Monday, September 15, 2014

PCOS Series Resumes

Image Credit: Jessi from www.LifeAbundant-Blog.com 
September is PCOS Awareness Month.

In honor of the many women of size who suffer with Polycystic Ovarian Syndrome (PCOS), we will be resuming our series of posts about PCOS this month.

In previous posts, we have discussed the definition and symptoms of PCOS, how it presents, its testing and diagnosis, and its possible causes.

Then we began discussing common treatment protocols for PCOS, and the pros and cons of each.   We've already discussed insulin-sensitizing medications like metformin, the TZDs, and inositol. Then we discussed glucose-lowering medications for those who have developed overt diabetes. We also discussed the use of progesterone for menstrual irregularity. Now it's time to continue that discussion about other treatment options for various aspects of PCOS.

Next up is a discussion of Oral Contraceptives for menstrual regularity and control of androgenic symptoms. Then we will continue the series with a discussion of anti-androgen medications, and finish up with a discussion of cosmetic treatment options for some of the most distressing side effects of PCOS, like hirsutism, cystic acne, and alopecia.

One of the difficult things about PCOS is how differently it can present in different women. Very few women suffer all the possible symptoms. I'm fortunate that my case is fairly mild, but that makes it more challenging to write about things I haven't personally experienced. Although I can write about it from an intellectual point of view, it's really important to bring out the personal stories of women and how they've dealt with the challenges of this condition.

Therefore, I am particularly looking for more personal stories to share. Stories have already been submitted, but I would like to have many more. Please spread the word on PCOS forums and social media.

Your submission need not be long; just a quick summary of your experiences with an oral contraceptive, an anti-androgen medication, or how you have dealt with hirsutism, acne, or alopecia. Don't forget to give permission for me to share your story and how you want it attributed (anonymous or first name only). Send your submission to me at kmom AT  plus-size-pregnancy DOT  org. (But remember, we want to avoid weight loss talk.*)

As a springboard to the renewal of the PCOS series, I invite you to leave a comment (feel free to be anonymous) about the most challenging or distressing symptom/aspect of PCOS for you. It's a hard condition to have, and the symptoms can provide many social and emotional challenges. Sharing about those is important for healing and dealing with the condition more proactively. Please share about your particular challenges so other women will know that they are not alone.

More PCOS posts will be forthcoming in the future, but for now, this is the current focus. I welcome appropriate feedback on the posts and hope the information is helpful to you.

*Please note that we are discussing PCOS treatment options from a size-friendly point of view (meaning no promotion of/focus on weight loss; no diet talk/no hate talk allowed in comments). There are plenty of other PCOS resources out there that promote weight loss or dieting approaches as treatment. You are certainly welcome to pursue that if you wish, but if you are only interested in that, this is not the site for you. Please find the site that is right for your needs. 
Remember, though, weight loss is not the only way to treat PCOS! Lifestyle management does not have to include trying to lose weight. The Health At Every Size® and HAES® approach to improve health and manage PCOS symptoms can also be useful. What we want here is a safe place to discuss PCOS treatment that does not center on weight loss, radical diets, or body hate talk; sadly, a safe place like that can be hard to find on many PCOS forums. Considering the tremendous failure and regain rate of diets (and the huge profits this brings the weight-loss industry), a weight-neutral approach to PCOS is long overdue. 

Tuesday, September 9, 2014

Preparing Your Family for an Emergency


Among other things, September is National Preparedness Month.

This means it's time to shore up your preparations for unexpected emergencies. This kind of preparation is especially important if you have children or other family members dependent upon you.

You should be asking yourself, do I have enough supplies to get through an emergency where grocery and water supplies might be interrupted? Do I know my school or childcare's emergency plans? How will I reunite my family after an emergency?

Here is a link to an article about emergency planning for families. Among the important points of the article, the author points out that:
  • Despite their disaster risk concerns, the majority of parents (63 percent) are not very familiar with emergency plans at their child’s school or child care
  • Two thirds (67 percent) don’t know if emergency drills are held frequently, or at all
  • Two in five (42 percent) wouldn't know where to reunite with children if evacuated from school or child care
So let's talk about a few important points for family emergency planning:

  • Family Emergency Kits
  • Family Communication Plans
  • Evaluating School Emergency Plans 
Family Emergency Kits

Many parents haven’t set aside key disaster supplies, such as the bare minimum three-day supply of food and water. (Most experts agree that a five-to-seven-day supply is better, and many recommend at least a two-week supply.)

It's most optimal to have multiple kits; one for at home, one in an outbuilding or garage near your home in case you can't get into your home due to damage, and one for your car in case you are away from home when an emergency occurs. Some people choose to have a small emergency kit for their workplaces as well.

These kits don't need to be elaborate. Remember, something is better than nothing.

Yet nothing is what most people have. Even if your kit isn't perfect or doesn't have every recommended thing in it, get SOMETHING going.

Water

The most critical thing to have on hand after a disaster is fresh drinking water ("potable" water). Have a gallon of fresh water in your car, just in case. Because a car is subject to extremes of temperatures, this water should be rotated every 6-12 months, but this is a very easy thing to do.

At home, store a few 5-gallon containers of drinking water in your house or outbuilding in case your regular water supply is disrupted. Each person in the household needs at least 1 gallon of water per day. Don't forget to add in some water for pets too.

Portable water bottles are an important part of any emergency kit. The best are stainless steel so they can be directly heated over a fire.

You should also have a way to filter and purify water in case the emergency extends beyond your stored water supply. You can read more about that process here. Water storage and purification supplies can be bought at most camping stores.

Food

Ready-made snacks are helpful for your emergency kit. Foods such as granola bars, energy bars, and fruit leather pack well and last a long time. Don't forget food for your pets too.

Emergency Information Card

An emergency information card is helpful. This should contain a recent picture of your child, a recent picture of your family, emergency contact information for family members, home address and phone number, the name and number for your child's doctor, a physical description of your child, a list of any special conditions/medications, and an out-of-state emergency contact. 

Most children benefit from a small activity in their emergency bag. A deck of cards, a small game, or a few small toys give an evacuated child something to do and bring a sense of familiarity and safety to an insecure situation. Young children also benefit from a comfort object, like a small stuffed animal, as well as a hand-written letter from a parent to offer them reassurance and love.

Family Communication Plan

Think of all the time you spend separated from your children each day, either due to work or school or their various activities. If an emergency occurs when you are away from your children, how will you find each other? How will you communicate?

A Family Communication Plan can help family members reconnect after an emergency. This doesn't have to be an elaborate plan; it can be quite simple. The key is to have talked about your plan before an emergency occurs.

Create Paper Back-Ups of Important Numbers

Create a paper copy of important contact phone numbers; this can be combined with the emergency information card listed above. Store a copy in each person's backpack, purse, or vehicle.

Most kids today don't bother to memorize their parents' cell phone or work numbers, let alone their relatives' numbers. It's all in their cell phones, so they don't feel the need to memorize anything. But phones fail, get damaged, get lost, or run out of power. Having a paper copy with all contact information on it is important as a back-up.

Even if your child knows all these numbers by heart, a person under stress can forget everyday information like where they live or their own phone number.Memorizing important phone numbers is still a good thing to do, but it's best to have paper back-up too, just in case.

Also designate an out-of-state contact as your emergency notification number. Ironically, it is often easier to reach someone out of state than it is to reach someone locally after a disaster. Have someone far away be the person who helps facilitate communication between family members. Have that number programmed into everyone's phone and written into your emergency information card.

TEXT, DON'T TALK!

If a disaster occurs, your first priority is securing your own safety and that of those around you. As soon as you can manage, however, use your cell phone to send a text message to your family members. Remember, experts recommend that you TEXT, DON'T TALK. 

