Thursday, December 29, 2011

Fourth Annual Turkey Awards: Leaps of Logic, the Dead Baby Card, and Scorched Earth Tactics

Well, it's that time of year again...time for my Fourth Annual Turkey Awards.

The Turkey Awards are my opportunity to highlight a biased or ignorant remark or media coverage of "obesity and pregnancy," a particularly insensitive treatment by a care provider towards a woman of size, or a trend in the care of women of size that is troubling and frustrating.

As always, I have plenty of candidates to choose from.  The hard part is limiting myself to just one.

Here's this year's nominee, another gem from My OB Said What.  I picked this one because it fails on several different levels:
“I am sure you have gestational diabetes because you are overweight, you need to be on Glucophage. If you are not comfortable taking that medication you will end up with a stillborn.”   – OB to mother, as found here
Sigh. This doctor may have meant well, but his statement has several things that demonstrate some of the troubling trends and perceptions around obesity and pregnancy, including:
  • Jumping To Conclusions About Risks
  • Scorched-Earth Tactics To Deal With Inflated Perception of Risk
  • Pulling the Dead Baby Card To Ensure Compliance with Intervention.
Jumping To Conclusions About Risk

Okay, let's start with the obvious ─ the exaggeration of risk around obesity and pregnancy. We've discussed this before, but it always bears repeating because it's such a common issue.

The problem with the coverage of risk around obesity and pregnancy is that providers often start doing "mental inflation" of the actual numerical risk, and then they start making unfounded leaps of logic from there.

A statement with some truth to it, such as "Obese women are at increased risk for gestational diabetes," gets hyped in the press and in the research until it becomes transformed in some caregivers' minds into "Most obese women get gestational diabetes."  Then it's just a short jump to "Nearly all obese women get gestational diabetes" to "This obese woman no doubt ALREADY HAS gestational diabetes right now."

But the fact of the matter is that while the risk for gestational diabetes is definitely increased in women of size, most women of size still don't get GD.  You can cherrypick whatever study you want, but no study shows a 100% GD rate in obese women, even the most obese women.

Many studies show around a 15% risk for GD in "morbidly obese" women.  This is definitely higher than the 2-4% range found in a "normal BMI" population, but hardly universal.  What most providers fail to do is the opposite math.....that is, if 15% of morbidly obese women get GD, then that means that 85% do NOT.

Yes, that's right.....the majority of even very fat women will not get GD.

Are fat women at increased risk for getting GD?  Yes, absolutely.  Do all of them get it?  No, not even remotely close.  In fact, most do not get it.

And remember, just because a particular group is at increased risk for a complication does not mean that everyone in that group will get that complication, nor does it mean that you can predict the outcome for any individual within that group.

Of course, you can make a case for this being a rogue doctor, jumping to conclusions. Hopefully, most providers who care for women of size understand that GD is by no means a foregone conclusion in this group.  But I'm hearing stories like these more and more often.

There are a lot of care providers out there who have a distorted sense of risk around obese women and GD, from the ones who force their obese clients to undergo really frequent GD testing to those that push weight loss during pregnancy as a way to avoid GD (despite evidence that weight loss in pregnancy is risky).

So this comment is a candidate for this year's Turkey Award because of this individual doctor's mental inflation of risk ─ turning a mere potential of risk into an inevitable outcome in his mind.

But this comment also gets nominated because it's not just about this doctor's individual bias; it demonstrates an overall troubling trend of a distorted sense of risk about pregnancy in women of size.

Scorched Earth Tactics for Inflated Perception of Risk

Another issue I see in the comment is the kind of Scorched Earth, over-the-top tactics that some providers take in order to try to reduce the risks associated with obesity and pregnancy.  There is little research on these tactics, mind, but because care providers have such an exaggerated sense of risk around obese pregnancies, they feel justified in taking the Napalm Option...just in case.

