harm, and using it can free up a woman from the irritating external tocometer belt.  

Although it is not a device that should be used routinely and it is best not to break a woman's waters in order to use the IUPC, it is an option that can be chosen once the waters have broken on their own, if there is any question about the real strength of your contractions.

Reasons To Minimize Use of Fetal Monitoring

The External Fetal Monitor (EFM) can be a useful tool in some situations, and is certainly necessary when strong labor drugs are being used.  However, it is associated with significant disadvantages too.  Because of this, it is best to minimize your use of EFM whenever possible.

Few people realize is that EFM uses ultrasound technology to monitor the baby's heartrate, and that this represents a very significant source of ultrasound exposure.  Diagnostic ultrasound, used earlier in pregnancy, uses high-intensity pulsed ultrasound for a short period of time.  Because it is pulsed, the cumulative dosage is very low. EFM uses low-intensity ultrasound, but uses it continuously.  Therefore, the cumulative effect is much higher, despite its lower intensity.  During labor, babies are often exposed to hours of continuous ultrasound. Unfortunately, little is known about the effects of such extensive exposure.  Using intermittent monitoring is advantageous because it helps your baby avoid long-term exposure to ultrasound. 

Overuse of EFM is linked by many studies to unnecessary medical interventions and a higher cesarean rate. Use of the external monitor often means that you have to be reclining and stay in one position in order to get a reading, and readings are sometimes a bit harder in women with more girth, so you have to be extra still. This is a terrible position to labor in. It makes labor much more painful and hard to handle---it is no wonder that so many women on continuous monitoring feel like they have to have drugs in order to get through labor!  And if your baby is not optimally positioned for birth, being so immobile makes it difficult for the baby to move and be born vaginally.

It's best to avoid excessive monitoring altogether. Periodic monitoring is almost always enough.  Insist on either intermittent monitoring with full movement possible between monitoring times, monitoring by wireless telemetry so you can get up and move, or to hire a monatrice (professional labor assistant) to do manual monitoring for you with a fetoscope or hand-held Doppler.  Be sure to question your health provider about their use of monitoring; if they view continual monitoring as standard and required, find another provider.  

The very strong drugs used for inducing labor do require continuous monitoring. Most inductions are unnecessary and involve more risk than generally acknowledged to women, so definitely avoid an induction if it's not truly medically necessary.  An epidural will also require constant monitoring of the baby to be sure that it is tolerating the drugs, so try to avoid an epidural or delay it as long as possible.   Big moms are often pressured to have more inductions and early epidurals, which would necessitate continuous monitoring.  Thus, a big mom may need to be prepared to resist pressure for these interventions.

It is normal to have a somewhat longer period of monitoring in order to establish a baseline when you first enter the hospital, usually 15-30 minutes. Although this is usually done with the woman lying down, this is not truly necessary.  You can request that it be done while you sit quietly in the rocking chair or on the edge of the bed, or while you lean against the bed.  However, you may want to clear this with your provider ahead of time, and you may want to have their permission written into your birth plan so you are not hassled about it.  

After the baseline reading has established that all is well with the baby, many health providers like midwives will not require continuous monitoring (as long as you do not require induction/augmentation or pain drugs).   Be sure to be assertive about coming OFF of the monitor after the initial monitoring strip is over, and enlist your labor support personnel to help you achieve this.  Many women are tricked into remaining on the monitor even when all is well; you will need to have a plan in place for evaluating and dealing with hassles over this.  

If there is a lot of resistance to you not having continuous monitoring, some providers will be willing to work out a compromise.  This can include using the monitor by hand instead of attaching it by belt, or agreeing upon set intervals for more extensive monitoring with total freedom of movement in between.  Continuous monitoring by wireless telemetry is another option in many hospitals, although not one they encourage.

As noted above, many large women find that  if there is a problem hearing the heartbeat or keeping track of it, a hand-held Doppler held against them works much more efficiently.  This also tends to be much more comfortable for larger women, so do check into this possibility with your provider, and request it in your birth plan if possible.  

Summary

Use of fetal monitors is a critical and controversial health issue at this time, so be sure to discuss it in detail with your health provider ahead of time. Generally, continuous monitoring has been found to be harmful more than helpful, and results in a much higher cesarean rate (without improving outcome) in most studies.  

However, monitoring is still used because medical personnel believes it offers them some legal protection in case they are sued.  In this case, they are doing what's best for themselves, not what's best for the mother or the baby.  

Big mothers are often subjected to extra monitoring requirements, either indirectly or directly.  Some doctors routinely induce their big mothers early, or require an epidural at an early stage of labor (see below).  Others do not allow big moms out of bed at all, or will require continuous monitoring (external or internal), simply because of a woman's size.

Unless you are induced or get an epidural/pain meds, continuous monitoring is NOT necessary.  Nor did big mothers automatically require extra monitoring.  However, it may take an assertive and proactive big mom to avoid the situations where continuous monitoring becomes necessary.  Having professional labor support (a doula or monatrice) may help you work proactively around these situations.  

If continuous monitoring becomes necessary for some reason and your waters have already broken, some big moms find that an internal monitor gave them a bit more freedom and was more comfortable to use than an external monitor.  You have to use your judgment as to what is best in your own situation.  

Women's Stories       [Note:  "EFM" means External Fetal Monitoring, IFM means Internal Fetal Monitoring.]

Angela's Story: I have to say that when I got [to] the hospital [and] they had put the monitor on me...they really couldn't get anything with it. We tried it in all kinds of places but I really thought it was because of all of the fat over my belly that they couldn't get to it.  The nurses never said anything remotely like that, but I guess I just assumed.

I don't know why, but they just left me alone about it, which I am really happy for.  They KNEW I was having contractions (I was yelling loud enough!) and that is basically what my nurse said.  I think I would have really freaked about the internal monitor, because I think [that] literally sticking it into the baby's head thing is REALLY creepy.  After a while, I just took it off [the EFM] and no one said anything, and that is all that happened.  

C.M.'s Story: During the pregnancy, we had enough trouble trying to find her heartbeat on the Doppler.  They tried hooking me up to the Non-Stress Test once and they couldn't get anything.  Whenever we couldn't find her on Doppler and anytime I needed a NST...they just sent me into an ultrasound.  When I was in labor I had an internal monitor because my water broke before my contractions started...She doesn't have any permanent marks from [the internal monitor] that I can tell.  

Margarita's Story: It was often difficult for them to hear the baby [with EFM].  We had to spend quite a bit of time moving the thing around to hear.  Also, once it was attached, if I moved they usually lost sound...The belts they had [in Delivery] were completely useless; I breathed and the thing moved.  So I borrowed belts from Pre-Natal Testing.  These are long and stretchy, but they don't attach with Velcro or go over my head.  [Eventually they used an internal monitor] because of pre-eclampsia.  

If the belts they have in Labor and Delivery don't work, have your husband/labor partner go over to the Pre-Natal area and ask them for the belts they used.  Actually...it might be a good idea to figure out what the best [type of monitor belts are for you] and if...you're going to be undergoing a lot of fetal monitoring [because of induction etc.], bring your own belts.  Also, don't sweat it too much if contact is lost and try to negotiate to have only intermittent monitoring.

Mina's Story: They didn't have any problem with the external monitor---the belt they used just fit, and the monitor was able to stay in place.  They used a stretchy belt with Velcro...They decided to use an internal monitor when they discovered that the baby's heart rate wasn't coming back after contractions and pushing, because they thought the baby had the cord wrapped around its neck.  They didn't push for internal monitoring because of my size [but because of the baby's heart rate].  And it ended up the baby DID have the cord around its neck, and using internal monitoring enabled me to have him vaginally because we found his heart rate would come back if I was positioned on one side.  So my experience with the internal monitor was a good and necessary one.  

Aramanth's Story: I had a LOT of monitoring done because I had severe pre-eclampsia and a 7+ week premature delivery with [my first], and moderate pre-eclampsia and a full-term delivery with [my second].  [They used a] belt wrapped around and fastened with Velcro.  When I was in labor with [my second], she was REALLY mobile (turned about completely during labour, as confirmed by ultrasound), which made for a few problems.  So for a lot of the time, this was supplemented with a midwife holding the monitor in place and moving it when she moved.  

Never once was it suggested that my size was a difficulty, just that my baby was not behaving normally during labour.  She eventually turned transverse and had to be delivered by emergency c/s after trying to come out shoulder-first...[The tocometer] recorded contractions pretty much spot-on with the way they felt before the epidural kicked in.  Then I didn't feel much at all, so the monitor's advice was really useful. 

D.K.'s Story: I did have a problem with the EFM both during Non-Stress Tests and during induction/labor.  [During NSTs] we could find the heartbeat with no trouble but the tracking equipment would not KEEP tracking him.  The resolution was to send me for a BioPhysical Profile every week.  

For the NSTs they used a belt with Velcro. For the induction, they used stretchy material that slipped over my head...Both fit around me with no trouble.

Once I was induced, my water broke. They were having some trouble keeping his heartbeat on the monitor, so I was made to have an internal fetal monitor...I think the internal monitor did a better job [at checking the strength of contractions], since they were showing as moderate at the highest point.

Shari's Story: They really couldn't use the EFM for me.  It just wouldn't pick up [my daughter].  My midwife opted for intermittent manual monitoring instead.  That worked pretty well, although [my daughter] was very active and kept moving and kicking at the probe when they used it.  She was positioned correctly when she was born, however.  Their EFM had a Velcro attachment, and was very tight and uncomfortable.  

I had "premature rupture of membranes" at 35 weeks 5 days, so they did not have to break my water.  They put the Internal Fetal Monitor on [my daughter] when I was in transition, in bed.  They did rush delivery at the end, though.  Her heartbeat dropped to 50-60 and didn't recover after contractions, so they used a vacuum extractor to help her a little early...She had a mild conehead from that.  Also, a little red spot from the IFM, which disappeared after a couple of weeks.

They couldn't pick up any of my contractions on their monitor, either.  Never did, even when the contractions were severe.  All of my contractions were very low, though; it felt like they were all found my pelvic floor/hips, and a little in my lower back. 