After an emergency, phone networks will be overwhelmed, and many cell towers will go down pretty quickly or have limited power. Texting takes only a brief amount of power and as a result texts are much more likely to go through during an emergency.

Create a texting tree for your most important contacts. Send a brief message as soon as you safely can after an emergency, as it is more likely to get through sooner than later. Briefly summarize how you are and where you are, remind everyone of your designated meeting place, and tell them to update their status with the out-of-state emergency contact.

You can also briefly post to social media like Facebook or Twitter to let a wider circle of people know that you are all right. Minimize contact, though, to reduce network congestion and help others get through to their families.

The Red Cross also has a program called "Safe and Well" which can help you communicate with loved ones in a disaster. This can help people who have been evacuated to a shelter but who may have very limited online access to connect with loved ones.

Put "ICE" Contacts Onto Your Phone

Identify several ICE ("In Case of Emergency") contacts and program them into your phone. There are smartphone ICE apps now (some free, some at a very low cost) that will show ICE numbers on the cover wallpaper of your cell phone (without someone having to know your phone code to unlock it).

Emergency Responders have been trained to look at your phone to see if there are ICE numbers available. If you are unconscious, they will contact those ICE numbers for you. The emergency information card in your wallet or purse can also serve this function if your phone is damaged or lost, but most Emergency Responders will look at your phone first.

Again, have the information in more than one place. Have it on your phone because that is the first place Emergency Responders will look, and also on a paper back-up in case your phone is broken or not accessible.

Designate a Family Meeting Place

If the family is apart when an emergency happens, where will you meet? The first choice is usually at home, but what if your home is damaged or the neighborhood off-limits because of road washouts from a storm or toxic fumes from a chemical spill?

Be specific about where you'll meet. If you are going to meet at a church, are you going to meet in on the front steps? The back entrance? By the announcements board?

Designate a back-up emergency meeting place in case your first choice doesn't work out. Experts also suggest a regional meeting place in case you have to evacuate out of the immediate area and are not allowed to return for a while.

Establish Retrieval Responsibilities 

Establish ahead of time who is responsible for retrieving which child. If you have multiple children in different schools or activities, having someone assigned ahead of time to each of those children will help minimize duplication of efforts and wasted time. If there is only one parent available, then establish a routine of which child will be fetched in what order (usually youngest to oldest).

Evaluating School Emergency Plans

By a certain age, most kids spend considerable time away from their parents at school or daycare or other activities. How can you help these organizations improve the students' safety profile for when you are not there?

One way to help them is to evaluate their emergency plans and press them to improve drills and planning. Another is to familiarize yourself with their Family Reunification Plan.

Improving Emergency Drills

Your school undoubtedly already holds regular fire drills, since this is required of all public and private schools by law. However, you should ask further questions about the types of drills your school holds. Some not only have fire drills, they also have drills unique to the potential disasters in their area, such as earthquakes, tornadoes, or tsunamis. In addition, many schools these days have Lock-Down Drills and Shelter-In-Place Drills. Ask your school which drills they are holding and press them to hold drills appropriate to the area they are in. 

Also encourage your school administrator to hold emergency drills with a twist. Many kids know exactly what to do if a fire drill occurs in the middle of class (which is when nearly all fire drills are held). But what if a fire occurs during recess? During passing time/bathroom breaks? What if your child's designated exit is blocked during the fire? It's important for schools to practice not just "plain vanilla" drills, but also Deluxe Drills, where unexpected things happen or where drills occur at times of more confusion. 

Reunification Plan

Become familiar with your school's Emergency Reunification Plan. Would you know where you should report to pick up your child in an emergency? Do you know what the protocol is to sign your student out?

Because schools are legally accountable for knowing where students are at all times, there must be an orderly reunification process that documents all actions. Parents will not be allowed to just rush in and grab their children and leave. 

Usually students will be evacuated to a designated area, away from parents and the school building. Parents come to an assigned reunification area and request their student. A runner brings the child to the reunification area, the parent shows ID verifying their identity and signs the child out, and then the parent may leave with the child.

You can save a lot of time and stress by knowing ahead of time where the reunification area is and heading straight there. Also ask how your school plans to communicate with parents in an emergency situation if power is out or phone networks are overwhelmed. It may be that the planned reunification area has to be moved.

As with emergency drills, work with your administrators to improve the planning around the family reunification process. Encourage them to actually do a dry run some time so they can see what the strengths and weaknesses of the procedure are before a true emergency occurs. 




Summary

Emergencies can be scary, but remember, most don't turn into life and death situations. Even so, having a good emergency kit, a family communication plan, and knowing your school's emergency plans can help keep an emergency situation more low-key and less confusing.

And in a true emergency, these things might just save some lives. So take the opportunity of National Preparedness Month and review your family emergency planning today.

Tuesday, September 2, 2014

Obstetric Insanity: An 80% Cesarean Rate in Super Obese Women?

Here is a recent study showing just how severe the problem of high cesarean rates in "obese" women is.

I have not read the full text of the study yet, but was so struck by the outrageous numbers in the abstract that I had to comment.

In this study, the authors unapologetically document a sky-high cesarean rate of 80% in women with a BMI above 50.

Women with a BMI over 50, by the way, is the newest scapegoat of bariatric obstetrics. By focusing on the most obese group, these docs can ratchet up hysteria around obesity and drum up support for extreme interventions (even though intentional weight loss and its rebound afterwards is usually a substantial contributor to this level of obesity).

Listen to the emotionally-loaded way the authors discuss "Globesity." It's no wonder their patients have an 80% cesarean rate; they obviously see this group as a ticking time-bomb waiting to explode.

It's not that we should ignore that this group can have significant complications; they can. Some of them are documented in this study, including a maternal death and an increased rate of stillbirths. We can and should be concerned about these complications and debate ways to lower their rate.

But an 80% c-section rate? A 44% primary cesarean rate? How in the world can they justify that, even when complications exist?

Especially when a British study of women in the same BMI group found that 70% were able to give birth vaginally when given the chance!

We must get away from this obstetric culture of hysteria around obesity. We shouldn't ignore or downplay the risks, but we must not respond to those risks by introducing these women to even more risk by exposing EIGHTY PERCENT of them to the substantial risks of surgery, infection, anesthesia problems, and the downstream effects of cesareans.


Reference

Obstet Gynecol. 2014 May;123 Suppl 1:159S-60S. doi: 10.1097/01.AOG.0000447159.35865.07. Perinatal outcomes in the super obese: a community hospital experience. Papp MM1, Lindsay A, Mariona F, Chatterjee S. PMID: 24770057
INTRODUCTION: Globesity is recognized by the World Health Organization as a pandemic issue. Obesity is considered the second leading cause of preventable death in the United States. Michigan is considered the fifth fattest state in the country. METHODS: Ongoing observational study involving pregnant women with body mass index equal or above 50 kg/m. The study was approved by the Wayne State University institutional review board. The patients were identified in the outpatient clinic and private practice offices and followed during their prenatal care and delivery. RESULTS: One hundred thirteen women are included. Body mass index was between 50 and 106 kg/m. Delivery occurred between 26 and 40 weeks of gestation. A total of 44.24% were delivered by primary cesarean delivery, 36% by repeat cesarean delivery, and 19% by vaginal delivery...Wound infection occurred in 17%. CONCLUSIONS: Pregnant women with extreme obesity incurred a significantly higher number of obstetric-medical complications during the prenatal, intrapartum, and postpartum periods than their counterparts with recommended body mass index. Public health officials and clinicians must join efforts to increase the population awareness of the implications of obesity during pregnancy and the postpartum period. The effect of maternal obesity on the offspring should prompt a community effort to improve preconception health and weight control to improve the maternal and neonatal health.