For example, in the past, some care providers have advocated extremely restrictive diets for obese women in pregnancy.  Obese pregnant women have been put on 1200 calorie or even 1000 calorie diets during pregnancy, or told to drink Slim-Fast in order to limit their weight gain. Some are told that they have to lose weight during pregnancy....10, 20, even 50 pounds, during pregnancy.  It doesn't matter how this is achieved, the main goal is for them to lose weight in pregnancy, even if it sacrifices nutritional adequacy, since many care providers erroneously believe that fat women have extra nutritional stores to draw from instead.

This is the Napalm Option; resorting to extreme measures because you don't know what else to do or you are convinced that the risk is SOO high that only extreme measures will improve outcomes.

A new Scorched-Earth Tactic being considered is a move among some care providers to prophylactically prescribe metformin to all obese women during pregnancy in order to prevent big babies and other complications.

The use of Glucophage (metformin) in pregnancy is already somewhat controversial, even in women with strong indications for it (PCOS, severe insulin resistance, gestational diabetes). Its use prophylactically in all obese women, even those without other risk factors, should be even more controversial...yet many care providers are not questioning it at all.

Metformin is probably relatively safe during pregnancy for those with strong indications for it but some docs are very conservative about its use because the trials on it so far are small and some have found an increase in pre-eclampsia in women on metformin (while others have not). More data is needed.

Therefore, many docs err on the side of taking women off metformin during pregnancy, but there are a number of practices where the protocol is to continue metformin (with informed consent) because it lowers the risk for GD and possibly miscarriage and big babies as well.

I'm not opposed to the use of metformin in pregnancy in those for whom it is indicated and in those who have been given full informed consent.  They get to evaluate the research and decide for themselves whether they think it's a worthwhile intervention. However, I think across-the-board use of metformin on all obese women is highly questionable.

One early trial of metformin in pregnancy found an increase in both pre-eclampsia and stillbirth in the metformin group, so caution is clearly indicated.  [However, it has to be noted that there are two major confounding factors here. The women on metformin were mostly type 2 diabetics with pre-existing diabetes and poorer control; they also put these same women on 1200 calories a day, which might also be a factor.] Later trials have found no increase in stillbirth with metformin.

Another study of metformin vs. insulin for treatment of GD found a slightly higher rate of spontaneous-labor prematurity in the metformin group, although the confidence intervals were wide and crossed 1.0, so the trend could be attributable simply to chance.

Bottom line, we need more long-term data from larger groups on the safety of metformin during pregnancy in women with PCOS or GD, as well as the benefits and risks of metformin used in a wider population of women. Right now, the best data shows it lowers the risk for GD and miscarriage in women with PCOS, and probably does not increase the risk for birth defects. Other results vary from study to study. It’s probably a reasonably safe med for women with PCOS or GD, but we need more data to be sure.

Despite this, there is a trend to put ALL women of size on metformin prophylactically (there is a trial of this in the UK right now) and THAT I have problems with. It’s one thing to put a woman with severe PCOS or GD on this med, it’s entirely another to put all healthy high-BMI woman with no known glucose issues on it prophylactically. Ugh.

So this comment gets an individual nod for the Turkey Award because not only does the doctor assume the woman is automatically going to get gestational diabetes, he also wants to put her on metformin prophylactically, just on the basis of her being "overweight" (without proof of GD).

But it also gets a Disturbing Trend nod because it represents a new willingness among some care providers to prescribe extreme measures ─ like prescribing weight loss during pregnancy or putting all fat women on metformin ─ because of their inflated sense of risk around pregnancy in women of size.

Remember, the Napalm Option often harms more than it helps.  We must be cautious about being overly-interventive without proof that such interventions actually improve outcomes.

Pulling the Dead Baby Card to Ensure Compliance

Yet another problem highlighted by this quote is the issue of what we cynical activists call "The Dead Baby Card."

The Dead Baby Card is telling women in an emotionally manipulative way, your baby will die if you don't do exactly what I tell you.

(Its corollary is, And If You Question Me, You're A Bad Mother and Must Not Love Your Child.)

It's not merely informing a woman of the possibility of a poor outcome, it's medical bullying trying to force a woman (via scaring or shame or guilt etc.) to go along with a particular kind of highly interventive care the physician wants.