Lj's Story:  I did have a lot of trouble with [the EFM].  They were constantly adjusting it to try and get a reading.  They also kept tightening the belt, which didn't help.  It just hurt my back.  I wound up with a rash from the belt. [It was a Velcro belt.] I wasn't told the internal monitor was a requirement, but it was very strongly recommended.  I don't remember at exactly what point, but they did wait for my water to break on its own.  This happened with both babies and the weird thing is that they wanted to use the internal fetal monitor, but seemed reluctant to use the internal contraction monitor.  I had to request that both times.  I figured since they were already inserting an electrode into the baby's head, I wanted that damn belt OFF.

My daughter is 9 and still has a tiny bald spot, the size of a pencil eraser, where the [internal] monitor was attached to her scalp.  Luckily she has long thick hair that covers it, but as a baby it was easy to see...My son also had the internal monitor, as well as 2 blood samples drawn from his head, and though he had little scabs for the first week or so of life, he has no permanent marks. 

[As far as the tocometer goes], I was having horrendous back labor and the monitor was barely showing contractions.  I feel like this contributed to them increasing the pitocin dosage.  At one point they had cranked it up so high I was having one contraction after another with less than 30 seconds in between.  It wasn't until I reached that point that they turned down the pit again.  

Avoid continuous monitoring if you can.  If you've had an uncomplicated pregnancy and are not being induced, insist on intermittent monitoring only.  

Balek's Story: As a newborn, [my daughter] had a tiny spiral scab [from the internal monitor].  I cried when I saw it.  It was awful.  [However], I looked for a scar [now] and couldn't find one.

M.E.'s Story: They had a lot of difficulty reading the baby's heartbeat with the [Velcro belt] EFM.  They kept repositioning it and repositioning it and eventually they decided an IFM would be better. I agreed because by that point I was ready to throw the darn EFM out the window along with the nurse who kept pestering me about fixing it!

If they had just done intermittent fetal monitoring it probably wouldn't have been a problem, but because they wanted the continuous monitoring we ran into difficulties...Try to only allow intermittent monitoring.  Unless of course continuous monitoring is required because there is a problem.  

 

Stirrups

Leg stirrups are designed for a traditional delivery position in which a woman is on her back or semi-sitting. Her calves are then put into leg stirrups, allowing a doctor easier access to the mother's vagina and perineum.  This position is much more for the doctor's convenience than for the mother's, as it's a very poor position for giving birth.  It should be avoided whenever possible.

Disadvantages of Stirrups

The stirrups position is criticized for working against gravity (it's like giving birth uphill!). It is not an optimal position for baby to make the passage easily, as it tends to make the pelvic opening smaller and less flexible. It is particularly important to avoid stirrups if you may be having a big baby (as some big moms do) and need maximum space and flexibility for birthing. Semi-sitting positions force the tailbone into the pelvic outlet and reduce the space available.  This can cause the baby to get stuck or have trouble getting out easily.  A better position for birthing a big baby is on hands and knees, squatting, side-lying, or standing with one knee elevated.

Using stirrups also puts too much pressure on the perineum, making the area more prone to severe tears or episiotomy extensions that may tear all the way to the rectum.  These can have a very negative effect on women's health and quality of life.  You can quite likely lower your risk for episiotomy or tears by avoiding stirrups and using a more physiological position for birth.  

Stirrups are also important to avoid if you have had significant pubic pain during pregnancy (see the FAQ on Pubic Pain).  If your pubic symphysis joint (at the front of your pelvis where the pubic bones join) is too "loose" from pregnancy hormones or a pelvic misalignment, you may experience pain rolling over in bed, lifting one leg up to put on clothes, tenderness in the pubic area, or sciatic pain.  Great care must be taken to protect the "loose" pubic symphysis joint during birth, and the mother should avoid positions that pull her legs apart too far because they strain the joint. This includes stirrups. Many women with pubic symphysis joint pain suffer long-term injuries from being put in stirrups.

Use of Stirrups 

Stirrups were developed to hold apart the legs of heavily drugged or unconscious women so that doctors could use forceps and drag the babies out.  These heavy drugs are no longer used in childbirth now; there is no need for stirrups to be used in most births. They are simply a tradition in medicine now, not medically necessary.  

Doctors like stirrups because it is easy to see in that position, they can sit comfortably while they attend the birth, and it is easy to cut episiotomies in that position.  But stirrups are not a good position for the mother, for the baby, or for a safe birth.  When the needs of the mother/baby and the doctor are in conflict, frankly, the mother/baby's comfort and safety should be the bigger priority, but unfortunately, many doctors do not see it that way.  Some even regard birthing in other positions as "primitive" or "barbaric."  Actually, the barbaric thing is to make a woman birth in a position that is more painful and more likely to cause damage, simply because it's more convenient for you.   

Stirrups still have one use in modern obstetrics. If you choose to have an epidural, stirrups are often an unquestioned part of the process because your leg control is weak, and because it's simply tradition. However, as an alternative, you can have the nurse and your labor support hold back your legs for you, which may be more comfortable than stirrups.  

If you have a lighter epidural and have some leg control, you may still be able to use some alternative positioning with assistance from your labor support people.  Sidelying is an excellent position for a woman with an epidural, as it lets the pelvis open wider and lets the tailbone move freely. This often provides crucial extra room if baby is big or is slightly malpositioned. 

Often doctors will "let" you push in various positions but will insist on the traditional semi-sitting or stirrups position once baby is crowning.  This is unnecessary and still adds to the risk of perineal damage.  If at all possible, try to AVOID stirrups at all times, whether all through pushing or even just at the end.  It is not a good physiological position for birth, and it causes a lot of harm.  

Make birthing position part of your interview when hiring a provider to attend your birth. Ask your providers what positions most of their clients use for the last bit of pushing out the baby.  If they say in stirrups or semi-sitting with legs pulled back, you know that this is not the best provider for you.  Find another provider who is more open to better and more comfortable birthing positions.

Stirrups and Big Moms

Many big moms fear that their legs will not fit in stirrups, not realizing that stirrups are not a required part of birth anymore. Many also fear that if they do the semi-sitting position seen in most TV shows, they will not have the physical strength to hold their legs back.  

Rest assured, if somehow you do end up using stirrups, your legs will probably fit just fine.  It may not be the most comfortable fit, but remember that you will be in the pushing stage and will have your mind on other things!  Even if they are not perfectly sized for you, they will work well enough and you will be too busy pushing to dwell much on any discomfort!  

As far as holding up your legs go, most of the work will be done by your labor support people; you will be concentrating on pushing out the baby!  Let them help you; that is what they are there for.  However, remember that if you do get tired, you can always put your legs in the stirrups, or better yet, get up off your bottom and give birth in a more physiological position like kneeling, sidelying, or on your hands and knees.  There are always ways to work around size and fatigue issues, as long as you listen to your body and let it tell you what you need to do. 

The most important thing is finding a position that works best for you and the baby, not what's convenient for the doctor. If your doctor is not open to this, it is time to find a new doctor!  Or better yet, hire a midwife.  

Women's Stories

Kmom's Story: For my first baby, I was induced, which eventually necessitated an epidural.  When it came time to push, my OB had me put my legs in stirrups, even though I had some feeling left in my legs and was able to move them on my own.  The stirrups did fit my legs okay, although they certainly were not terribly comfortable. Unfortunately, they really were a lousy way to push.  With my next two babies, I used hands and knees, on the bed with arched back, and sidelying positions for pushing, which were MUCH better than using stirrups. 

 

Intravenous Catheters

At some point in labor, many women will have an intravenous catheter put in ("IV").  This small tube goes into your vein and provides access for medications (if used) and hydrating fluids (if needed).  

IV's can be more difficult to put into larger women.  Our fat layers may make our veins deeper and more difficult to locate.  That doesn't mean that problems with it will happen; not every large person has difficulty with IV access.  However, enough do that it is important to be aware that it can be a problem.  It may particularly be a problem with big women who are experiencing swelling and fluid retention from problems like pre-eclampsia; conversely, it may also be a problem for those who become very dehydrated. 

Getting Expert Help If Needed

In some medical procedures (like amniocentesis or regional anesthesia), being large may necessitate an extra-long needle.  However, no special equipment is usually needed to put an IV in most large people.  

But because it can be more difficult to do an IV on a big person, it may help to request a nurse who is really expert at putting in IVs.  If you know you have veins that are difficult to find, or if you are significantly swollen from fluid retention or dehydrated from lack of fluids , you might want to strongly request an IV expert.  

This is done informally at first.  Confide in your labor nurse that you think you will probably be a "difficult stick" and you don't want to suffer through repeated attempts at placing an IV.  Request that if problems are encountered on the first "stick," an expert be brought in.   

Some heavy people have reported suffering through stick after stick with a nurse that just cannot find their veins properly.  There is no need to endure such a problem.  Let your labor nurse try one or two times, and if that doesn't work, don't mess around anymore.  Tell them you do not consent to an IV until an expert is brought in.  

This expert may be a nurse on the labor ward who is recognized for her ability to do "difficult sticks," or it may be that they have a special "IV" team that rotates around the hospital to work on the toughest cases.  But chances are your hospital has a protocol in place to handle IV's that are difficult to place.  Take advantage of that instead of suffering through repeated sticks.

Most of the time, big moms report no trouble with placement of IV's.  However, occasionally problems are encountered, and in those cases, it's important to not become a pin cushion.  Politely but strongly request that the experts be brought in for your case.

Is An IV Mandatory?

Must you have an IV while in labor?  No, an IV is not required to have a baby.  Birthing women over millions of years have had their babies without having to have tubes in their arms!  You don't need an IV to give birth.  In fact, many women find that an IV hampers their ability to birth normally by strongly restricting their movements.  If too many fluids (or the wrong kind of fluids) are given, then many women actually have complications caused by having the IV in the first place.  

But some hospitals strongly encourage or even require birthing women to have automatic IV's. This is usually simply protocol; it's not strictly necessary medically speaking.  The concern is that if there is an emergency and your veins collapse, it might be difficult to get an IV inserted in time to help you.  They want an IV in place "just in case," even though the likelihood of such a dire emergency is very low.  Because hospitals in the past used very strong medications on birthing women, they felt that an automatic IV was a reasonable step to ensure faster assistance if a woman or baby crashed as a result of the drugs.