Monday, August 18, 2014

Even "Complicated" Pregnancies Should Labor Whenever Possible


There's an interesting new study out from Finland. 

I haven't read the full study yet, but from the abstract it looks like the gist is that even in "complicated" pregnancies, women should be given a chance to labor and have a vaginal birth, not just scheduled for a cesarean. 

Many times, in "complicated" pregnancies, there are care providers who believe that there is no point in "trying" for a vaginal birth. They just plan to do a cesarean before labor. They feel they will minimize maternal morbidity that way. 

Not all providers are like this, by any means, but there certainly are quite a few out there that just jump from "complicated" to "planned cesarean."

This very large study shows that the best outcomes were associated with planning a vaginal birth

Of course, each case has to be judged on an individual basis. This study doesn't mean that a planned cesarean is never appropriate; just that outcomes were better on a population-wide basis if the women were usually given the chance to have a vaginal birth.

The only exception was in pre-eclampsia, which in severe cases can sometimes have very poor outcomes. But outcomes in women with pre-eclampsia were equivalent between vaginal birth and planned cesarean...so you could certainly make a case for laboring there too, as long as the condition of the mother and the baby allow it. 

Bottom line, care providers should utilize planned cesareans only when truly necessary. 


Reference

Arch Gynecol Obstet. 2014 Aug 13. [Epub ahead of print] The impact of maternal obesity, age, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity by mode of delivery-a register-based cohort study. Pallasmaa N1, Ekblad U, Gissler M, Alanen A. PMID: 25115277
PURPOSE: To determine the rate of severe maternal morbidity related to delivery by delivery mode and to assess if the impact of studied risk factors varies by delivery mode. 
METHODS: A register-based study including all women having singleton delivery in Finland in 2007-2011, n = 292,253, data derived from the Finnish Medical Birth Registry and Hospital Discharge Registry. Diagnoses and interventions indicating a severe maternal complication were searched and the mode of delivery was assessed by data linkage. The impact of obesity, maternal age 35 years or more, pre-eclampsia and insulin dependent diabetes on severe maternal morbidity (all severe complications, severe infections and severe) was studied in each mode of delivery and calculated as Odds ratios.  
RESULTS: The overall incidence of severe complications was 12.8/1,000 deliveries. The total complication rate was lowest in vaginal deliveries (VD) in all risk groups. Obesity increased the risk for all severe complications and severe infections in the total population, but not significantly in specific delivery modes. Age increased the risk of hemorrhage in VD. Pre-eclampsia increased the risk for hemorrhage in all deliveries except elective CS. In women with pre-eclampsia, overall morbidity was similar in VD, attempted VD and elective CS. The presence of any studied risk factor increased the risk for complications within the risk groups by the high proportion of emergency CS performed.  
CONCLUSIONS: An attempt of VD is the safest way to deliver even for high-risk women with the exception of women with pre-eclampsia, who had a similar risk in an attempt of VD and elective CS.

Sunday, August 3, 2014

Very Low Weight Gain or Gestational Weight Loss in Pregnant Obese Women Risky

[Actual news headline and picture from 2009 media release
because, you know, all obese pregnant women are
constantly stuffing their faces with chocolate]

Here is yet another study that confirms the potential risks of extreme restrictions of prenatal weight gain in women of size.

In this study done by the prestigious MFMU Network, gestational weight loss or a very low weight gain (less than the 11-20 lbs. recommended by the Institute of Medicine) in "obese" women was associated with about twice the rate of Small-for-Gestational-Age (SGA) babies.

This is a concern because SGA babies are at higher risk for metabolic disease as they grow older, including insulin resistance, diabetes, abdominal fatness, the metabolic syndrome, and cardiovascular disease.

In the rush to "cure" obesity, are care providers increasing the next generation's risk for the very conditions they are trying to prevent?

Alarmingly, many clinicians continue to advise high-BMI women to gain little or no weight in pregnancy (even with twins), and some are still telling women of size to lose weight during pregnancy.

This study joins several others that should indicate that extreme prenatal weight gain restriction is not advisable.

Reference

Am J Obstet Gynecol. 2014 Feb 11. pii: S0002-9378(14)00121-5. doi: 10.1016/j.ajog.2014.02.004. [Epub ahead of print] Inadequate weight gain in overweight and obese pregnant women: what is the effect on fetal growth? Catalano PM1, Mele L2, Landon MB3, Ramin SM4, Reddy UM5, Casey B6, Wapner RJ7, Varner MW8, Rouse DJ9, Thorp JM Jr10, Saade G11, Sorokin Y12, Peaceman AM13, Tolosa JE14; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. PMID: 24530820
OBJECTIVE: We sought to evaluate inadequate gestational weight gain and fetal growth among overweight and obese women. STUDY DESIGN: We conducted an analysis of prospective singleton term pregnancies in which 1053 overweight and obese women gained >5 kg (14.4 ± 6.2 kg) or 188 who either lost or gained ≤5 kg (1.1 ± 4.4 kg). Birthweight, fat mass, and lean mass were assessed using anthropometry. Small for gestational age (SGA) was defined as ≤10th percentile of a standard US population. Univariable and multivariable analysis evaluated the association between weight change and neonatal morphometry. RESULTS: There was no significant difference in age, race, smoking, parity, or gestational age between groups. Weight loss or gain ≤5 kg was associated with SGA, 18/188 (9.6%) vs 51/1053 (4.9%); (adjusted odds ratio, 2.6; 95% confidence interval, 1.4-4.7; P = .003). Neonates of women who lost or gained ≤5 kg had lower birthweight (3258 ± 443 vs 3467 ± 492 g, P < .0001), fat mass (403 ± 175 vs 471 ± 193 g, P < .0001), and lean mass (2855 ± 321 vs 2995 ± 347 g, P < .0001), and smaller length, percent fat mass, and head circumference. Adjusting for diabetic status, prepregnancy body mass index, smoking, parity, study site, gestational age, and sex, neonates of women who gained ≤5 kg had significantly lower birthweight, lean body mass, fat mass, percent fat mass, head circumference, and length. There were no significant differences in neonatal outcomes between those who lost weight and those who gained ≤5 kg. CONCLUSION: In overweight and obese women weight loss or gain ≤5 kg is associated with increased risk of SGA and decreased neonatal fat mass, lean mass, and head circumference.

Thursday, July 24, 2014

Induction or Waiting in Obese First-Time Mothers?


This is a follow-up post about a study reported on briefly here earlier this year.

It is about the question of whether "obese" women should have their labors induced proactively at term or be expectantly managed, and whether elective induction increases their risk for cesarean and other poor outcomes (like fetal distress, more Neonatal Intensive Care Unit utilization, etc.).

Induction of Labor: Help or Harm?

Induction of labor is an increasingly common intervention in women of all sizes. The question is whether it does more harm than good.

Much research shows it is associated with an increased risk for cesarean, but other research does not always show this. A definitive answer still eludes us on whether/when induction is appropriate.

Complicating this question is the whether or not the mother's cervix is ripe. Inducing on a very ripe cervix is much less likely to lead to a cesarean than inducing on an unripe cervix (Bishop Score less than 5-7, or cervical dilation more than 3 or 4).  And this is especially true in first-time mothers (nulliparous women).

An increased maternal BMI complicates this debate because of a perceived heightening of risk. One of the biggest dilemmas facing maternity care providers who are caring for "obese" women is how to manage them at term. Should they electively induce labor at 39 or 40 weeks, or should they wait for labor to start on its own if no complications occur?