It's not a reasonable or sensible precaution in the face of an extremely high-risk situation, it's using the mother's fears to manipulate her into some dubious intervention the doctor wants, usually for his own convenience or fear of litigation.  And it's implying that the woman is a Bad Mother if she even thinks about questioning these interventions.

It's statements like, "We think your baby is going to be 9 lbs., so you have to have a planned cesarean or your baby will get stuck and die," even though research shows that elective cesareans for macrosomia do not improve outcome and may actually worsen it.

Or telling a woman that if she chooses Vaginal Birth After Cesarean, her baby will almost certainly die. And if the woman dares to question the provider, it's using scare tactics or implying that she's selfish to even consider such another choice. It's using emotionally manipulative language to bully a mother into following a questionable course of treatment the doctor wants.

In the Metformin example above, telling the mother that if she does not go along with the doctor's preferred treatment plan (i.e. use of metformin), her baby will probably die is medical bullying, a.k.a. Pulling The Dead Baby Card.  The doctor is trying to scare her into complying with his questionable intervention by using the biggest scare tactic he knows.

Instead, the mother should be counseled about the possibility of gestational diabetes, the pros and cons of GD testing, the small but real possibility for stillbirth if there was uncontrolled pre-existing diabetes, and offered GD testing.  She should be informed that some care providers are using Glucophage to prevent/treat GD, she should be informed of the pros and cons of metformin, and offered the choice to consider it.

She should not be ordered to take metformin, or told that if she doesn't take it her baby will undoubtedly die.  That's classic Dead Baby Card territory, and that's unethical and unconscionable medical bullying.

So this comment is a "winner" a third time because of this doctor trying to scare this mother into an extreme intervention by using emotional manipulation, and because it sadly represents a tactic that's being used against women of size far too often these days.

Medical bullying is being used far too often these days, and particularly against women of size.  This kind of over-the-top manipulation has to stop.

Final Thoughts

This comment is nominated for my Fourth Annual Turkey Award because it demonstrates an Epic Fail on several different levels.

It presumes an "overweight" woman will automatically get gestational diabetes (when most will not), it orders her to take metformin prophylactically just on the basis of her weight alone (without proof of GD), and tries to scare her into compliance by suggesting that her baby will die if she doesn't agree to this intervention.  It's a classic case of medical bullying.

Of course, we need to make it clear that most providers don't treat women of size like this.  And hopefully most would never result to medical bullying like this.

But this comment does represent several troubling trends in the care of women of size, including the tendency to Jump to Conclusions about Risks, the increasing use of Scorched-Earth Tactics, and the use of the Dead Baby Card to scare women of size into whatever extremist intervention the doctor wants to use on them.

And that's why this little comment gets this year's nomination for a Turkey of the Year Award.

*By the way, My OB Said What is looking for submissions on the idiotic things caregivers sometimes say to women.  If you have more doozies on things they say to fat pregnant women, I hope you will submit them so we can document this kind of treatment.

Do note, they also accept submissions for positive, helpful things caregivers say to women─it doesn't always have to be bad. If you have had a really supportive caregiver as a woman of size, be sure to nominate those stories too.  It's so important to highlight the positive stuff too!

Either way, email your story to

Thursday, December 22, 2011

Dear Santa: Research on My Wish List

Dear Santa:

As I review the research on "obesity" and pregnancy, it always strikes me what's missing from this research.

Santa, since you are Patron of the Plus-Sized, I'd like to request some improvements as my Christmas gift this year. Could you whisper in some researchers' ears and plant the following suggestions?

Do More Meaningful Research

First, I'd like to request that researchers stop going for the easy publishing hits and start making their research more meaningful.  For example, most research on obesity and pregnancy now is just a litany of risks....fat women have more risk for "x" or "y" ─ but without any insight as to why they are more at risk for these things.  Study after study reiterating a litany of risks is not very meaningful anymore, but it does tend to ratchet up doctors' perceptions of risk around obesity, especially when they only use odds ratios instead of actual numerical risk.