Today, women are no longer given "twilight sleep" and other similar drugs for birth.  Although pain medications and epidurals are available, many women labor and birth naturally, and the risk for complications is correspondingly lower.  To require that all birthing women must have an IV, regardless of drug status, is not a reasonable risk/benefit tradeoff.  It usually indicates a hospital that is not very birth-friendly. 

If you labor spontaneously and naturally, without labor medications, there is rarely any need for a mandatory IV.  If you become dehydrated during labor, an IV may become necessary, but if you drink fluids as you labor, this will help prevent dehydration.  Hospitals used to forbid laboring women from drinking any fluids at all, but now most hospitals permit clear fluids in labor, like water or non-acidic juices. An IV is not usually necessary to keep mom hydrated and energized during labor.  

IV's become truly necessary if you are given labor medications, either to start your contractions or make them stronger, or if you elect to receive pain medications by IV or epidural.  This is not negotiable.  Drugs carry significant risks, and because of this women are required to have constant monitoring and IVs.  Labor medications make it more likely that fetal distress or other emergencies could occur, and if a crash cesarean happens, instant access for anesthesia is needed. In that situation, an IV is necessary. 

This is actually a good argument for completely avoiding induction, pain meds, and epidurals.  If these procedures were truly safe, there would be no need for constant monitoring and instant vein access.  Because they are NOT safe and carry substantial risk for harm, constant vigilance and preparation for emergencies needs to happen.  Women should not incur that risk lightly.  In some situations, their use may justify the risks involved, but in most situations, their routine use is questionable.  Because the risk they present is substantial, an IV and constant monitoring becomes necessary.

If your hospital mandates that all birthing women must have IVs (even those laboring naturally and spontaneously), you might want to explore giving birth elsewhere, as such a hospital is likely to be highly interventive and you are not likely to birth without significant harm (episiotomies, higher risk for cesarean or vacuum extraction, etc.). The best defense is a good offense; why risk giving birth at a place that would require such an unnecessary intervention automatically? Choose a less interventive place of birth.

But if you feel you have little choice in your place of birth and your hospital requires an IV, then you might want to negotiate with your doctor for other options.  One alternative is a Heplock. This inserts a "port" for IV access, keeping the vein open so very quick access is available in an emergency.  

The advantage of a Heplock is that no tube or fluids are attached.  Your mobility is not limited, and you are not receiving anything via the port except a very small amount of heparin to keep the vein access open.  If fluids, medications, or instant IV access is needed at some point, the port is already there and the IV process is greatly expedited.   A Heplock can be an excellent compromise if hospital protocols are rigid.

But the best choice of all is to select a midwife or doctor who actually believes in birth and doesn't attach all kinds of unnecessary "requirements" onto your labor, who will help you work around or avoid unneeded interventions, and who will encourage you to give birth in the way that YOU want to birth.

Women's Stories 

Shari's Story: It took multiple attempts to get an IV.  They said they kept hitting valves, and couldn't thread the IV catheter.

M.L.'s Story: A hint.  I don't know if it was because of my weight or how swollen I was, but it was absolutely impossible for the nurses to put an IV on me.  Unfortunately, I had 3 or more tries before they gave up.  It was REALLY painful.  If you have that problem, after one botched try ask that they have the anesthesiologist come and do it.  They are the real experts on this stuff.

 

Amniocentesis Needles

An amniocentesis is done to test the baby for birth defects.  First the ultrasound is used to figure out where the baby is, then using the ultrasound as a guide, a large hollow needle is inserted through the mother's abdomen and into her womb to withdraw some amniotic fluid.  This fluid is sent off for testing to check for any genetic defects the baby might have.  

Large Women and Amniocentesis

Most large women who choose to have amniocentesis do not have difficulty.  However, an amnio is technically a bit more difficult on women with significant abdominal fat, so it is best to select a doctor for this procedure that has considerable experience doing amnios on larger women, and who is comfortable and non-judgmental working with larger women.  If you wish to have an amnio, call ahead and ask some questions about your amnio doctor's size-friendliness and experience.  

Occasionally, in an amnio on women who are supersized or who have lots of abdominal fat, the doctor may need a longer needle.  If the needle used is too short, he may have trouble getting in or getting enough fluid out and may need to repeat the test.  

Kmom has been told conflicting information about whether amnio needles actually come in more than one size; some sources have said they come in only one size, while some supersized mothers have reported that their doctor was able to get and use a longer needle on them.  Call ahead to discuss this issue with your doctor and their support team; if they say there is only one size of needle, call around to other amnio/prenatal diagnosis doctors and continue to inquire.  

Occasionally doctors will have trouble doing amnios on big moms if the amnios are done too early.  If you are supersized, it may help to delay your amnio a few weeks.  If you are using the test for prenatal diagnosis and would consider an abortion for non-reassuring results, obviously delaying the test is not a good idea. However, if you would not consider an abortion but still want to do an amnio, delaying the test a few weeks might help the process go more easily. 

Most big moms do not need a longer needle or to delay the amnio, but it is best to discuss the possibility with your doctor before the procedure. Also remember to ask how much experience they have in performing amnios on large women, and whether they are comfortable working with women of size. Listen between the lines for how they discuss the issue as well as what they say.

Consider Amniocentesis Decisions Carefully

Finally, before committing to an amniocentesis, consider strongly whether an amnio is really necessary or desired.  There are significant risks in this procedure, whatever the size of the needle.  The miscarriage rate is increased with an amnio; consider whether the possible advantages of knowing of a genetic birth defect is worth a 0.5 - 1.0% increased chance of the death of that child.  

Also consider what you would do with that knowledge; if abortion is an acceptable option for you, then the risk/benefit ratio of amniocentesis may make more sense.  If you would not consider abortion, regardless of the results, the risk/benefit ratio of amniocentesis may not make as much sense. However, some people want to know the baby's status, regardless of their opinions on abortion.  For those people, amniocentesis make make sense. Whatever your opinion, think ahead to ALL the implications of doing an amnio and how you would handle them.

There are other concerns associated with amnios.  Amniocentesis may also be associated with a somewhat increased risk of respiratory problems for the baby.  Amniocentesis doesn't always work on the first try, so a significant minority of recipients must have multiple tests.  Amnios may be more risky for some women than for others (for example, women who have experienced bleeding earlier in pregnancy may be at more risk for miscarriage).  Early amniocentesis (before 15-16 weeks) is associated with many severe problems and is no longer recommended.  

Amniocentesis is a valuable diagnostic tool for those who desire it and who are well-educated about the risks and benefits associated with it.  In certain situations, it can be extremely useful.  However, most women do not fully think through the advantages and disadvantages of amniocentesis before they have it.  

Remember, diagnostic testing like this is NEVER required.  Just because you are an older mom does NOT mean that you must (or even should) have this test. Many women, including moms well over 35, choose not to have it.  However, the common assumption in many OB practices is that "of course" you will be having this test, and they may pressure you strongly into accepting it.

Don't let your doctor or family members pressure you into a test you don't want.  Before you choose one way or another, educate yourself thoroughly about amniocentesis and then decide what is the best choice for your situation. (See web section on Large Women and Prenatal Testing for lots more details on the risks/benefits of this procedure.)

Women's Stories

Kmom's Story: I was pressured into an amnio with my first baby. The full story is in the Prenatal Testing: Amniocentesis FAQ on this website, but suffice it to say that it was not a pleasant experience.  The doctor was not size-friendly at all.  

The needle went in fine on the first attempt but the baby moved and we had to re-insert the needle.  The second time, I had a Braxton-Hicks contraction during the needle placement and it would not go in easily.  The doctor had a hard time getting out enough fluid, and he pressed so hard it was extremely uncomfortable.  After the amnio, he yelled at me and blamed my size for the difficulties he had during the test.  Although size can make amnios more difficult, the fact that the first needle insertion went just fine tells me that it is more likely that doing the amnio during a contraction was the real source of the problem, not my size.  Women much larger than me have had amnios with no problems. Chances are the doctor simply blamed the difficulties on the most convenient scapegoat he could find, my size.

My doctor never informed me that I was at a higher risk for miscarriage than most because I had experienced bleeding early in my pregnancy.  I went on to have cramping and bleeding after this amnio, and we were afraid that we might lose the baby for having done an amnio.  Fortunately, the bleeding and cramping stopped, and the pregnancy proceeded normally.  

The emotional tumult of the whole procedure and aftermath left a lingering emotional toll. In later pregnancies, I chose not to have the AFP/Triple Screen, nor any amniocentesis, despite being over 35.  

Lj's Story: Yes, [the needle was long enough for the amniocentesis.]

 

Anesthesia Equipment

Kmom Special Note: Please remember that this particular FAQ is not designed to fully discuss the pros and cons of selecting an epidural during labor or of choosing an elective cesarean.  It is only designed to give some basic overview of anesthesia techniques as they apply to equipment concerns for people of size.  Anesthesia of ANY type offers significant risks to both mother and baby and should NOT be undertaken lightly. A person should be fully cognizant of the pros and cons before making decisions about any anesthesia procedures. 

Overview of Anesthesia Choices

There are two types of anesthesia for surgical procedures: general anesthesia and regional anesthesia.  Either can be used in women of size, although there are risks with both types of anesthesia for women of any size.  Generally speaking, regional anesthesia is preferred for cesarean sections, and especially so in women of size.

In general anesthesia (GA), you are given drugs to knock you out and your body is paralyzed. The anesthesiologist places a tube to help you breathe and maintain an airway.  You are not conscious for the birth of your baby and generally have more postsurgical pain and grogginess.  Nursing tends to be delayed longer, and more drugs tend to get into the baby's system, making baby groggier and slower to respond.  General anesthesia tends to be riskier than regional anesthesia, and so has fallen out of use for most cesareans. However, general anesthesia can be done extremely quickly (a great advantage in a true emergency), no needles go into the spine, and less specialized training is needed to administer general anesthesia.

In regional anesthesia (RA), a needle is inserted into your spine and drugs are injected there, partially paralyzing you and preventing pain messages from traveling to the brain.  You remain awake (though often woozy) for the procedure.  Regional Anesthesia is advantageous because you can see and hear your baby right away, are able to nurse sooner, are less "out of it" afterwards, and have better pain relief post surgery.  The baby probably has less overall drug exposure this way as well (although there is some drug exposure).  However, RA takes longer to initiate, requires very specialized training to administer, is not suitable for all women, and does carry a very small risk for paralysis or other complications because it does involve a needle in the spine.  There are two main types of regional anesthesia, the spinal and the epidural.  