Many care providers these days seem to be electively inducing obese women at 39 or 40 weeks, sometimes regardless of cervical ripeness (when they are not trying to talk them into a planned cesarean).

Many have the best intentions with this; they think inducing a smaller baby will lessen the risk for cesarean or shoulder dystocia, or they think that baby will have better outcomes if they induce before complications might develop. But do these assumptions hold up under scrutiny?

The problem is that little research has actually examined the question of whether it is beneficial to routinely induce obese mothers without specific medical indications for induction.

Care providers usually go ahead and do so, assuming that inducing obese women at term is beneficial, but there has been little direct evidence one way or the other in a study specifically designed to look at the benefits and risks of routine elective induction in high-BMI women.

Sadly, there is still no large study that rigorously examines this question.

However, we now have a small study that begins to address it. The study looks at the outcomes of elective induction or expectant management of obese first-time mothers with an unripe cervix.

The Study

This retrospective study was conducted by doctors at a hospital in Washington D.C. They studied obese (BMI 30 or more) first-time mothers with no chronic medical co-morbidities (like chronic hypertension, pre-existing diabetes, etc.). Women were admitted to the study between 39 and 41 weeks, and only if they had an unripe cervix (Bishop score less than 5) that was documented during week 38.

The researchers compared the results of electively inducing obese first-time mothers with an unripe cervix (n=60) at 39-41 weeks with expectant management (waiting for spontaneous labor or inducing only if medical indications arose, n=410). Age, BMI at delivery, and prenatal weight gain were similar between groups.

It's important to note that the authors did not compare elective induction to only spontaneous labor. They compared elective induction to expectant management, many of whom eventually were induced if medical indications for induction of labor arose.

The results of this study would probably be even more striking if they compared elective induction only to spontaneous labor, but the authors felt that this was not an appropriate comparison, stating,
"Because spontaneous labor is not something a provider can choose for a patient, it is not realistic to use this as a comparison control group; it is more appropriate to compare the induction of labor to expectant management."

Even so, the bottom line was that the researchers found that electively inducing labor in high-BMI first-time mothers with an unripe cervix raised the risk for cesarean. By quite a bit.

The cesarean rate was 25.9% in the obese women in the expectant management group, and the cesarean rate was 40% in the elective induction group.

That's a significant increase in risk for cesarean.

Only 10.7% of women in the expectant management group were still pregnant by 41 weeks; all the others had either gone into labor spontaneously (36.8%) or had been induced for commonly-accepted medical indications (rupture of membranes, gestational hypertension, non-reassuring fetal heart rate tracings, etc.). So quite a few of the expectant management group were eventually induced, yet the difference in the cesarean rate was still quite marked.

Another important finding was that the elective induction group had three times the rate of admission to the Neonatal Intensive Care Unit (NICU) after the birth (18.3% vs. 6.3%).

This suggests that instead of reducing harm to the baby (as many care providers believe), elective induction in this population may actually increase the risks of poor outcomes.

Now, of course the study had a relatively small sample size, especially in the electively induced group. It was also a retrospective study. So the authors point out that further research on this topic is needed, preferably with a large prospective study.

Still, even with the study's weaknesses, it suggests strong caution towards elective induction in obese women with an unripe cervix. As the authors note:
In a joint summary from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Society for Maternal-Fetal Medicine, and the American College of Obstetricians and Gynecologists, physicians are urged to perform labor induction primarily for a medical indication and if done for nonmedical indications...to ensure that the 'cervix should be favorable, especially in the nulliparous patient.' Our findings support this assertion.
Other studies 

This study echoes a number of studies which have found higher c-section rates and complications in obese women who were induced (especially first-time obese mothers).

Of course, these studies did not specifically examine the question of whether routine induction in obese women improved overall outcomes. Still, their findings seem to also suggest caution around the idea of routine induction in obese women.

Although a higher rate of complications like pre-eclampsia means that some obese women will be induced for true medical indications, many others are induced for more dubious indications, based on questionable beliefs. These must be examined carefully.

For example, many providers believe that inducing early when the baby is smaller will lessen the risk for cesarean. Yet a number of studies have shown that it actually increases the risk for cesarean.

The combination of a suspected big baby and a high-BMI mother is a particularly potent combination that leads to many cesareans. A 2006 Massachusetts study found that the combination of induction, a suspected big baby, and first-time mother doubled the cesarean rate in the high-BMI women studied.

Many women of size are induced labor at term ostensibly to prevent a shoulder dystocia. Yet a recent New York study found that induction of labor actually increased the risk for shoulder dystocia (2.85x the risk), and especially so in obese women (5.64x the risk). By inducing women of size, providers may often be creating the very situation they are trying to avoid.

Other care providers induce because they believe it will improve outcomes in high-BMI women. A 2005 Welsh study on obese women with no complications found that the cesarean rate was 19% in the group with spontaneous labor and 41% in the induced group. Like in the present study, the Welsh study noted that the induction of labor was the start of many problems for the obese women in the group, including more blood loss, more UTIs, more babies in the NICU, more feeding difficulties, more neonatal trauma, etc.

So while many care providers think they are doing obese women a favor by inducing them proactively at term, there is strong reason to suspect that they may actually be doing more harm than good.

So much so that a 2013 Irish study (which found higher rates of emergency cesarean in induced obese first-time mothers) concluded:
Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
Conclusion

Research is clear that induction of labor is an extremely common intervention in obese women.

These and other studies suggest that perhaps a little more time and patience is needed at the end of pregnancy in obese women, and that induction should only be undertaken for strict medical indications.

Furthermore, it is time that larger studies directly address the question of whether routine induction at term improves or harms outcomes in obese women and their babies.

These potential studies should particularly look at outcomes among subsets of high-BMI populations, including obese women with complications and those without, those with differing levels of obesity, obese first-time mothers with an unripe cervix, obese multips with a prior vaginal birth, obese women where a big baby is suspected, etc.

Only then will care providers receive clearer guidance on the best management of women of size at term in many of the scenarios they are likely to encounter. It's FAR past time for such targeted research to occur.

We need care based on real evidence, not simply on assumptions about what's best for obese women.