I think it's well-established that women of size are more at risk for certain things....the question is what can we do about it. That's where our focus needs to be in obesity and pregnancy research right now; not just documenting increased risk but what to do about it.  And that leads us directly to the next item on my Dear Santa List.....

Research Improving Outcomes Without Weight Loss 

Without fail, nearly every study pushes weight loss as the answer to Life, the Universe, and Everything. Yet they stubbornly fail to connect the dots from other research that clearly shows that long-term weight loss is extremely unlikely, and that weight loss attempts often actually lead instead to further weight gain.   

If the only tool in our toolkit for improving outcome is one that is extremely unlikely to succeed, then it's time to develop some new tools in the toolkit.  We must start looking beyond weight loss as the only answer to improving outcomes.

Distinguish Between Correlation and Causation 

I would love to see more obesity research differentiate between correlation and causation when it comes to obesity.  Just because a certain outcome is associated with obesity does not mean obesity causes it (or that weight loss cures it).  In fact, a third factor common to both may actually be the cause...or some factor we don't understand yet.

I'd love to see researchers consider the possibility the obesity is a symptom of an underlying difference (in genetics, in metabolism, in hormonal issues, in ability to process insulin, etc.), rather than the automatic cause of problems.  If obesity is just another symptom, then focusing on weight loss is just a band-aid approach (and would explain why weight loss is often unsuccessful).  Focusing on the exact cause would lead to more improvement in outcomes long-term, which is what we really want, isn't it?

We have to move beyond our "blame the victim" mentality around obesity (i.e., obesity is a voluntary state caused mostly by bad behaviors), and start considering the possibility that obesity may often be simply another symptom of an underlying physical or metabolic difference.

Examine Interventions to See If They Improve Outcome

Many interventions to improve outcome have been proposed for women of size, especially "morbidly obese" women.  RCOG, the British version of ACOG, recommends that morbidly obese women be put on a low-dose aspirin regimen prophylactically to try and lower the rate of pre-eclampsia in this group.  The SOGC (Canadian version of ACOG) now recommends that morbidly obese women be put on regimens of ultra-high dose folic acid to try and lower the rate of birth defects in this group. Yet both of these recommendations were undertaken without research to show that they improve outcome, nor am I aware of any current studies looking to see if such regimens improve outcome.

Doctors often recommend care regimens in fat women in hopes that they will reduce poor outcomes, but without follow-up testing to see if these interventions improve outcome.  For example, as we recently discussed, doctors were taught for years that a vertical incision would lower the wound complication rate in very obese women, but when someone finally actually did a study of this question, they found that vertical incisions actually performed more poorly.

There's nothing wrong with proposing a potential intervention to see if it improves outcome in women of size (and prophylactic aspirin or high-dose folic acid may actually be a reasonable precaution for at least some very heavy women), but researchers have to then follow up and examine whether the proposed intervention actually improves outcomes or not.

Ideas for Specific Studies I'd Love To See

Antibiotic Dosing - In size acceptance circles, we've been saying for years that weight-based dosing may be needed to improve outcomes in people of size after surgery (depends on the type of antibiotic and its mechanism of action; some need weight-based dosing and some do not).  But we've consistently had difficulty in getting care providers to actually do this.

A recent study showed that 2 g of cefazolin given shortly before a planned cesarean did not reach minimal inhibitory concentration to knock out gram-negative bacteria in nearly half of morbidly obese women.  Since cefazolin is the antibiotic of choice in many surgical procedures (especially cesareans), it's time for a randomized controlled trial to find out what the optimal dosage for morbidly obese women actually is.

This shouldn't be that hard or that difficult a study to do; it's beyond me why it hasn't been done already. And it's vital that this be done, since chronically underdosing obese people may be adding to the increasing societal problem of antibiotic-resistant bugs, not to mention worsening outcomes among women of size.

Midwifery Model of Care - I'd love to see a study that specifically compared outcomes for obese women who experienced a low-intervention, "midwifery" model of care, vs. obese women who experienced a high-intervention, high-risk "bariatric obstetrics" model of care.  Research clearly shows that cesarean rates are lower for most women who experience a midwifery model of care, but there is no study that directly compares the two models of care specifically for obese women.

