Wednesday, December 26, 2012

A Lovely VBAC After CBAC Story

The "OMG, A Baby Just Came Out of My Vagina!" VBAC Face
(Also called The Official VBACFace™ by Jill at the Unnecesarean)

As we enjoy the holidays, it's nice to be able to share some good news for a change.  And what better news can there be than a lovely birth story, with GREAT pictures to boot?

Below is a brief summary of Melek's birth stories and some of her birth pictures, all shared with permission. You can find longer versions of her stories on the ICAN blog, which she helps run.

I love these stories and just had to share them because she has some of the best birth photos EVER.  They just brought a giant smile of happiness to my face when I saw them.  And what better time of year to share them?

I always love to share VBAC (Vaginal Birth After Cesarean) stories.  This one is particularly poignant to me because she had a CBAC (Cesarean Birth After Cesarean) when she tried for her first VBAC, as I did also.  And yet we both went on to have VBACs afterwards.

Many care providers assume that once you've had a cesarean, somehow your body is just not capable of birthing a baby vaginally.  Research shows that most of these women can, in fact, birth vaginally if given the chance to VBAC, but many are erroneously told they cannot.

And if you've gone for a VBAC and ended up with another cesarean instead, care providers almost without exception assume that you are somehow "broken" and cannot possibly have a vaginal birth.

Yet the experiences of Melek (and me, and many others I know) show that it is possible to have a VBAC after having gone through a CBAC.  And research shows that VBAC after more than one prior cesarean is definitely possible and reasonable.

It's important to note, of course, that not every cesarean or CBAC mother goes on to have a VBAC.  Sometimes it's truly not possible, sometimes medical considerations make it prudent to have a repeat cesarean, sometimes the mother is just done having children or doesn't want to consider laboring again, or sometimes she simply cannot find a supportive provider.  A vaginal birth is not the end-all, be-all of birth.  You are a mother regardless of how your baby arrives.  

But even so, there is something wonderful about women finally able to get their desired birth, something incredibly special about women who keep pushing for VBAC despite lack of support from some in the obstetric establishment, something incredibly brave about the tenacity of women who persevere despite medical professionals telling them that they are "broken*" or "damaged," something incredibly affirming about women showing that their bodies can give birth vaginally after all.

This is one of those stories.

Congratulations, Melek, we are so happy for you.  Congratulations on your new baby.  Thank you for being willing to share your birth pictures and your joy with us all.  Bless you and all your children.

*Sometimes when a birth story like this (i.e., someone who felt "broken" by their cesarean, etc.) is posted, some people's feathers get ruffled.  It's important to remember that this is one woman's story, one woman's perceptions about her births, and it doesn't have to reflect your own reality or opinions.  It's okay if your story is different.  Be happy for her anyhow.

Melek's Stories

Baby #1 (Cesarean):

Risked out of a birth at a birthing center with midwives because of essential hypertension, Melek was induced and ended with a c-section.  She was emotionally devastated when her doctor told her, "Well, all your babies will have to be born by cesarean and seeing how difficult this pregnancy was, you should probably only try for one more.”  She felt broken and damaged.

After the disappointment of her first birth and her doctor's discouraging words, Melek let her health habits slip for a while.  Realizing that she wanted to avoid intervention in a future pregnancy, she made an effort to improve her health. [Trigger warning for brief weight loss talk in the original story.]  In time, she was able to get off her blood pressure medications and conceive again.

An abbreviated version of this story can be found here, near the top of the entry.