References

Am J Obstet Gynecol. 2014 Jul;211(1):53.e1-5. doi: 10.1016/j.ajog.2014.01.034. Epub 2014 Jan 31. Risk of cesarean in obese nulliparous women with unfavorable cervix: elective induction vs expectant management at term. Wolfe H1, Timofeev J2, Tefera E3, Desale S3, Driggers RW2. PMID: 24486226
OBJECTIVE: The objective of the study was to examine maternal and neonatal outcomes in obese nulliparous women with an unfavorable cervix undergoing elective induction of labor compared with expectant management after 39.0 weeks. STUDY DESIGN: This was a retrospective analysis of a cohort of nulliparous women with a vertex singleton gestation who delivered at MedStar Washington Hospital Center from 2007 to 2012. Patients with unfavorable cervix between 38.0 and 38.9 weeks (modified Bishop <5) and a body mass index of 30.0 kg/m(2) or greater at the time of delivery were included. Women undergoing elective induction between 39.0 and 40.9 weeks' gestation were compared with those who were expectantly managed beyond 39.0 weeks...RESULTS: Sixty patients meeting inclusion criteria underwent elective induction of labor and were compared with 410 patients expectantly managed beyond 39.0 weeks. The rate of cesarean delivery was significantly higher in the electively induced group (40.0% vs 25.9%, respectively, P = .022). Other maternal outcomes, including operative vaginal delivery, rate of third- or fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage, and a need for a blood transfusion were similar. The neonatal intensive care unit admission rate was higher in the electively induced group (18.3% vs 6.3%, P = .001). Birthweight, umbilical artery pH less than 7.0, and Apgar less than 7 at 5 minutes were similar. CONCLUSION: Elective labor induction at term in obese nulliparous parturients carries an increased risk of cesarean delivery and higher neonatal intensive care unit admission rate as compared with expectant management.
Acta Obstet Gynecol Scand. 2013 Dec;92(12):1414-8. doi: 10.1111/aogs.12263. Maternal obesity and induction of labor. O'Dwyer V1, O'Kelly S, Monaghan B, Rowan A, Farah N, Turner MJ. PMID: 24116732
...Of 2000 women enrolled, 50.4% (n = 1008) were primigravidas and 17.3% (n = 346) were obese. The induction rate was 25.6% and the overall cesarean section rate 22.0%. Primigravidas were more likely to have labor induced than multigravidas (38.1% vs. 23.4%, p < 0.001). Compared with women with a normal BMI, obese primigravidas but not obese multigravidas were more likely to have labor induced. In primigravidas who had labor induced, the cesarean section rate was 20.6% (91/442) compared with 8.3% (17/206) in multigravidas who had labor induced (p < 0.001). In obese primigravidas, induction of labor was also more likely to be associated with other interventions such as epidural analgesia, fetal blood sampling and emergency cesarean section. In contrast, induction of labor in obese multigravidas was not only less common but also not associated with an increase in other interventions compared with multigravidas with a normal BMI. CONCLUSIONS: Due to the short-term and long-term implications of an unsuccessful induction in an obese primigravida, we recommend that induction of labor should only be undertaken for strict obstetric indications after careful consideration by an experienced clinician.
BJOG. 2005 Jun;112(6):768-72. Outcome of pregnancy in a woman with an increased body mass index. Usha Kiran TS1, Hemmadi S, Bethel J, Evans J. PMID: 15924535
...The study sample was drawn from the Cardiff Births Survey, a population-based database comprising of a total of 60,167 deliveries in the South Glamorgan area between 1990 and 1999. POPULATION: Primigravid women with a singleton uncomplicated pregnancy with cephalic presentation of 37 or more weeks of gestation... METHODS: Comparisons were made between women with a body mass index of 20-30 and those with more than 30...RESULTS: We report an increased risk [quoted as odds ratio (OR) and confidence intervals CI)] of postdates, 1.4 (1.2-1.7); induction of labour, 1.6 (1.3-1.9); caesarean section, 1.6 (1.4-2); macrosomia, 2.1 (1.6-2.6); shoulder dystocia, 2.9 (1.4-5.8); failed instrumental delivery, 1.75 (1.1-2.9); increased maternal complications such as blood loss of more than 500 mL, 1.5 (1.2-1.8); urinary tract infections, 1.9 (1.1-3.4); and increased neonatal admissions with complications such as neonatal trauma, feeding difficulties and incubator requirement. CONCLUSION: Obese women appear to be at risk of intrapartum and postpartum complications. Induction of labour appears to be the starting point in the cascade of events....
J Midwifery Womens Health. 2006 Jul-Aug;51(4):254-9. Maternal body mass index, delivery route, and induction of labor in a midwifery caseload. Graves BW1, DeJoy SA, Heath A, Pekow P. PMID: 16814219
...This retrospective cohort study examined the outcomes of 1500 consecutively delivered women who were cared for by two midwifery practices and delivered between January 1, 1998, and December 31, 2000. Cesarean delivery was significantly associated with the obese BMI (P < .001), nulliparity (P < .02), and newborn birth weight (P =.006). Prenatal weight gain did not have a significant correlation with cesarean birth (P = .24). In multivariable modeling, obese BMI, high newborn birth weight, nulliparity, and induction of labor increased the risk of cesarean birth. There was also a significant association between higher BMI and risk of induction of labor (P < .001). In a secondary analysis, obese BMI was associated with increased risk of induction in cases with ruptured membranes (OR 2.2; 95% CI 1.4-3.4) and postdates pregnancy (OR 2.0; 95% CI 1.1-3.4).
Obstet Gynecol. 2014 May;123 Suppl 1:172S. doi: 10.1097/01.AOG.0000447182.21511.09. Shoulder dystocia and labor induction stratified by maternal weight: to induce or not to induce? Sirota I1, Francis A, Chevalier M, Ashmead G. PMID: 24770084
...Retrospective study of all shoulder dystocia patients who delivered from 1998 to 2010, women in a control group without shoulder dystocia were matched two to one by maternal BMI, age, parity, and diabetic status...RESULTS: Included in the study was 57,259 deliveries; 144 shoulder dystocia cases and 288 women in the control group met study criteria. One hundred seven (74%) shoulder dystocia cases were induced or augmented; 37 (26%) labored spontaneously. One hundred thirty-six (47%) women in the control group were induced or augmented; 152 (53%) labored spontaneously... Across all BMIs, induced patients were 2.85 times more likely to have shoulder dystocia than noninduced patients (95% confidence interval 1.57-6.14; P<.001). After stratifying by BMI, induced normal-weight patients were 2.11 times more likely to have shoulder dystocia than spontaneously laboring normal-weight patients; induced or augmented overweight patients were 4.74 times more likely to have shoulder dystocia than their spontaneously laboring counterparts; and induced or augmented obese patients were 5.64 times more likely to have shoulder dystocia than their noninduced cohorts...CONCLUSION: Induction or augmentation appears to be associated with an increased shoulder dystocia risk with increasing maternal BMI.
Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A114-5. doi: 10.1136/archdischild-2014-306576.330. PLD.30 A 5-year review of maternal obesity and induction of labour on mode of delivery and risk of labour, anaesthetic and neonatal complications. Joannides C, Hon M, McGlone P, Parasuraman R, Al-Rawi S. PMID: 25020968
...Retrospective analysis of women with a booking BMI >45 between January 2009 and October 2013...RESULTS: 158 patients were analysed (mean BMI 49). 68% of all patients were either induced or required labour augmentation (background rate of 39%). 64% of these women achieved a vaginal delivery, increasing to 70% if no induction or augmentation. 71% of multiparous women who spontaneously laboured and had previously achieved a vaginal delivery, delivered vaginally again. Half of primiparous women requiring induction or labour augmentation had an emergency caesarean. 49% had intrapartum regional anaesthetic. 42% required multiple attempts, 19% needed an epidural re-site or spinal for theatre. CONCLUSION: These results mirror the UKOSS study findings. Higher maternal BMI is associated with an increased incidence of induction and augmentation of labour. Despite this the vaginal delivery rate is high. Primiparous women requiring induction or augmentation of labour were most susceptible to obstetric intervention....

Monday, July 14, 2014

Nice Is Not Enough: Questions for Interviewing a Maternity Care Provider

Many women want to choose their pregnancy care provider carefully, but aren't sure what questions to ask when interviewing doctors or midwives. 

Here are some general questions that some care providers* have suggested asking any provider you are considering during your pregnancy and birth.
  1. How do you define “normal birth”?
  2. Can you give me an example how you typically manage a normal birth?
  3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
  4. How long will you “allow me” to wait if I go overdue?
  5. What position(s) will you allow me to use when giving birth?
  6. How do you feel about IVs and continuous fetal monitoring?
  7. How do you feel about a woman eating and drinking in labor?
  8. What are your thoughts on pain relief in labor?
  9. How do you feel about cesareans?
Some childbirth educators would substitute different questions here and there from this list but it's a reasonable basic list to start with. Adapt as necessary for your own personal situation and concerns.

Also pay close attention to the provider's response to your questions. Of course, care providers have limited amounts of time to answer questions at most visits so it's important to be considerate and concise when you ask questions, but if they are impatient with your questions or dismissive of your concerns, that's a sign you might want to look elsewhere.