Given the strong move in many places to deny women of size the right to access low-intervention midwifery care ─ or even just regular obstetric care ─ and "alternative" options like waterbirth, birth centers, and homebirth, it behooves us to examine the which model of care actually improves outcomes better in this population.  What data we have and anecdotal stories suggest that the midwifery model will be advantageous for women of size who do not experience severe complications ─ but we need direct studies of the issue to confirm or deny that.

Fetal Malpositions - I'd love to see another modern study examine whether women of size have more malpositioned babies. Many very old studies mention a common perception that obese women have higher rates of malposition, and there is one modern study that confirms nearly twice the rate of posterior babies in obese women ─ but we really need more than that.  From the stories women have submitted to me (and from my own experiences), it seems like more women of size have malpositions, and this may be a prime reason behind our higher rates of labor dystocia and slower labors, but it'd be really useful to be able to show that conclusively.

If we can document more malpositions in women of size, then we could raise awareness of the possibility among care providers and then use chiropractic care (to prevent malpositions) and manual rotation techniques (to lower the c-section rate associated with OP babies during labor) to improve outcomes.  And perhaps we could keep care providers from just assuming that inefficient uterine contractions and/or soft tissue dystocia is always to blame, as they usually do now.  

Bottom line, if we can elucidate whether or not there are increased rates of malpositions in women of size, we can incorporate the interventions that improve outcome when malpositions are encountered (chiropractic care, maternal repositioning, more patience during labor, manual rotation) and probably lower the cesarean rate in women of size.

Iatrogenic Factors in Cesarean Rates - A couple of recent studies have found that the labors of obese women were managed differently, with far more interventions, more inductions, and a lower threshold for surgical delivery.  When these factors are controlled for, the higher cesarean rate in obese women was either markedly attenuated or it completely disappeared.  I'd love to see more follow-up on these studies in a similar vein.  

The high cesarean rate in women of size is not only about direct iatrogenic factors, but they do likely play a strong role in it.  Until care providers are willing to objectively look at their own role in poorer outcomes, care will not improve markedly in this group.  

Compare Those with Good Outcomes to Those with Poorer Outcomes - Researchers need to start acknowledging that many women of size have good outcomes and start studying these women.  They need to compare women who had good outcomes vs. those who had poorer outcomes and see if they can gain more clues about underlying causes of problems.

For example, if obese women who experience pre-eclampsia have higher hyperinsulinemia rates than obese women who do not experience pre-eclampsia, then perhaps treating women with metformin or fixing insulin receptor/signaling issues will help lower the rates of pre-eclampsia.  Or if obese women who experience a birth defect have lower pre-existing folate stores, then pre-conception blood testing and treating those with low folate stores will help prevent more birth defects in this group. Or if they find that obese women who do not develop GD have consistently higher exercise rates than those who do develop it, then increasing exercise rates is an easy intervention to promote.

The point is that at this point, everyone is so busy blaming and shaming the fat mother for complications that virtually no one is exploring why some fat women have great outcomes and some do not.  Examining the differences between the two groups might help elucidate the real causes of complications in women of size, and might give some really concrete directions for improving outcome.

PCOS and Breastfeeding - There is some preliminary research that shows that PCOS can impact milk supply and lower breastfeeding rates, but we have very little data on how many women with PCOS are affected, and why some with PCOS are affected and others are not.

Research on the impact of PCOS on milk supply has been out for more than 10 years, yet little follow-up research  has been done, and rarely is this confounding factor even mentioned in studies on why breastfeeding rates are lower in women of size. Nor has anyone studied possible interventions (metformin, goat's rue, progesterone supplements, etc.) to see if these could improve milk supply in affected PCOS women.  Considering how important breastfeeding is to a mother and baby's long-term health, it's long past time for far more attention to be paid to this issue.