In a spinal, a needle is inserted into the space right next to the spinal cord and a drug cocktail of narcotics and anesthetics is injected.  A spinal is usually only used for surgery (not labor) because its effect lasts only an hour or two.  It is often preferred for elective cesareans (or cesareans where no prior epidural exists) because coverage from a spinal is so quick and dense that it offers the best pain relief during surgery.  It is quick and relatively easy to administer most of the time, and takes less technical expertise to do than an epidural.  However, it is a one-time shot and cannot be repeated.  

In an epidural, a hollow needle with a catheter in it is inserted into the spine, but instead of going into the space next to the spine, the needle only goes to the epidural space, which is slightly farther out.  Although this sounds easier, it is actually harder to locate and potentially more risky because of the many blood vessels that also are located in this space. When the anesthesiologist is sure that the needle is in the right space and has not inadvertently been placed in a blood vessel, a drug cocktail of narcotics and anesthetics is injected.  The catheter is left in this space so that more drugs can be added later if needed.  An epidural can be used for pain relief during labor, or a stronger dose can be given in order to use it for a cesarean.  

The advantage of an epidural is that it can be used for both labor and surgery, and that it can be dosed if more pain relief is needed.  However, because the drugs are not directly next to the spinal cord, coverage tends to be more spotty and not as thoroughly effective.  Breakthrough pain does happen in some women.  Thus it is not as good a choice for a planned, elective cesarean. If the woman is in labor and has an existing epidural, the epidural can usually be topped off with extra medication to make it suitable for surgery, but if the pain relief has been spotty and inadequate throughout labor, the epidural should either be re-placed or converted to a different form of anesthesia for surgery.

Recently, a third kind of regional anesthesia has come into use in some hospitals.  This type of anesthesia combines the best advantages of the spinal (dense, quick pain relief) and the epidural (ability to re-dose for stronger or longer pain relief), so it is usually called the "Combined Spinal-Epidural Anesthesia" (CSEA).  Proponents advertise it as the best of both worlds. 

In the CSEA, usually a needle-within-a-needle technique is used.  The inner needle goes into the space next to the spine and delivers a shot of drugs to this inner space (the "spinal"), then the inner needle is withdrawn, leaving the outer needle in the epidural space temporarily so the catheter can be placed there to be dosed later on if needed (the "epidural").   Another technique that is sometimes used is the two-needle technique, where the spinal and epidural portions are performed with two separate needles, placed at two separate spots on the spine.  

CSEA has gained in popularity in some areas but is not available everywhere because it is more difficult to perform, requires extra training, and needs special equipment.  It is relatively new and is still being studied, but may be a promising new development in obstetric anesthesia.  Because it provides denser and longer-lasting pain relief, it may be particularly useful for surgery in truly supersized people (>400 lbs.), in whom operating times are likely to be extended.  It may also be especially useful for women who have had multiple prior cesareans (whose scar tissue may make surgery more difficult and prolonged), women who may encounter surgical complications, or women who have had problems with ineffective anesthesia in the past.

Anesthesia Choices in Obese Women

Vaginal birth is far safer than a cesarean.  However, if you must have a cesarean, regional anesthesia is significantly less risky than general anesthesia, particularly for heavy women.  

Although maternal mortality is rare in cesareans now, it does still happen and is more common with general anesthesia.  This is especially true in obese women because it is harder to intubate and maintain the airway in obese people.  Of the few modern deaths documented to have occurred in women of size in pregnancy, most have occurred during a cesarean, especially those under general anesthesia.  Although you would likely be fine with general anesthesia if you were to have it, research clearly shows that regional anesthesia is the safer choice for women of size whenever possible.  

Either a spinal or an epidural can be used in women of size.  However, sometimes special longer needles are needed for very heavy women.  In the notes on "Cesarean Section in the Morbidly Obese" found at www.manbit.com/oa/c105.htm, the author notes, "Long (12 cm) or extra-long (18 and 20 cm) needles may be necessary to gain access to the epidural or subarachnoid spaces."  These longer needles may not always be available in every hospital.

Another study found that a special type of needle used in the past with a Combined Spinal-Epidural Anesthesia (the 26-g Gertie-Marx needle) may not be sufficiently long to use for some people of size.  In that study, 7 of the 11 patients in whom they could not establish successful anesthesia weighed more than 220 lbs.  So if you are going to have a CSEA, you might want to raise the question of needle length with your anesthesiologist to see if this will be a problem.

Kuczkowski (2002) reported that a set of longer needles for CSEA has now been put on the market, and reported its successful use with a 460 lb. woman with a history of multiple cesareans and anesthesia complications. Continuous Spinal Epidural anesthesia presents a significant advantage for cesareans in truly supersized women, because it provides more dense pain relief with the option for continuous dosing in case surgery is prolonged.  It is indeed good news that CSEA needles for the supersized are now available.  

If you are sure that you are going to want an epidural in your labor, if you are supersized, or if you think there is a strong chance that you may have a cesarean, you should inquire ahead of time whether a sufficiently long needle is available.  You do not want to find out in the midst of labor or just before your cesarean that you cannot have Regional Anesthesia after all!  In most cases, a longer needle can be obtained, but the anesthesia department may need some notice ahead of time to do so, especially in smaller, community hospitals.  

Although most hospitals are prepared with adequate anesthesia equipment for larger sizes, occasionally women of size have found that some hospitals were not prepared and they ended up having to have general anesthesia for a cesarean instead.  This is unfortunate because general anesthesia patients tend to have more problems, more pain, more bonding difficulties with their babies afterwards, and more difficulties breastfeeding.  Thus it is best to ask ahead of time if possible.

Anonymous Story:   My daughter was born in October of 2002. I "had to have" a repeat c-section.  When I was in the operating room, I was supposed to have a spinal block [for the elective repeat cesarean].  

I am a supersize mom.  The needle they were trying to use was not long enough to reach the right spot in my spine and they were not prepared with a longer needle.  I had to be totally put under [with general anesthesia]...[This] was very traumatic for me.

This mother's hospital was not prepared with the right equipment, despite knowing ahead of time that she was supersized and would be having a repeat elective cesarean.  When the equipment problem was discovered, the operation should have been postponed until the correct equipment could be found; there was no emergency and the cesarean did not have to be performed that day.  But no one suggested this idea to this mother and she did not realize she had any choice other than to submit to a general right then.  Thus the lack of preparation from this hospital and its unwillingness to reschedule put this woman and her baby at more risk because of the general anesthesia, and prevented her from being conscious for the birth of her baby.

Occasionally heavy women are told early in the pregnancy that they cannot have regional anesthesia and must have a general if a cesarean becomes necessary.  If you are told this then you should seek another hospital for your care.  Regional anesthesia, while not risk-free, is clearly safer for women of size than general anesthesia and is available in most hospitals for women of size.  Regional anesthesia has been used successfully for cesareans in women around 500 lbs., so being supersized should not be a factor if personnel plan ahead and obtain the correct equipment ahead of time.   Don't let someone force you into general anesthesia based on your size---find another hospital instead.

Potential Difficulties in Regional Anesthesia Placement in Obese Women

Regional anesthesia of any type is more difficult to place in women of size because of the heavier fat pads on the back.  Because of this, it is usually administered to women of size in the sitting position (sitting with the back hunched over as much as possible) instead of the lateral position (lying down on your side with your back curved).  Sitting in a hunched position makes the distance to the interior of the spine much smaller and helps the anesthesiologist palpate the bony landmarks of your back more easily.  A nurse may also help by pulling fat pads away from the spine if your back is particularly heavy.  This is not to make you feel bad, but rather to help the anesthesiologist find the best spot for needle placement.  

Be prepared that it may also take multiple attempts to place the epidural or spinal properly.  The thicker fat layer on the back of heavy women makes it difficult to estimate the depth of penetration that will be necessary, and makes it more difficult to know exactly where and at what angle to insert the needle.  Research clearly shows that it can take multiple attempts to place an epidural or spinal in women of size.  

Most of the time, when a cesarean during labor becomes necessary, it is not an absolute emergency where every second counts. Doctors usually have enough time to place a spinal or epidural for a labor cesarean even in morbidly obese women, despite the problem of needing multiple attempts.  A spinal in particular can be placed relatively quickly and takes effect much faster than an epidural, so if a cesarean becomes necessary, it should be the anesthesia of choice.  However, in a truly emergent situation or if the regional anesthesia cannot be placed quickly enough, it is true that general anesthesia may sometimes need to be used instead.  This is uncommon but can sometimes happen.

Sometimes epidurals are not as effective in women of size because the catheter to the back becomes partially dislodged when the woman moves. Catheter "migration" like this is more common in obese people.  However, research has shown that if personnel tape the catheter to your back AFTER you have lain back down instead of while you are still sitting, problems with inadequate anesthesia and catheter displacement decrease significantly in heavy women.  

One study (Hamilton, 1997) examined the rate of inadequate anesthesia and catheter migration in women in labor, with special attention to the obese group.  It found that when they taped the catheter down AFTER the woman had laid back down, the rate of inadequate anesthesia dropped to zero in the obese group.  So it is very important that you discuss this issue ahead of time with your anesthesiologist and have your labor coaches remind medical personnel to tape the catheter down only AFTER you have lain back down!

Unfortunately, this research is not well-known by most anesthesiologists.  You may have to actually provide them with a copy of this study's abstract in order for them to take your request to tape the catheter after you have moved seriously.  In order to get a copy of this abstract, go to http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9105221&dopt=Abstract.  

Must Obese Women Have Mandatory, Early Epidurals?

In recent years, some doctors and hospitals have begun to tell women of size that they must get an epidural put into place early in labor.  One report presented to the 1999 annual meeting of American Society of Anesthesiologists promoted this idea and was widely publicized.  The media message was that women of size have such a high rate of cesareans that prophylactic placement of an epidural catheter early in labor will enable a smoother and safer transition in the highly likely event of a cesarean.

Many doctors have picked up on this idea and promote early and prophylactic epidurals in women of size.  They see it as a solution to the problem of multiple placement failures for epidurals in women of size, and quicker access in case of an emergency (which they of course view as highly likely in obese women).  