There are other additional questions you might want to ask if you are a woman of size, but more on that in future posts. If anything, women of size need to be even more vigilant in asking questions of potential care providers because size bias is so prevalent in maternity care. But for now, the above questions are a reasonable start to the process.

Sample Answers to These Questions

So what are reasonable answers to the above questions? It really depends on the type of birth you are looking for and how interventive you want your care provider to be.

Some people want a totally natural birth, and some want all the interventions and machines that go PING that technology can give them. Neither approach is right or wrong; it's more a matter of what you prefer and the unique needs of your pregnancy.

However, it's far more difficult to find a provider truly supportive of natural birth than a provider that routinely uses lots of technology and interventions. So the slant of this post is going to lean more in the direction of finding someone supportive of natural birth, but readers should not infer any judgment of their own personal preferences. Again, adapt the questions to your own personal needs and preferences.

1. How do you define "normal birth"? 

To some care providers, "normal" birth means just about anything (including significant amounts of interventions), whereas to others it means an undisturbed, spontaneous labor resulting in a vaginal birth without any interventions. You can get some idea of a care provider's attitude towards birth and interventions by what they think of as "normal" in birth.

2. Can you give me an example how you typically manage a normal birth?

To some care providers, typical management includes inducing labor at 39 or 40 weeks, mandatory IV, epidural by 4 cm dilation, and active management of care (breaking the waters early in labor, aggressive management of contractions with oxytocin, etc.). To other care providers, induction is used only when medically indicated (concern over blood pressure, baby not growing well, etc.), IVs are not mandatory, epidurals are completely up to the mother's choice, and routine interventions in labor are not utilized unless medically indicated.

Again, neither is inherently right or wrong, just different ways of looking at and managing labor. By asking the question of how the care provider typically manages normal birth, they can begin to understand where the caregiver falls on the continuum of intervention.

3. How would you feel if I disagreed with you about a procedure you recommended during labor or birth?

This is an important question because it speaks to the caregiver's respect for patient autonomy and how they prefer to interact with patients. Some care providers never want their dictates questioned. Others give education on the pros and cons of procedures and make strong recommendations based on their training and knowledge, but respect the mother's right to choose for herself.

It's important to also point out that women vary greatly in their desire for informed decision-making. Some prefer to leave all the decision-making up to the care provider and don't want to be "burdened" with having to make those choices. Others want to be very involved in the decision-making. The question is designed to help you figure out which style of care you prefer, and whether that aligns with the care style of the provider you are interviewing.

4. How long will you "allow me" to wait if I go overdue?

There is a great deal of controversy about the safest time for women to go into labor. There is a small but significant risk for stillbirth as gestational age increases, but this risk has to be weighed against the significant risks of inducing labor earlier, which may increase the risk for harm from strong drugs or may increase the risk for cesarean. Current research varies quite a bit on whether a pregnancy should be induced to lower the risk for stillbirth or other poor outcomes. There is no "right" answer here, only an answer that reveals to you what your care provider routinely does.

Many care providers induce labor right at 39 or 40 weeks, some wait till 41 weeks, some wait till 42 weeks, some wait even longer as long as the baby's status is reassuring. Some prefer inducing earlier but will respect the mother's decision to wait if baby looks okay. The point is to know your care provider's preferences on this very important point and to explore how flexible they are about it.

5. What position(s) will you allow me to use when giving birth?

Most hospital births occur with the mother either flat on her back, propped up with her legs in stirrups, or with the mother pulling back on her knees ("supine" or "lithotomy" positions). This is our cultural expectation of birth, and nearly all media images of birth show this position.

In other cultures, however, many other birth positions are used, including kneeling, squatting, side-lying, hands-and-knees, and asymmetrical positions, and these labor positions have distinct advantages. Some providers are very comfortable allowing the mother to labor in positions like these, while other providers restrict the mother to only the typical hospital positions. The question is designed to help you find out how your provider feels about birth positions.

Be careful how you word the question, though. Many care providers tell you that they will "let" you labor in whatever position you want, but fail to reveal that when it comes time to actually push out the baby they want you in the usual positions. Many providers are extremely uncomfortable attending a birth in a position other than supine or lithotomy and will pressure you to change positions, even though there is quite a bit of evidence for the benefit of upright and other positions in birth.

Some women don't care about what position they give birth in or are uncomfortable experimenting with different positions. Others are adamant about having the freedom to move as their bodies dictate, especially as the baby emerges. The important thing is to find a provider that is comfortable with your preferences, so be sure to ask ahead of time about not only labor positions, but also what position they want you in for when the baby is actually coming out.

6. How do you feel about IVs and continuous fetal monitoring?

It is important to establish your provider's preferences about routine interventions like IVs and continuous fetal monitoring.

Some providers are fine with women laboring without an IV. Others mandate an IV for all their patients, while still others strike a middle course and only request that a heplock be placed so that emergency access would be faster if an IV became needed.

Although continuous fetal monitoring has not been shown to improve outcomes in low-risk women, it is still extremely common in nearly all hospitals. However, some providers are more flexible than others about when it starts, whether intermittent monitoring can be used instead, and whether mobile monitoring is allowed.

7. How do you feel about a woman eating and drinking in labor?

Some care providers and hospitals have strict rules about whether a woman is "allowed" to eat food or drink during labor, despite a lack of evidence showing harm from this practice. Many allow only ice chips to be used during labor. It is important to understand your caregiver's policies before labor.

8. What are your thoughts on pain relief in labor?

Women vary greatly in their wishes towards pain relief during labor. Some prefer to go natural, some want an epidural "in the parking lot," some would rather take a wait-and-see-if-it's-needed approach.

Some care providers are very respectful of a woman's wishes about pain management in labor. However, some practically mandate that all their patients receive an epidural, while others can be judgmental about any use of pain medications. Still others know many "tricks" to help women lower their need for pain relief in labor but are supportive of whatever the woman chooses at the time.

Respect for one's wishes regarding pain management during labor plays a strong role in women's satisfaction with their birth experience. It is vitally important to find a care provider who is aligned with your preferences and who will be supportive of your choices.

9. How do you feel about cesareans?

Some providers truly believe that vaginal birth is dangerous and that cesarean birth is to be preferred. Others believe that cesareans are to be avoided at virtually any cost. Most providers fall somewhere in between, but most tend to "lean" one way or the other. Obviously, every caregiver is supportive of cesareans when they are truly life-saving but their attitudes towards other cesareans (and the current cesarean rate in first-world countries) can be revealing about their underlying philosophies of birth and likelihood to use a cesarean.

Beware: Nice Is Not Enough

Don't let a care provider's bedside charm and personality supercede your own commonsense about interventions. A care provider can be really charming, caring, and nice and still have a 50+% c-section rate and a 40+% episiotomy rate, which will do far more harm than good in the long run.

Just because they are "nice" doesn't mean you are going to get care from them that doesn't put you at risk for more complications. 

One midwife told the story of the following doctor on her blog:
What is the definition of a “good doctor”? I once knew a physician whom everyone believed was a “good doctor”. Let’s call him Dr. Wonderful. He had a very high cesarean rate, a high episiotomy rate, a high forceps/vacuum rate, and yet his patients adored him. Why?
He made each woman who came to him feel special. He was handsome and charming, and would treat each woman as if she were the only patient in the world that mattered to him. This is not necessarily a bad thing–I believe each patient should feel special and important to her provider. However, when this perception of being special clouds a woman’s judgment, it is time to have a reality check.
Dr. Wonderful would visit his patient after whatever unnecessary procedure he did, sit by the bedside, take her hand, and very regretfully tell her how sorry he was that she needed ___________ (insert the procedure of your choice), but if he had not done it, ___________ would have happened (insert catastrophe of your choice). So he very reluctantly had heroically intervened to save her life, or the life of her baby. The woman would be trembling with gratitude toward this marvelous physician by the time he left the room. None of his patients could ever believe that any of these procedures were unnecessary.
This bait-and-switch tactic is very common among some care providers. They know how to manipulate patients into going along with what they think is best and/or what is most convenient, even when the actual research doesn't support these interventions as best practice. 