Health at Every Size® and Pregnancy Outcome - Again, if weight loss before pregnancy is the only tool in our toolkit for improving outcome, we are greatly limiting our choices.  A Health At Every Size approach has been shown to improve outcomes in non-pregnant women; might it improve outcomes in pregnancy too?  

We need to uncouple weight loss from exercise and promotion of healthy habits in the research.  When "lifestyle interventions" are shown to improve outcome, was it really from the minimal weight loss associated with these interventions, or from the increased levels of exercise and improved habits instead?  If we focus on exercise and improved habits, will we improve outcomes without risking the long-term weight gain so commonly associated with weight cycling?  We need research targeted to this question, and we need it now.

Final Thoughts

Thanks for listening, Santa. I will be waiting with bated breath for studies on these topics and a general improvement in the direction of research around obesity and pregnancy.

Researchers and care providers, are you listening too?  Wouldn't you like to be a Santa's Helper and help improve outcomes among women of size?  A more thoughtful and targeted approach to research on obesity and pregnancy would go a long way towards achieving that goal.

Friday, December 16, 2011

Friday Fluff: Yoga Cat Silliness

Here's a cute little Friday Fluff entry for the holidays.

This is a video of a woman doing yoga, and her cat "helping."

I did prenatal yoga and loved it.  I tried to carry it over outside of pregnancy but between the babies and the cats climbing all over me, I could never make it work very well

This woman makes it work impressively, even with feline "help."  I'm impressed!

Tuesday, December 13, 2011

Misleading Wording: Vertical vs. Low Transverse Incisions

Recently, we discussed cesarean incisions in "obese" women, and specifically the pros and cons of a low transverse (side-to-side) incision vs. a vertical (up-down) incision.

As we noted before, for many years doctors were taught that doing an incision under an obese woman's belly fat ("pannus" in medical jargon) made it prone to infection because of the "bacteriologic cesspool" (yes, actual quote) found in the warm, moist conditions in that area.  Many were therefore taught to do a vertical incision in very fat women to lower the risk for wound complications.

However, some studies show a greatly increased risk for wound complications/blood loss with vertical incisions in obese women.  Yet to this day, many still cling to this teaching, despite a lack of support in the medical literature for it.  

Just after my post on the topic was published, a new study on the subject came out.  Here's what the abstract says (my emphasis):
After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding.
Sure makes it sound like a vertical incision is just as good as a low transverse one, right?  But look more closely at the full text of the study and the picture begins to change.

What The Study Really Shows

In the study, the number of vertical incisions was n=25, whereas the number of low transverse incisions was much higher, n=213.  The authors note that this was not enough to conclusively decide which incision was better, and that bigger trials were needed.  Very true.

Although the abstract gives lip service to this, the phrasing in the abstract makes it sound like vertical incisions did not result in worse outcomes, but that they needed larger studies to confirm that.  

But the thing is, the study did find worse outcomes with vertical incisions.  5 of the 25 vertical incisions (or 20%) experienced a problem with wound separation, as opposed to 22 out of 213 (or 10%) of the low transverse incisions.

So in the study, vertical incisions had twice the rate of wound separation, but because of the small number of vertical incisions, this difference did not rise to statistical significance.  

The authors were quite forward with this information in their conclusion:
We found that vertical skin incisions are associated with increased odds of postoperative wound separation, although this difference did not reach statistical significance. Although many variables factor into a surgeon’s decision on what type of skin incision to perform, the results of our study do not support the use of vertical skin incisions to reduce wound complications among obese women at the time of cesarean delivery.
That doesn't sound like what the abstract was implying, does it? Too bad the editors of the journal did not see fit to word the abstract more clearly.  They should have acknolwedged that there was no statistical significance, yes, but that there was a strong trend towards worse outcomes with vertical incisions, and that the study was underpowered to detect a statistically significant difference.

They did acknowledge the need for larger studies, but in the context of this abstract's wording it sounded like they needed larger studies to confirm that vertical was just as safe ─ when that's not at all what the authors said in the study.