They often try to scare women into a mandatory epidural by telling them that IF they refuse to have an early epidural AND then end up needing a cesarean AND it's an emergency, their only choice will be to have general anesthesia.  This, of course, is more risky in women of size and means you won't be awake for your baby's birth.  Thus, they bully many women of size into having an early epidural, based on unlikely "what if" scenarios. 

However, this is disingenuous.  Even if an epidural is already in place if an emergent cesarean is needed, it must be "topped off" to make it strong enough for surgery, and this takes quite a bit of time.  A spinal could easily have been administered instead, as a spinal takes much less time to administer than an epidural, is much easier to place than an epidural (even in heavy women), and is effective for surgery MUCH more rapidly.  

Some doctors might argue that a substantial amount of fluids must be pre-loaded by IV before either an epidural or a spinal, and doing this with an early epidural lessens the time to cesarean later on. However, this is only an issue with a truly emergent cesarean.  Most cesareans done during labor are not true "emergencies," but occur after problems have become apparent for quite some time.  If problems appear during labor and the likelihood of a cesarean is increased, an IV can be placed and fluids pushed, "just in case." There is no need to pre-load fluids before any sign of problem appears.  To ease doctors' worries, big women can agree to a prophylactic Heplock IV port placed in early labor, if she wants (see above).  

Only in a truly emergent situation where seconds count would lack of pre-loaded fluids become a disadvantage.  However, general anesthesia would have to be used even if an epidural is already in effect, as a labor cesarean is not strong enough for surgery, and the epidural could not be "topped off" quickly enough for immediate surgery in such a situation.  So the "lack of pre-loaded fluids" argument is not valid either.

The argument from some anesthesiologists that early 'prophylactic' placement of an epidural is a good idea in women of size, "just in case" a cesarean is needed, is dishonest and misleading.  If a cesarean during labor becomes necessary, a spinal is usually able to be done quickly, even in women of size, and rarely is a cesarean so truly emergent that there is not time to do a spinal, even with pre-loading of fluids.  Epidurals take time to "top off" for surgery, so they are not useful in a truly emergent cesarean anyhow.  If there was really an emergency where seconds count, general anesthesia would have to be used, no matter what.

Furthermore, there is substantial evidence that epidurals may increase the need for a cesarean section, especially when placed very early in labor.  By arguing for early prophylactic epidural placement in women of size, anesthesiologists may actually be creating the need for the cesarean instead.  Furthermore, epidurals are well-known to increase the risk of forceps/vacuum extraction, and they reduce a woman's mobility drastically.  Both of these are risk factors for shoulder dystocia, another potential risk for big moms.  By promoting early epidurals in women of size, doctors may be increasing the risk for cesareans, and increasing the risk for shoulder dystocia/birth trauma to the children of big moms.  

The arguments in favor of early epidurals in women of size fall apart when examined more carefully.  In reality, early placement of an epidural in labor does not protect big moms but actually puts them more at risk for complications like shoulder dystocia and cesarean.  Kmom is adamantly against mandatory routine or early use of epidurals simply because of a woman's size.  

Summary

If a cesarean is needed, either general anesthesia or regional anesthesia may be chosen. If a cesarean is not a true emergency, regional anesthesia is almost always the best option, regardless of size.  General anesthesia is usually the anesthesia of choice only if a true emergency occurs and time is absolutely critical, or if regional anesthesia cannot be placed for some reason.  However, the exact type of anesthesia which should be used will depend on the circumstances of each individual situation.

Generally speaking, if an epidural is already in place and was working well during labor, it will be "topped off" and used for surgery.  These epidurals usually do relatively well for surgery. Most women who have cesareans these days have a "topped off" epidural from labor for surgery anesthesia. 

However, if the cesarean is elective or an epidural is not already in place, a spinal is probably the better choice for cesarean anesthesia, as it is placed quickly and offers more dense and complete pain relief.  Most hospitals outside the United States routinely use spinals for cesareans in these situations, but many US hospitals still use epidurals instead.  This is unfortunate because breakthrough pain is more common with epidurals than with spinals.  

Epidurals used to be chosen over spinals because of the risk of a spinal headache afterwards.  Nowadays, with the small "pencil point" spinal needles, this risk is much lower.  In many people's opinions, this lower incidence of spinal headaches changes the balance of risks more in favor of the spinal. 

If you must have a cesarean and an epidural is not already in place, you and your labor coaches may want to request a spinal instead of an epidural. If your surgery is elective, a spinal may be the best choice unless there are extenuating medical circumstances.  Discuss your anesthesia options ahead of time with the anesthesiologist and then decide which option is best for you.

If an epidural is already in place from labor but has not been working very well, it should be re-placed or converted to a different form of anesthesia for the cesarean.  Unfortunately, this is often not done and can lead to women going through surgery without sufficient anesthesia, a very devastating experience, as Kmom knows personally.  Thus the mother and her labor advocates may need to be quite assertive about pain relief choices if a cesarean is needed and the epidural has not been working well.  Make sure the anesthesiologist and surgeons take your concerns seriously before surgery starts. 

Regional anesthesia (a spinal or an epidural) is considered a far more desirable anesthesia choice for cesareans in women of size.  A woman should never "have" to have general anesthesia simply because of her size.  Regional anesthesia is much safer for larger women, and if medical personnel plan ahead, suitable equipment can be had even for extremely large women.  

However, Regional Anesthesia can be more difficult to place in women of size and may take more than one try to place correctly. To aid in its placement in obese women, RA should be done with the woman sitting up (instead of lying down) and hunched over as much as she can.  Some big women have found it easier to arch their spine more for placement if they sit with their heels together on the hospital bed and lean forward slightly (see below).  It may also help if a nurse or doula pulls any fat pads away from the spine.  In some women, a longer needle than usual may be necessary.  Check with your doctors ahead of time to be sure a longer needle is available and that medical personnel know to use it if needed.  

In addition, be sure that medical personnel tape down the epidural catheter AFTER the mother lies back down, rather than while she is still sitting.  Taping the catheter down later can lower the risk that the catheter will migrate and thus be less effective for pain relief.   This is a very important but subtle point, one that is often overlooked or unknown by many anesthesiologists.  

Large women should NOT automatically be required to have an epidural simply because of their size, nor should they be told to have an early epidural because of their size.  It can take multiple tries to place an epidural in larger people, but this is not sufficient justification for early or mandatory epidurals.  

If a cesarean becomes necessary during labor, a spinal can be done about as quickly as topping off an epidural, and in truly emergent situations, general anesthesia is going to be necessary regardless of whether a woman already has an epidural or not.  Requiring or recommending mandatory or early epidurals is fat-phobic policy, and probably actually increases a fat woman's likelihood of having a cesarean and other complications. 

Occasionally some large women are not able to have regional anesthesia for various reasons.  To lower the risk of this happening to you, you may want to have a consultation with the anesthesiology department ahead of time, especially if:

Most of the time, regional anesthesia works just fine for women of size.  Although it is more difficult to administer RA to a larger patient, with care and the right equipment it can usually be done, even in very large women.   

Women's Stories

D.K.'s Story: I don't believe there was any trouble with the epidural needle.  I felt that I was bent over (like a "C") for about the same length of time I have heard the normal epidural takes.

Aramanth's Story: [I had no trouble at all with the epidural.] Both anesthetists I had were *really* experienced and the needle slid home exactly right each time.

Mina's Story: This was one where there were BIG problems...I had an epidural, and it took FOREVER for them to get it in and it was extremely painful because the needle they were using just wasn't long enough.  They weren't numbing me in far enough, so every time they'd try to get the epidural in it was VERY painful.  It took three anesthesiologists a bunch of tries before the last one finally figured out that the needle wasn't long enough, and took a different approach.  

This is one of the things I'm scared about with subsequent pregnancies...I really want to avoid an epidural if I can, because the pain from that was worse than the actual labor pain.  Add that pain on top of contractions I was having every few minutes, and it was pretty difficult to deal with.  It ended up taking them about an hour and a half to finally get the epidural in, although I will say that once it was in it was wonderful after all the pain I'd just been through.

Lj's Story: I had no problem with my first baby.  The epidural worked on the first try and provided complete pain relief.  With my second [baby], they tried several times (four, I think) and each time the needle would shift and I would not be getting any pain relief at all.  I was warned before they even started that my size might make it difficult (and I weighed about 20 lbs. less than I had with my first).  They also said my skin was so "clammy," they were having trouble taping the tubing in place.  I was sweating...and they didn't know how to keep the tubing in place on wet skin.

M.E.'s Story: They had trouble with my epidural.  The anesthesiologist had to attempt it 3 or 4 times before she finally thought it worked and in fact it hadn't.  My *personal* opinion is that she just didn't know exactly what to do for my size.

Kmom's Story: I was induced with my first child, and after they broke my water the pain became unbearable because the baby was not positioned well.  I eventually opted for an epidural.  It did not work well for me.  Although it gave me some relief, I needed multiple redoses, and had a fair amount of breakthrough pain.  When the baby's position prevented a normal birth, a cesarean was chosen.  They topped off the epidural instead of re-placing it (which they should have done), so the epidural wasn't working properly for the surgery.  We think the catheter may have moved during labor, and the baby's poor positioning may also be a factor in the inadequate anesthesia I experienced. It was very difficult.

With my second child, I labored well (without pain medication), but this baby was also malpositioned and got 'stuck.' I was afraid I would have anesthesia problems again in this cesarean, so I insisted we use spinal anesthesia instead.  The spinal worked very well for the surgery, with only a little extra local anesthetic being needed in one spot.  It was a much better experience.  I went on to have a VBAC eventually, but if I ever needed a cesarean again I would choose a spinal or CSEA if it was available.  My research has shown that far fewer problems are encountered with spinals during surgery, and I believe that unless an epidural is already in place from labor, a spinal is the better choice for most cesareans.

C.M.'s Story: I had to be tapped on two separate occasions.  The first one wore off after 12 hours (I was in labor for 25.5 hours).  The first time I got tapped it took up to 10 attempts until I convinced the guy to let me put my legs up on the bed.  With my legs hanging off the bed I couldn't get my big belly...down far enough to get my back arched over enough. Once I got my legs on the bed I sat with the soles of my feet together and my knees out to the sides, and then my belly could hang between my legs and I was able to lean over far enough to give him enough room to work in my spine. On the second tapping, the guy was a butthead and wouldn't agree to let me put my legs on the bed...He finally got in.  That one never "took" though, so it was all for nothing.  