Most women think that if their doctor recommends a procedure to them, it must be necessary, and who are they to question the doctor's judgment? But most don't realize how much interventions vary from caregiver to caregiver. Nor are most given adequate information about the pros and cons of most procedures.

The point is not that all interventions are "bad" or must be avoided, but that the benefits and risks of proposed interventions should be discussed thoroughly and true patient autonomy respected, not manipulated. 

If you are sure you want a hospital birth but you'd like to try and find a provider who is more friendly to natural childbirth and patient autonomy than most, the midwife above summarized one strategy for scoping out the possibilities:
I suggest that women who are planning hospital birth call their local [Labor and Delivery] unit, and ask to speak to a nurse who enjoys helping women who want unmedicated birth. Then ask that nurse for names of doctors [or midwives] that she thinks are most likely to support you in your goals.
Last, and perhaps most important, don’t be fooled by a charming bedside manner. Make sure there is substance behind it.
Amen to that. "Nice" is wonderful, but some care providers use it as a way to convince women into all kinds of risky interventions as a way to lower the risk for being sued or because it's more convenient for him/her. 

In particular, many women of size are just so grateful just to find a doctor who doesn't yell at them about their weight that they fail to ask further questions about the provider's rates of interventions that increase the risk for cesarean (a high induction rate, inducing for suspected big baby, etc.). 

I've been there done that myself and gotten burned, so learn from my mistakes.

Don't fall for "nice" over substance. Nice is a good start, but you still have to ask further questions.

Ask for Specific Intervention Rates

It's really important to ask a provider's intervention rates, especially his/her intervention rates for first-time moms.

What's his/her induction rate, cesarean rate, episiotomy rate? 

Also observe how the provider responds to questions about these things. That's as telling as the actual intervention rate.

For example, "I only do them when necessary" is not a helpful answer; for some docs, interventions like these are seen as "necessary" 60% of the time, and that rate presents far more risk than benefit. 

For example, episiotomy rates should be quite low; if it's not, the provider is not practicing evidence-based medicine, which has clearly shown routine episiotomy to be more harmful than helpful

Many doctors say they "only do episiotomies when necessary" --- but if they find it "necessary" 40% of the time, there is something wrong with their definition of "necessary."

Moral of the story: Actual numbers are important for evaluating a provider.

Primary cesarean rates (cesareans in first-time moms or mothers who have never had a cesarean before) is another benchmark by which you can judge providers. Women who have not had cesareans before should not have a very high rate of cesareans during labor; if they do, it suggests that the doctor has a low threshold for surgery or encourages a lot of interventions that lead to more cesareans.

(Of course, if a provider regularly provides care to many high-risk women, the cesarean rate is going to be higher than a provider who mostly sees only low-risk women.....but generally speaking a high cesarean rate is a red flag.) 

It's also helpful to ask how the care provider feels about cesareans. 

If they have a high cesarean rate but are defensive about that, they'll likely say something that minimizes the impact of cesareans and ridicules the mother for caring. 

Watch out for comments like, "The real priority is a healthy baby" or "A healthy baby is more important than the delivery method".....as if that justifies any intervention the doctor uses, as if the mother's outcome is of no importance, and as if the mother questioning things means she doesn't really care about her baby over herself.

Of course the priority is a healthy baby, but a healthy mother is also a priority, and one recovering from unnecessary surgery is not a healthy mother. Nor should a woman be ridiculed for caring about avoiding a cesarean or an episiotomy whenever possible. 

A provider that avoids the question of intervention rates by blaming the mother, brushing off her concern, or making her feel selfish for caring is a giant red flag.

Beware care providers that "don't know" their cesarean rate, or who subtly deride anyone who asks questions about cesarean or episiotomy rates. All providers should have a general idea of their cesarean and episiotomy rates. If they don't, that suggests that they don't think these rates are important or aren't concerned about their use.

Also ask when/why the provider would want to induce labor. If they routinely induce labor if the baby is thought to be  "big," that's another tremendous red flag.  Research shows that inducing early for a "big baby" actually increases the cesarean rate, but despite the evidence, many providers still induce early for a big baby anyway.  [This is one major factor driving the high rate of cesareans in women of size.]

If you interview a provider and they would induce early for a big baby, this is a huge red flag.

Many providers also routinely induce labor at 39, 40 or 41 weeks, and research is mixed on the pros and cons of this practice

Particularly for women of size (whose pregnancies tend to last longer), inducing labor early or right around term "just in case" probably leads to more cesarean risk and a whole host of other potential complications. You may want to find a provider who is more willing to wait and not rush things as long as mother and baby are doing well.

Conclusion

You can have the "nicest" doctor or midwife in the world, and he or she can still coax you straight down the path to a cesarean or episiotomy you don't need by engaging in unnecessarily high rates of interventions with dubious benefits.

Being nice is just not enough. You have to ask careful questions when interviewing a care provider, you have to ask for specific intervention rates, and it's very important to watch for the classic red "alarm" flags.

What questions were most helpful to you when you were interviewing providers? What questions do you wish you had asked? What advice do you have for other pregnant women looking for maternity care providers?


*July 2014 Update: These questions were originally shared in a much longer article ("In Search of Dr. Right: 11 Questions to Ask" by The Midwife Next Door) on another website, and I gave credit and linked to that article in my original post in 2010. Sadly, the original link has since been compromised and now goes to an extremely undesirable site, so I have stripped out all those links and am re-posting this article without them. The questions are helpful so I am keeping the post; but it's important to note that it originally arose from another's work.

Saturday, July 5, 2014

Looking for PCOS Stories

Happy holiday weekend everyone!

Just wanted to let you know that I'm working on continuing my series on PCOS (Polycystic Ovarian Syndrome) later this summer.

While, as always, I'll have lots of research and facts, I'd also like to add some stories from real women with PCOS. One of the difficult things about PCOS is that it's a syndrome, and that means it can present really differently in different people. Not everyone's experience is going to be the same, and not every treatment regimen is right for every person.

Thus it's important to represent a wide variety of experiences and treatment regimens, and it's really important to bring that personal voice of experience to the discussion, especially as we start to delve into some of the more personal aspects of PCOS.

In the past we've worked on discussing treatment choices for various aspects of PCOS, and I'd like to continue that. We've been focusing on treatment for menstrual irregularity and insulin resistance/blood sugar issues; now I'd like to focus on treatment for other common aspects of PCOS.

I'll be looking particularly for stories dealing with treatment choices for androgen excess, for hirsutism, for hair loss, and for infertility. Not all at once, of course...each one separately.

So, for example, if you are a person who has used The Pill to deal with androgen excess or menstrual irregularity, share which one was recommended to you and your experience in using it. Did it help? Did it make things worse in some ways but better in others? Did you have any complications with it? How did treatment recommendations for it change as you aged? What types are best for women with PCOS in your experience?

Or if you are a person who has dealt with hirsutism (excess hair on the face and body) or alopecia (hair loss on the head), summarize how you have dealt with it. Did you choose to do anti-androgen medications, cosmetic methods, or a combo of both? How successful were the treatments? Or did you opt out of treatment eventually? What information would you like to have read about treatment choices when you were first dealing with PCOS? What encouragement can you give to other women dealing with these challenges to their self-esteem?