Baby #2 (CBAC):

After getting off her blood pressure meds, Melek planned a home birth with wonderful midwives.  When she went into labor, however, baby's position was not quite optimal and labor was long and slow, then turned hard. Some non-reassuring signs were found and a hospital transfer was made.  She ended up with another cesarean, but while disappointed, did find the experience empowering in the end.  She wrote:
I was expecting to be devastated if I had a repeat c/s, but I was surprised with how not only content, but happy I was about my birthing. I had worked so hard for two days, listening to my body and working through contractions. I felt really respected by the hospital staff. No one ever once made me feel bad about being a home birth transfer. In fact, the OB that delivered Emre told me that he is sorry that it ended in a cesarean because he knew how badly I wanted a natural childbirth and how hard I worked for it. He didn't downplay the importance of my birth to me and that was so very special to me. I felt respected, validated and valued by every single person who was part of my birth experience. I never knew that a CBAC could feel like that.
Melek's full CBAC story can be found here.

Baby #3 (VBA2C): 

Melek spent a lot of time emotionally processing her first two births while preparing for her third.  She also prepared physically, utilizing Maya Abdominal Massage to help break up any scar tissue, chiropractic care to help promote a good fetal position, and acupuncture near term to ready her body for labor.

Her midwives were totally supportive, but, like many CBAC moms, she had many concerns that something was going to interfere with her much-desired VBAC.  She despaired that she would have another big baby, would go well past her due date, and that as a result, baby's head would be big and not mold-able enough to be born vaginally.

In the end, she had the baby a week past her due date, one with a big head that did not mold, and he was another sizable baby (9 lbs. 13 ounces).  And she still had a VBAC.

And what a beautiful VBAC it was.

Full story can be found here.

More Birth Photos

Here are some more birth photos from Melek's VBA2C (Vaginal Birth After 2 Cesareans).  Keep in mind that some are from a cell phone, and I re-posted the picture from the top of this post to show its context in the birth story (and because it may be one of my all-time favorite birth photos!).  I couldn't get Blogger to rotate the second-to-last photo, but it was too wonderful to omit, so turn your head to the side and enjoy her giant smile of joy anyhow.


in labor

Best VBAC Photo Ever?

overwhelmed 


snuggling up


beaming with joy


the happy family

Sunday, December 16, 2012

Thoughts for the Old, Fat and Pregnant

Picasso
This is a comment turned post from here.*

A fat woman shared on a forum that she was unexpectedly pregnant in her 40s and was asking for resources and hints on pregnancy in this situation.  Several folks responded by recommending my sites (thanks for recommending me, folks!), which alerted me to the post.

I left a comment about things to think about as a fat, old pregnant person.  Then it struck me that I really should expand on this for my blog!  Who knows this topic more personally than I do?

I know pregnancy as a fat and old person.  I had three of my four children at "advanced maternal age" (35 or over) and my last was at age 42.  I was "morbidly obese" for all four pregnancies.  I know pregnancy as an old, fat chick.

And having done it several times, I definitely have some suggestions for things to consider for those contemplating the journey.

Find Your Tribe

Honestly, pregnancy as an old fat chick was really no big deal, at least to me.  My babies were healthy every time, and everything was fine.  Did I worry?  Yes, but what mother doesn't?  I didn't obsess about age.

The doctors, on the other hand, were a different story.  Some saw me as a ticking time bomb.  They particularly feared what they saw as the additive risks of being both an older mom and a morbidly obese one.  They slated me for all kinds of extra tests, induction of labor, and extra monitoring. They assumed that I would develop a complication, not that I might develop one.

I was pressured into the high-tech, highly-tested route with my first child (ironically, the only one not born at advanced maternal age), and was traumatized by the fear-laden, interventive "birth" that followed. When I saw that even more interventions were being suggested for the next pregnancy, based on my age, I bolted.  I found that my sanity was better when I found caregivers who didn't freak out about my age or size, which for me meant midwives.  I also had way easier births when I saw less-interventive caregivers.

However, that was me.  You have to find the level of care that YOU are comfortable with. I found I strongly preferred the less-interventive care model, but not everyone does. Some older or bigger moms are comforted by more intervention. Some just want it. A few truly need it. There's no "right" or "wrong" approach here, just one that aligns with your personal birthing preferences and medical needs.