 

Conclusion

Big moms have many concerns about facilities and equipment when they are pregnant.  They worry whether medical facilities will have equipment appropriate for larger women, whether the scales will go high enough for them and their pregnancy gain, whether gowns will  fit them, whether fetal monitor belts will go around them, whether their legs are too heavy to fit in the stirrups, whether longer needles will be needed, etc.  

It is reassuring to know that most of the time, the equipment needs of big moms are able to be met in most facilities.  Most big moms do not report major problems with scales, gowns, stirrups, etc. It is good to know that facilities are finally starting to take the needs of large people into account and are willing to work with them to meet those needs.  (It's about time!)  

However, sometimes there can be problems with equipment or facilities, and you must learn to speak up about these.  Remember that if you need a specialized item, it is often available online, and many places will order it for you if they know about it.  Or you can buy it yourself so you are prepared if the need arises.  Medical personnel need to know when equipment is a problem and what to do about it.   Sometimes, they will only know if YOU tell them.  

Common Equipment Problems To Watch Out For

One of the most common equipment problems for people of size is blood pressure cuffs.  While this doesn't sound like a serious problem, it actually is.  Research clearly shows that using a BP cuff that is too small SIGNIFICANTLY overestimates blood pressure. Undercuffing is particularly serious in pregnancy when even very small "elevations" in blood pressure can lead to very serious interventions, yet many obstetrics workers are less aware of cuff issues. Many big moms anecdotally report problems with undercuffing, and research confirms the problem is still common.  

Undercuffing is one situation where big people find a lot of resistance from health care workers, who often say that cuff size is unimportant, that a big cuff is unavailable, or that cuff size doesn't make that much difference.  It DOES make a difference, and it is VITAL that you know what BP cuff size (large or 'thigh' cuff) is most appropriate for you.  It is also extremely important that you ask about cuff size EVERY TIME your blood pressure is taken, and that you train your labor support to also monitor this for you when you are occupied during labor.

If you are supersized, you will want to check that your provider has a scale that goes high enough, gowns in your size, and "thigh" blood pressure cuffs.  Some supersized women may want to invest in their own gowns and blood pressure cuffs, and if needed, arrange for a scale counterweight if their doctor's office needs one.  Supersized women may also need to check whether they'd need a longer needle if an amniocentesis or regional anesthesia (epidural or spinal) is done.  

Fetal monitors can sometimes be a problem for obese women.  Although most hospitals have monitor belts that fit most big women, sometimes they fit very tightly and are uncomfortable.  Some large women find that their size makes it more difficult to track the baby's heartbeat easily, especially if the baby is malpositioned or highly mobile.  

Some women have found it more helpful if they ask for a fetal monitor from the Prenatal Screening section of the hospital, which sometimes are larger or in better shape than those in Labor and Delivery.  Other women have found it helpful to use an internal monitor (after their waters have broken).  Probably the most useful technique when having difficulty tracking the heartbeat is for someone to hold a Doptone device by hand for intermittent monitoring.  

Tocometers to measure the strength of a woman's contractions are often less accurate in women of size.  Women and their labor support need to be aware that their contractions may not register as strongly on the monitor as they truly are, and they may need to make health care workers aware of this as well.  Sometimes women of size have their contractions augmented with drugs unnecessarily because tocometers can underestimate their contraction strength.  Pitocin should never be added only on the basis of tocometer readings in people of size.   

Sometimes, obese women are told they must be monitored constantly because of their size.  This is size-phobic treatment.  It is not necessary if the mother has no other special health concerns and is not using labor drugs.  Intermittent monitoring is enough for most labors and is highly preferable for the sake of both mother and baby.  

Research clearly shows that women of size are induced more often, have their labors augmented more often, and often are encouraged to have early placement of an epidural in labor, "just in case."  Because of the risks of these procedures, all require continuous monitoring.  So even when a  big mom is not automatically required to have continuous monitoring based on her size, she often ends up with it anyhow as a secondary effect of other size-phobic policies.  Neither early induction, liberal augmentation, nor early epidural placement have been shown to improve outcome and should be avoided whenever possible because continuous monitoring is often a disaster for women of size.

Continuous monitoring ties women down to the bed, does not let them shift positions easily, increases use of pain medications and epidurals, and is clearly shown in research to increase the rate of cesareans without improving outcome.  It is important for women of size to avoid continuous monitoring in labor unless medically required, and to avoid labor scenarios where continuous monitoring becomes necessary (like unnecessary inductions, elective epidurals, etc.).  If you know you may choose an epidural in labor, try to delay it for as long as possible so your exposure to continuous monitoring and restricted mobility is minimized.  

Stirrups can be more uncomfortable if you have very large legs, but almost everybody is able to use them, regardless of size.  However, stirrups are a VERY poor position for birthing a baby and should be avoided unless there is no other choice.  Any back-lying or semi-sitting position for pushing decreases the amount of space for a baby to come out easily, and this can be an important factor especially in big moms.  Big moms do better if they are able to use other positions for birthing, like upright positions, kneeling, hands and knees, one knee up, etc.  Epidurals tend to involve use of stirrups---another reason to avoid choosing an epidural if you can.  However, if you find you need an epidural in labor, try a side-lying position for pushing.  Anything but on your back or in stirrups!

IV placement can be more difficult in people of size.  However, an IV is NOT necessary to have a baby and should not be automatically required.  If hospital personnel hassle you about "needing" an IV, one option is to agree to a Heplock so that an IV port is readily available if an emergency occurs.  If you choose an epidural or your labor is induced/augmented, an IV does become necessary.  If you find that your labor nurse is having trouble placing an IV in you, don't suffer through repeated botched attempts.  Request that the hospital's special IV team be called in for you.  They are specialists in "difficult sticks" and usually are able to accomplish the IV much more easily and painlessly.  

Big moms should realize that it can be harder to place epidurals and spinals in big women, and sometimes it takes multiple attempts.  They may be able to help the process by sitting with their heels together on the bed and leaning forward so that they can hunch over as much as possible. It may also help if a nurse pulls any fat pads to the side if your back is really heavy. These steps help the anesthesiologist palpate the bony landmarks of the spine more easily in heavy women.  The anesthesiologist may also need to use a longer needle for the epidural, especially in supersized women. 

Anesthesiologists should also wait to tape down the epidural catheter until after a big mom has lain back down.  Taping it while the mother is still sitting often results in the catheter being slightly displaced when a big mom lies back down, and thus may cause the epidural to be less effective.  Research shows that the simple step of waiting to tape the catheter until the mother has shifter her position may help the epidural be more effective.

Big moms are sometimes told that because an epidural is more difficult to place in obese women, they should have an epidural done early in labor, "just in case."  This is based on faulty reasoning, and probably increases a big mom's risk for cesarean and other complications.  If anything, big moms should be discouraged  from having epidurals unnecessarily, because of the decreased mobility, increased risk for forceps/vacuum extractor and shoulder dystocia, mandatory continuous monitoring, and increased risk for cesarean associated with epidurals.  

If a cesarean becomes necessary, regional anesthesia is clearly the technique of choice for obese women.  General anesthesia is much riskier, especially for people of size.  Although in a severe emergency general anesthesia may need to be chosen, most cesareans are not so emergent and allow plenty of time for regional anesthesia to be placed.

There are two types of regional anesthesia, the spinal and the epidural, as well as a new technique that combines both the spinal and the epidural together.   If an epidural is already in place from labor, the epidural will be "topped off" for surgery.  However, if it has not been functioning well, the epidural should be re-placed for the cesarean.

If the cesarean is elective or if an epidural is not already in place, many doctors now feel that a spinal is a better choice for a cesarean. Since it is technically easier to do than epidurals, this may be especially true for women of size.  However, again, the anesthesiologist may need to have longer needles to place it effectively.  For the severely obese or those whose medical situation may require a longer surgery, combined spinal epidural anesthesia offers a new and more flexible anesthesia choice, and there are now longer needles for the 'morbidly obese' available for this too.

Become An Advocate For Yourself and Other People Of Size

Most of the time, medical facilities have worked with large people (often far larger than you!) before and have developed techniques for adapting equipment as needed.  And most medical personnel are genuinely concerned and want to help you have a good experience.  Most are willing to listen if you have concerns or suggestions.  As one big mom writes, "Chances are you are not the biggest person they have seen...try not to be self-conscious.  You deserve a positive birth experience, regardless of size!"  

However, size bias exists, and is especially tenacious in some medical personnel and institutions.  They may not always have the correct equipment for your size, or may be reluctant to find ways to help accommodate your special needs. Sometimes, big women encounter downright hostility when they ask for their needs to be met.  You must not let such bias stop you.  

If you are really encountering problems, some big women find it helpful to bring someone with them who can act as an advocate on their behalf.  This is often someone other than your partner, who may find it difficult to really advocate for you because he is wrapped up in his own issues of becoming a daddy.  A friend, a professional labor support person ("doula"), a relative---bring along whomever you feel can separate themselves from the situation and be an objective voice for your concerns and point of view.  Remember that you can also request a patient advocate from the hospital, whose job it is to help mediate with the staff and get your  needs met.  

Big moms have to find the inner strength to KNOW that they deserve a good experience, respectful treatment, and equipment that meets their needs.  They need to find the strength to campaign for what they need, and to speak up about any problems they encounter.  Realize that you may have to educate your health care personnel about the needs of larger people, and that you have to speak up about behavior that is disrespectful or rude.  You may even need to write a letter or speak to a supervisor in some cases.  Resolve to do whatever it takes to get your needs met and to be treated with respect and dignity.  

Speak up for yourself, speak up for all the larger women who will come after you, and for the sake of your children.  

Yes, they probably will have equipment that fits you, but realize that sometimes you may have to educate health care workers  about the needs of larger people, or advocate to get the equipment you need.  Don't hesitate to stand up for your rights and the rights of your child.  You deserve a positive birth experience too!

 

Equipment Resources

The following resources may have equipment for larger-sized people.  There are probably others around as well; if you know of a resource that is not listed here, please email Kmom with details.