Final Thoughts

OBs are very busy people and they often do not have time to read the full text of every journal article they run across.  Many just go by the conclusion of the abstracts.  Unfortunately, this abstract gives the mistaken impression that vertical incisions have outcomes just as good as low transverse incisions, when what data we have does not support this.  

A more definitive study is needed, one with a large enough sample to confirm or deny whether vertical incisions are associated with poorer outcomes.  All our research so far suggests that they are, but what we need is access to a really large database that records maternal BMI, types of incision used, and tracks post-op complications thoroughly. Perhaps the MFMU database? Researchers, are you listening?

In the meantime, I suppose it's some comfort that apparently, most women of size who have cesareans are getting low transverse incisions.  YAY.  We need to do less cesareans in women of size, period, but at least most of the cesareans in this group are being done with low transverse incisions.  Small comfort, but I'll take it.

But the stories I hear from women of size suggest that even so, too many obese women are STILL being subjected to the greater risks and ugliness of vertical incisions.  In fact, in this study, 11% of obese women were still being subjected to vertical incisions.  That's too many.  Sometimes, vertical incisions can be needed, but not one out of every ten sections.

Vertical incisions don't "prevent" infection or improve outcome in any way; research suggests it actually increases blood loss, operative time, and wound complications; it increases the likelihood of a classical uterine incision underneath (which is associated with more morbidity short- and long-term); and it creates an ugly scar that negatively impacts a fat woman's sense of self. 

Considering the number of cesareans done every year on women of size, it's time someone accessed a large database and debunked this outdated teaching once and for all.  Until that is done, however, doctors need to acknowledge the clear trend in the research and not use vertical incisions routinely in women of size

Am J Perinatol. 2011 Nov 21. Type of Skin Incision and Wound Complications in the Obese Parturient. McLean M, et al. PMID: 22105439
We examined the relationship between type of skin incision at time of cesarean delivery and postoperative wound complications in the obese parturient. Women with a body mass index (BMI) of greater than 29 who had undergone cesarean delivery at The University of North Carolina were identified from the Pregnancy, Infection and Nutrition study. Inpatient and outpatient medical records were reviewed for maternal demographics as well as intrapartum and intraoperative characteristics. The exposure of interest was type of incision, classified as vertical or transverse. The primary outcome was wound complication, defined as partial or complete wound separation. Logistic regression analysis was used to create a final model of risk factors for wound complications while controlling for potentially confounding variables. From 1998 to 2005, 238 women with a BMI greater than 29 who underwent cesarean delivery were identified. Of these 238 women, a vertical skin incision was performed in 25 (11%) and a transverse skin incision in 213 (89%). The overall incidence of wound complications in this group was 13%. BMI was associated with wound complications (p less than 0.01). After controlling for confounding factors, no difference in wound complication based on type of skin incision was apparent. The type of skin incision does not appear to be associated with wound complications in the obese parturient; however, larger studies would be needed to confirm this finding. Increased BMI is associated with a higher rate of wound complications.

Friday, December 2, 2011

Open Thread: What Do You Want To Tell Caregivers?

I'm speaking next week to a group of midwives (and possibly some doctors) about caring for women of size.

I'll be presenting lots of facts and figures and discussing research studies, but I'm also there to represent the voice of consumers, specifically of women of size.

So what in particular do you think is most important for these caregivers to know about caring for women of size?  How do you want to be treated? How do you not want to be treated?

How should caregivers responsibly discuss risk with women of size?  How can they improve outcomes in women of size? What do you most wish you could say to your own caregivers about the care you received during your pregnancies (or if you were to have one)?  About your gynecological care?  What constitutes good care in women of size?

This is an open thread; please feel free to add your comments.  However, remember that caregivers will be reading this thread in the future and we want to promote constructive dialogue about improving care in women of size.  Please keep comments constructive and helpful, even as you make the points you feel need to be made.

I hope this will generate some interesting dialogue and give some thought-provoking feedback to caregivers.

*P.S. Logistical note: For those who no means am I done with the PCOS series.  It just went on hiatus for a bit while I worked on some major deadlines on other projects.  It will be a periodic series. Stay tuned!