Or if you are one of the many women with PCOS who have dealt with infertility, share your infertility journey and what has helped you. Did you use Clomid or other medications, did you use IVF, did you use alternative treatment like herbs or acupuncture, or something else? How long did you try? What was most effective for you? What was a waste of time and money? What would you like to have known about treatment choices ahead of time? If you were not able to have children, did you choose to remain childless or did you choose to adopt or go with surrogacy? If you were able to have children, what was most helpful in that process?

Obviously, some of these issues are very personal. Rest assured that your story will be shared anonymously or under a pseudonym (pen name). If you do have a story to share, please email a brief summary of your experiences to kmom AT plus-size-pregnancy DOT  org. Don't forget to give me specific permission to share your story, and please tell me what pseudonym you'd like to use (if you have a preference).

Because I may be sharing multiple stories, it's important that you keep your story brief. Focus on one or two aspects of your treatment or experience rather than trying to cover the whole thing. Ask yourself, what would you most like to get across to another woman with PCOS who is starting to deal with the same issues?

Keep in mind that I may not be able to use all entries, or I may choose to quote only part of your story. I may also edit for practical stuff like grammar, spelling, etc. Again, I will not be publishing under anyone's real name, so choose a pseudonym you are comfortable with.

Try not to give medical advice in your piece; none of us are healthcare providers, and we don't know the details of anyone else's case. It's okay to share what has worked for you or to advocate awareness of a particular treatment approach, but avoid telling people what they should do or getting preachy. We are all adults, we all make our own choices, and what's right for one person may not be right for another. Raise awareness, educate people about their options, but respect their right to make their own choices.

I'd also love for people to share their favorite PCOS resources....books, websites, blogs, and links. I'm aware of many of them but I'm sure there are many more out there I'm not familiar with. Tell me the resource, give its link, describe what it deals with, and tell me why you think it's helpful for women with PCOS.

Rest assured, this will be a continuing periodic series. In the future, we will be dealing with PCOS pregnancy, birth, breastfeeding, menopause issues, and many other things. But for now, it's time to continue posting about treatment options for some of the more common PCOS symptoms and health concerns, and it's time to add some personal voices to these discussions.

I look forward to reading your stories!

Friday, June 27, 2014

Canning Books for Beginners

Image by Carter Housh

It's that time of year, when all the bounty of summer fruits are starting to roll in. Strawberries are in, rhubarb is in, the raspberries have just sprung to fruition, and cherries are hitting full force. Blueberries are just around the corner, and then it's time for plums. Yummm!

For me, that means it's time to start canning in order to preserve all these delicious fruits so I can enjoy them next winter too.

This is not something I grew up doing or learned from my mother; I had to learn it on my own. I came to it only in middle age, but it's a skill I'm determined to teach all my children because I think it's something everyone should know how to do.

If for no other reason, people should know how to preserve food so they have some emergency food on hand that doesn't depend on a refrigerator or freezer to keep it safe. And of course it's great to have these summer foods available to eat out of season, and they make great homemade gifts. But the best reason is because these foods just taste delicious!

So let's talk about the very easiest foods to can, jams and preserves, and the best books for learning how to prepare these.

Canning Books for Jams

When I was first learning how to can, I looked for a book that was quick and easy to understand, had great diagrams and instructions, and which had a lot of interesting recipes.

I found quite a number of good canning books and resources out there. Each one had something different to recommend it. Here are the best ones for beginners.

Put 'Em Up by Sherri Brooks Vinton is my favorite canning book and the one I recommend to beginners. I find the explanations very clear and concise, with some of the most clear illustrations of the process I've seen. When I was a beginner, this was the book that was most helpful to me.

I also liked that she organized the book by types of produce, so if cherries are in season and you are looking for something new to do with your overload of fresh cherries, you just turn to the "cherry" section of the book (which is clearly labeled and easy to find). That is really helpful. Many canning books are not organized like this.

The author has a great sequel too, just for fruits, with further recipes and hints on how to use them. And she now has a Preserving Answer Book, to answer common questions about canning, drying, freezing, etc. for those fairly new to food preservation.

One of the most common canning books, of course, is the Ball Blue Book Guide to Preserving and the Ball Complete Book of Home Preserving. Its companion website is www.freshpreserving.com, and it has a great guide to getting started with canning if you want to learn about canning without having to spend the money to buy a book.

This book is the classic canning book, and all its recipes have been extensively tested for safety. It's been around forever so it's got lots of time-tested recipes that have been favorites for generations. It goes far beyond the basic jam recipes included in most books and has recipes for many other types of foods besides jams.

A newer canning book that many people seem to like is Food In Jars by Marisa McClellan. The author has an excellent blog from which the book sprang. It has lots of interesting hints for canning and links to unusual products like special canning jars.

One interesting thing about Food In Jars recipes is that they often have unusual flavor combinations that go beyond the usual basic recipes found in most books. She typically does not use pectin in her recipes, but teaches the old-fashioned cook-em-till-they-set method. She has a great Canning 101 section on her blog where she answers a lot of questions about canning technique and safety.

The author has also written Preserving By The Pint, which specializes in canning recipes for very small batches, which can seem more do-able to the beginning canner since no special equipment and no huge pots of water are needed. You don't need to buy big batches of fruit and you end up with only a few jars to store, which is important if you have only limited storage. Most canning recipes were written for women with large families to feed; this is the scaled-down version for folks with very small families, not much time, or limited storage.

Another bonus is that the author does a lot of touring and offers classes all over the country teaching many of the recipes used in her book. That's good marketing and it helps a lot of people who feel insecure with canning to get past the fear and start doing it.

Another book which might be really handy for some is Preserving with Pomona's Pectin by Allison Carroll Duffy. This book specializes in recipes using Pomona's Pectin, which is a somewhat harder-to-find pectin but which offers the distinct advantage of being able to adjust the sugar content in a recipe.

With most other pectins, you have very little flexibility about how much sugar to use in a recipe. The full-sugar pectins use insane amounts of sugar in their recipes; usually far more sugar than fruit. Even the "reduced sugar" pectins (like Sure-Jell in the pink box) still use quite a bit of sugar.

But Pomona's Pectin works differently than other pectins. It doesn't need sugar to help "gel" the jam; it uses calcium water instead to get the gel. This means that the sugar content of these jams can be adjusted to your heart's content. You can use as much or as little as you prefer, and you can use honey, agave syrup, fruit juice, or artificial sweeteners to sweeten your jam instead of sugar. If you are one of the many people trying to reduce the sugar content in your diet for health reasons, this is a great option to have.

Pomona's Pectin offers a lot more flexibility than other pectins, but it has a little steeper learning curve than the full-sugar pectins. Having a book that discusses the process of using this pectin in minute detail can be useful for those new to canning with Pomona's Pectin.

Summary

There are many, many great canning books available out there, but these are some of the best canning books for beginners. Youtube also has many video tutorials available on canning, and you can find many canning instructional DVDs as well.

Once you get good at the basics, then you can start adding wet and dry "zing" (spices and liqueurs) to your fruit ingredients and creating your own custom recipes. Or you can learn how to make pectin-free jams. But first, it's helpful to get comfortable with the fundamentals.

There are so many great resources on learning to can out there; get started on learning this important skill this summer! Or take your basic knowledge of canning to a whole new level of experimentation instead by playing around with the more advanced recipes in these books and blogs.

Remember, it's perfectly okay not to be a Canning Diva; you're not a canning failure if you don't spend all your time in the kitchen or put up great quantities of food. Do as much or as little canning as you have time for, but do learn to can so we keep this important skill alive and so that you have shelf-stable food put aside for emergencies.