Large Blood Pressure Cuffs

Amplestuff

There are 4 cuffs available. Economy Cuffs run between $30-40. Size L is for 13"-19" circumference arms, and size XL is for 17"-26" arms. Deluxe cuffs are MUCH more expensive (like $90!) but these are tapered to fit better, have 'stays' to help keep shape on very large arms, and tend to be more comfortable for the super-sized. The Deluxe Cuffs come in size XL for arms from 17"-26" and size XXL, for arms from 23"-25".

Medical Supply Stores

Check your phone directory to see if there is a medical supply store in your area.  They often carry (or are able to order) large blood pressure cuffs.  There are a number of different sizes of cuffs, so be sure you ask about sizing.

Scales and Scale Adaptors

Medical Supply and Scale Stores

These companies all carry counterweights that can be used on beam balance scales (standard in most doctors' offices).  They will extend a 350 lb. scale up to 450 lbs.  Be sure to ask what brand scale your provider has; you may need to order the exact kind that goes with that brand.  Most counterweights run between $35-60 (averaging about $45), depending on the brand and the company.  Be sure to shop around; you may find it cheaper somewhere else.  

Amplestuff

They have digital scales that go into supersizes, including some that go to 500 lbs. or more.  

Large-Sized Gowns

Exami-Gowns

Sells hospital gowns for consumers, including some in special sizes.  They have strong Velcro closures front and back, and generally come down to about mid-calf.  Ask for the IV gowns where they snap on the arms, in case you need an IV during the birth and for ease of breastfeeding afterwards. Sizes up to at least 4x.  Prices generally run $30-40, cheaper than some of the other custom gown options on the web, and get good reviews from moms who have ordered them. 

NAAFA Feminist SIG (Lynn Meletiche) 

Will custom-make a hospital gown for you.  Will go well into supersizes.  Call or email for details.

 

References

Books

Birth As an American Rite of Passage, Dr. Robbie Davis-Floyd. Berkeley, California:  University of California Press, 1992. Complete book available from Birth and Life Bookstore; excerpts available online at www.itp.tsoa.nyu.edu/~alumni/birthmessages.

Excellent sociological view of how American culture ritualizes birth and how many of the procedures most women encounter are actually not always medically necessary but culturally imposed---an analysis of the technocratic model of birth. *Fascinating* reading!

The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood.  Barbara Katz Rothman.  New York: W. W. Norton & Company, 1993.  Available from www.birthworks.org or www.1cascade.com or www.amazon.com

An excellent overview of the debate over prenatal testing of all kinds, but especially amnios.  Notes that prior bleeding in pregnancy may increase the risk for miscarriage from amniocentesis, among other interesting and rarely-discussed risks of amnios.  Represents multiple points of view fairly.  Author interviewed a number of genetic counselors, doctors and other health professionals, as well as parents who had been through prenatal testing.  Shares the stories of families who chose testing, who received reassuring and non-reassuring results, and the choices that they made.  Not an easy book to read but certainly one that anyone dealing with prenatal testing should read. 

What Every Pregnant Woman Should Know. Brewer, Gail Sforza and Brewer, Tom.  Revised Edition.  New York: Penguin Books, 1985.    

Classic book that discusses how doctors in the past actually caused many cases of pre-eclampsia in women by using diuretics and restricting protein, calories and salt in pregnant women.  These doctors were trying to prevent pre-eclampsia (toxemia) by trying to prevent its symptoms, but they often ended up causing the very problem they were trying to avoid.  In the book, Brewer notes, "Obese women are often incorrectly diagnosed as hypertensive when a standard-size blood pressure cuff is used to take a reading.  When the cuff is too small, additional pressure on the mother's arm reads on the meter as elevated blood pressure.  Using a larger cuff prevents this error."  

Anesthesia and Obesity References

Hamilton, CL et al.  Changes in the position of epidural catheters associated with patient movement.  Anesthesiology.  April 1997.  86(4):778-84.

Authors theorized that taping down the epidural catheter before moving a patient back to the lying down position might cause excessive movement in the catheter and increase the rate of patchy or inadequate blocks.  They hypothesized that this problem was probably particularly significant in obese women and might be the reason for the higher epidural failure rate in obese women.  They set out to see if securing the catheter to the skin AFTER the woman laid back down would decrease the rate of problems, especially in the obese group.  It did.  

"Of particular note was the zero failure rate in our BMI >30 group, given the known increased risk for epidural block failure in obese parturients...Patients who are estimated to be either obese or to have an obese back should lie down before epidural catheter taping because epidural catheter movement is greater in these patients."

Hood, DD and Dewan, DM. Anesthetic and obstetric outcome in morbidly obese parturients.  Anesthesiology.  December 1993.  79(6):1210-8.

117 "morbidly obese" women whose weight exceeded 300 pounds were studied from 1978-1989, then compared with a control group.  An extremely high cesarean rate of 62% was found, many of which were repeat cesarean sections.  Of those who labored, 48% ended up having a cesarean.  [The authors do not specify how many of these were induced and under what limitations they labored; this probably is a factor in this very high cesarean rate.]  Epidural anesthesia was used successfully for labor and cesarean delivery of most of the morbidly obese group.  

"When compared with control patients, initial epidural anesthesia failure was significantly more likely in morbidly obese women, requiring epidural catheter replacement.  Difficult tracheal intubation occurred in 6 of 17 morbidly obese women...Epidural anesthesia is feasible; however, the high initial failure rate necessitates early catheter placement, critical block assessment and catheter replacement when indicated, and provision for alternative airway management."

Ku, A and Ravindran, RS.  Combined spinal and epidural anesthesia for labor and delivery using Gertie-Marx spinal needle.  IMD International Medical Development website.  www.imd-inc.com/w_labordelivery.html 

Studied CSEA with the use of the less-common Gertie-Marx spinal needle.  "Seven out of the 11 patients in whom successful spinal anesthesia could not be accomplished with GM needle in this study were noted to weigh >220 lb."  Thus, if you plan on having a CSEA, you might want to inquire ahead of time whether their needles will be long enough for you.

Endler, GC et al. Anesthesia-related maternal mortality in Michigan1972-1984.  American Journal of Obstetrics and Gynecology.  July 1988.  159(1):187-93.  

Maternal deaths relating to anesthesia were reviewed in Michigan from 1972 to 1984. There were 15 deaths studied; 11 of the 15 had undergone cesarean section, 7 with general anesthesia.  Obesity was a risk factor for 12/15 women who died. 6 deaths were in obese women having a cesarean under general anesthesia. 4 deaths were in obese women having a c/s with spinal anesthesia, but these deaths were all in the early part of the study and there were no regional anesthesia deaths in the second half of the time period after regional anesthesia techniques were refined (pre-loading with I.V. fluids and smaller anesthesia doses).  

Hypertensive disorders of pregnancy were a risk factor in more than half of all the deaths.  Because the hypertensive mother tends to have a constricted blood volume and because of the "sympathetic blockade" regional blocks produce, regional anesthesia can cause precipitous drops in blood pressure.  Therefore, pre-loading with IV fluids ahead of time is important (and helped prevent further deaths in the second half of the study period), but doctors must be careful not to overload fluids either, which can produce pulmonary edema.  Should a patient with a hypertensive disorder need general anesthesia and intubation, this is also more difficult because they have a tendency towards laryngeal edema. Thus hypertensive disorders are a major risk factor for any type of anesthesia.

Besides hypertensive disorders and obesity, other significant risk factors included a truly emergent operation (12/15 patients) and race (13/15 were black).  Many of those who died had 2 or 3 of all of these risk factors together; only 1 person who died did not have any of these risk factors.  In particular, deaths were most common in black obese women with severe and/or poorly controlled hypertensive disorders of pregnancy.

The study notes several difficulties of anesthesia in obese patients.  First, when an endotracheal tube is placed, it may be difficult to hear breath sounds properly to verify the proper location of the tube, so the tube may be placed improperly.   Second, the combination of pregnancy and obesity causes a higher intra-abdominal pressure, and this causes a greater spread of local anesthetics injected into the spine, so it is easy to overdose a patient inadvertently and cause respiratory difficulties.  Third, very heavy patients are more sensitive to the respiratory depressant effects of drugs used in cesarean anesthesia.

To lower the risk for maternal death due to anesthesia problems, the authors suggest using regional anesthesia more often, a more well-developed plan for dealing with airway problems, equipment improvements, and the routine use of antacids.

Conklin, KA.  Can anesthetic-related maternal mortality be reduced?  American Journal of Obstetrics and Gynecology.  July 1990.  163(1 Pt 1):253-4.  [letter]

The author of this letter notes that "at least 90% of maternal deaths [due to anesthesia] are attributable to general anesthesia, primarily as a result of failed endotracheal intubation or pulmonary aspiration of gastric contents."  The author also states, "I also believe that the morbidly obese parturient is especially suited for regional anesthesia.  Obese individuals, because of more difficulties with intubation and higher gastric volume, lower gastric pH, and diminished barrier pressure (lower esophageal sphincter tone minus intragastric pressure) compared with normal patients, are exposed to much greater risk during general anesthesia..."

"I believe, as do others, that regional anesthesia...is the technique of choice for cesarean section in the obese parturient.  In addition to eliminating the risks of inducing unconsciousness and performing endotracheal intubation, use of regional anesthesia reduces postoperative pulmonary complications in obese patients. Intraspinal narcotics can be used, and obese individuals who receive epidural narcotics for postoperative analgesia ambulate earlier, suffer fewer pulmonary complications, have shorter hospital stays, and have less respiratory depression than patients who receive parenteral narcotics."

"Another situation in which I think increased use of regional anesthesia is appropriate is that of emergency cesarean for fetal distress. Although many clinicians favor general anesthesia in this situation, use of regional anesthesia (epidural via catheter already in place, or spinal) results in equivalent or better neonatal outcome, despite the fact that institution of regional anesthesia may (but not necessarily) take longer.  This is probably because of the fact that general anesthesia compromises uterine blood flow and fetal well-being, in association with enhanced maternal sympathetic nervous system activity from endotracheal intubation and maternal cardiovascular depression from the thiobarbiturate, whereas regional anesthesia blocks sympathetic nervous system activity and improves uterine blood flow (provided adequate fluid preloading is used)."

"In my opinion, regional anesthesia is the technique of choice in all situations (including emergency cesarean section and for the morbidly obese parturient) unless an absolute contraindication exists."

Kuczkowski, K and Benumof J.  Repeat Cesarean Section in a Morbidly Obese Parturient: A New Anesthetic Option.  Acta Anaesthesiol Scand.  July 2002. 46(6):753-4.

Until recently, Continuous Spinal Epidural Anesthesia (CSEA) was not an option for very heavy women, because the needles were not long enough.  However, this is a case report of the "recently introduced, commercially produced CSEA needle set, specifically designed for morbidly obese patients."  

This repeat cesarean (her fourth) was performed on a 460 lb. woman.  Her first 3 cesareans were done with a single dose spinal (which worked well), continuous epidural (which proved inadequate), and continuous spinal (which worked well but gave her a severe postdural puncture headache).  Given her size, history of anesthesia problems, and history of multiple cesareans (which might require an extended surgical time), the doctors opted for CSEA. 

They note, "As most cesarean sections in morbidly obese patients require longer ('uncertain') operative time, the CSEA technique may be uniquely advantageous for these patients."  They also note that some studies have reported a very low incidence of spinal headache with CSEA, and this may be especially helpful for women with a history of spinal headaches from anesthesia.  They also note that the CSEA technique may help confirm needle placement in obese women, another advantage.  "In conclusion, the introduction of a new (longer) needle design, the CSEA technique should become an attractive anesthetic option for the morbidly obese patient."

Electronic Fetal Monitoring

Banta DH, Thacker SB.  Historical controversy in health technology assessment: the case of electronic fetal monitoring.  Obstet Gynecol Surv 2001 Nov;56(11):707-19.

"Electronic fetal monitoring (EFM) was introduced in the late 1950s as an alternative to traditional auscultation by stethoscope or fetoscope in the management of labor and delivery. The new technology was seen as a valuable tool in the prevention of cerebral palsy and other adverse fetal outcomes and diffused rapidly into clinical practice. In the late 1970s, some scepticism began to be voiced about the evidence for the effectiveness of EFM. The authors published a systematic review of the evidence in 1979 that concluded that there was insufficient evidence for the effectiveness of the routine use of EFM and a clear rise in the cesarean delivery rate associated with its use. The analysis was based on a thorough review of approximately 600 books and articles, but focused heavily on the evidence of four randomized clinical trials (RCTs) that had been published. An economic analysis further underscored the importance of this issue. The report was met with harsh ad hominem criticism from clinicians both in public venues and in the medical literature. Subsequently, additional RCTs were conducted and other analyzes were published, and in 1987 the American College of Obstetricians and Gynecologists recommended that auscultation was an acceptable alternative to EFM in routine labor and delivery. Yet, today EFM continues to be the standard of practice, used in 80% of labors in this country. The most important conclusion drawn from this experience is the need to evaluate new technologies before their widespread diffusion into clinical practice."

Blood Pressure Cuff References

Maxwell, MH et al.  Error in Blood-Pressure Measurement Due to Incorrect Cuff Size in Obese Patients.  Lancet.  July 3, 1982.  2(8288):33-6.  

Classic study that found that 37% of obese "hypertensives" were actually normotensive, and had been misdiagnosed because the wrong-sized cuff was used.  They recommended the following cutoffs for arm size/cuff size:  <33 cm (13 inches) = regular cuff;  33-41 cm (13-16 inches) = large cuff; and >41 cm (16 inches) = thigh cuff.  Also has a fascinating 'conversion' table for correction of blood pressures taken with different sized cuffs.  

O'Brien, E. Review: A Century of Confusion; Which Bladder for Accurate Blood Pressure Measurement? J Human Hypertens. September 1996.  10(9):565-72. 

"The use of cuffs containing inappropriate bladders is a serious source of error which must inevitably lead to 
incorrect diagnosis in practice, and erroneous conclusions in hypertension research. There is unequivocal evidence that either too narrow or too short a bladder (undercuffing) will cause overestimation of BP...A detailed review of the literature permits a definitive statement on bladder dimensions for a given arm circumference and clearly indicates that substantial error is caused by the use of inappropriate cuffs." 

Wittenberg, C et al. Which Cuff Size is Preferable for Blood Pressure Monitoring in Most Hypertensive Patients? J Hum Hypertens. November 1994. 8(11):819-22.

"These findings suggest that in overweight hypertensives, the use of the standard cuff results in overestimation of 
BP and that large cuffs should be used exclusively in this population."

Guagnano, MT et al. Many Factors Can Affect the Prevalence of Hypertension in Obese Patients: Role of Cuff Size and Type of Obesity. Panminerva Med. March 1998. 40(1):22-7. 

Found that when the correct large-sized cuff was used, the prevalence of hypertension was "strikingly lower" in 
overweight and obese women, compared to when the regular-sized cuff was used. Also investigated the role of type of obesity in hypertension; basically, apple shapes were much more likely to have true hypertension than pear shapes (53% vs. 29%).

Graves, JW. Prevalence of Blood Pressure Cuff Sizes in a Referral Practice of 430 Consecutive Adult Hypertensives. Blood Press Monit. Feb 2001. 6(1):17-20. 

"Overestimation of blood pressure by using an inappropriately small cuff has been well documented." This study examined whether large cuffs were routinely available in those treating hypertensives, and cautions providers to have a range of cuffs.

Feher, MD et al. Fat Arms, Obesity and Choice of Blood Pressure Cuff Size in Diabetic Patients. Br J Clin Pract. Nov-Dec 1995.
49(6):286-7. 

Found that in their diabetic clinic, research showed most patients with a BMI > or = 25 were "likely to 
require an alternative adult BP cuff [i.e. a large cuff--kmom] if their blood pressure is to be measured
precisely." Used an arm circumference cutoff of 29 cm (11.4 inches) for needing a larger cuff.

Linfors, EW et al. Spurious Hypertension in the Obese Patient. Effect of Sphygmomanometer Cuff Size on Prevalence of Hypertension. Arch Intern Med. July 1984. 144(7):1482-5. 

"The prevalences of high blood pressure and borderline high blood pressure were twofold greater with the standard cuff than with the large adult or thigh cuffs in obese patients (arm circumference greater than or equal to 35 cm or body mass index greater than or equal to 34 or weight greater than or equal to 95 kg. Routine use of the large adult cuff will provide accurate BP measurement and avoid unneeded evaluation and treatment."

Stirrups and Birth Positions References

Borgatta L et al.  Association of episiotomy and delivery position with deep perineal laceration during spontaneous delivery in nulliparous women.  Am J Obstet Gynecol 1989 Feb;160(2):294-7.

"Spontaneous deliveries of 241 nulliparous women were analyzed to test the hypothesis that both episiotomy and use of stirrups for delivery of infants were related to the occurrence of third- and fourth-degree perineal lacerations. These deep perineal tears occurred in 0.9% of the women delivered of infants without the use of either episiotomy or stirrups and in 27.9% of the women delivered of infants with both episiotomy and stirrups. Women exposed to episiotomy alone or to stirrups alone had intermediate rates of laceration. There was no independent correlation of laceration with maternal age, 1- and 5-minute Apgar scores, or midwife or physician as delivery attendant. The results suggest that selective use of episiotomy and stirrups can minimize perineal trauma during spontaneous delivery in nulliparous women."

Golay J et al.  The squatting position for the second stage of labor: effects on labor and on maternal and fetal well-being.  Birth 1993 Jun;20(2):73-8.

"A cohort study was designed to assess the effects of maternal squatting position for the second stage of labor on the evolution and progress of labor, and on maternal and fetal well-being. Outcomes from 200 squatting births, randomly selected from a sample of 1000, were compared with 100 semirecumbent births, randomly selected from a sample of 300. Data collection was by chart review. The two groups were similar with respect to most antepartal, intrapartal, and socioeconomic variables likely to affect labor outcomes. The mean length of the second stage of labor was 23 minutes shorter in squatting primiparas and 13 minutes shorter in squatting multiparas than in semirecumbent women. Squatting women required significantly less labor stimulation by oxytocin during second stage (P = 0.0016), and they showed a trend toward fewer mechanically assisted deliveries. Significantly fewer and less severe perineal lacerations occurred, and fewer episiotomies were performed in the squatting group (P = 0.0001). No statistically significant differences were found between groups for third-stage complications and infant complications."

de Jong PR et al. Randomised trial comparing the upright and supine positions for the second stage of labour.  Br J Obstet Gynaecol 1997 May;104(5):567-71.

"Five hundred and seventeen women of low obstetrical risk assigned to deliver at the nursing home. RESULTS: The trial showed that women who adopted the upright posture for delivery experienced less pain. perineal trauma and fewer episiotomies than those who delivered in the supine position. CONCLUSION: The data suggest that in women of low obstetrical risk, choice of posture during delivery may be encouraged."

Gardosi J et al.  Alternative positions in the second stage of labour: a randomized controlled trial.  Br J Obstet Gynaecol 1989 Nov;96(11):1290-6

"A controlled clinical trial involving 151 primigravidae and 18 midwives assessed the acceptability and outcome of second-stage labour in upright positions. Women who had no specific antenatal preparation and preferences regarding labour positions were managed either conventionally (semi-recumbent and lateral), or encouraged to adopt upright positions (squatting, kneeling, sitting or standing) according to individual preference. Of the women allocated to the upright position 74% completed the second stage upright, with kneeling being the most favoured position, but squatting was, despite all assistance, too difficult to maintain. Adoption of upright positions resulted in a higher rate of intact perineums. There was a clinically apparent reduction of forceps deliveries in the upright group which influenced midwives' attitudes. Moving the parturient from recumbent to upright positions was often perceived to be beneficial when there was slow progress. Estimated blood loss was similar in the two groups, as was the condition of the newborn (Apgar score and umbilical artery pH). Alternative positions in the second stage of labour, in particular kneeling, are achievable even without specific birth aids and antenatal preparation. They appear safe, acceptable to most parturients and their midwives, and are easily integrated into modern labour ward practice; they may have clinical advantages which need further investigation."


Copyright 1996-2003 KMom@Vireday.Com. All rights reserved. No portion of this work may be reproduced or sold, either by itself or as part of a larger work, without the express written permission of the author; this restriction covers all publication media, electrical, chemical, mechanical or other such as may arise over time.


[ Back to Kmom Area ]