Therefore, I'd recommend exploring different birth options and figuring out ahead of time which care model you prefer and which is appropriate for your unique needs.  (You can read more about that here.)  Interview several types of care providers, ask lots of open-ended questions about their protocols for you given your age and size, then make a decision based on their answers and your intuitive reaction to the provider and his/her practice.

Be An Educated Consumer

Go into your provider interviews knowing that it's true that there is an increased risk for certain complications when you are an older mom.  There are higher rates of blood pressure and blood sugar issues, for example, and higher rates of birth defects.  And it's true that there is an increased risk for these things as well when you are "obese."

However, being at an increased risk for a problem does not mean that this risk will occur, only that it is a possibility.  The question is how your provider responds to this possibility.

Does the provider intend to order every test under the sun?  Is he/she comfortable with you declining tests?  Or wanting a particular test?  Does the provider truly provide informed consent about tests?  The key is to become an educated consumer about the various tests and procedures that may be suggested to an older obese mother, to know the benefits and risks of each, and to weigh them against your own values.

For example, there will be lots of pressure for prenatal tests because of the potential for birth defects.  Media reports make it sound like the risk is huge, but the absolute numerical risk of a birth defect is small.  So while it's important to know that the risk is increased somewhat, it's also important to keep that risk in perspective.  The vast majority of old moms, fat moms, and old fat moms will have healthy babies.  

Remember, all prenatal tests have pros and cons. Some providers downplay the potential risks (i.e., miscarriage), and women only come to appreciate these risks after they have experienced them. Some of these tests have high false-positive rates, and may create a strong fear that something is wrong when nothing actually is.

On the other hand, prenatal testing has potential benefits. It can be helpful to know about certain conditions ahead of time because some problems can be fixed in utero. Or additional plans can be made for the birth based on baby's condition, like giving birth in a hospital with a level III neonatal care unit, or having certain specialists immediately available at the birth.

Some couples feel it is best to know about problems ahead of time so they can become more informed about the baby's diagnosis, grieve the loss of a "normal" child, and therefore be more ready to welcome that unique baby into the world at its birth.

However, this knowledge can be a double-edged sword. Some parents feel like their experiences of pregnancy and birth were tainted by foreknowledge of a baby's problems, and that knowing of even very minor problems took much of the joy and anticipation out of their pregnancies. And all these tests raise the specter of what you would do if tests indicated a problem.

So the prenatal testing decision is a complex one. Parents need to be sure they really understand the following issues before any prenatal test takes place:
  • What is being tested for
  • What the test measures and how accurate it is
  • The difference between a screening test and a diagnostic test
  • What it means if they get a non-reassuring screening test result
  • What their choices would be if they had a non-reassuring test result
  • What further testing might be available
  • What kind of possible treatment might be available if a condition did exist
  • Whether this information before birth would be an advantage or disadvantage to them
  • What they would do with the information once they got it
Some older and larger moms choose to have these tests, some don't. Some love the tests, some do not.   It's really a very personal thing.

I was pressured into having all the prenatal tests in my first pregnancy and had a terrible experience with them, so I chose much more limited testing in future pregnancies, despite an older age each time.  However, I did choose to have at least an ultrasound each time, so I didn't refuse all testing either.  I found a middle ground that met my comfort level and needs.

Like me, some women feel that these tests are a mixed blessing and choose to opt out of them or to use them in limited ways.  Other women have good experiences with these tests and felt very reassured by having them.

No one can tell you what's right for you in the prenatal testing realm, but do know that it's always YOUR choice how much and what testing to do.  You don't "have" to do anything just because of your age or weight.  Research the issue and then find a provider who is supportive of your choices.

(You can read more about certain types of prenatal testing and how they are impacted by a high BMI here.)

Consider Delivery Protocols

Pressure for early delivery can be intense in both older pregnancies and in the pregnancies of women of size.  This intense pressure to deliver no later than the due date means the induction rate in both groups is very high, and is intricately related to the high cesarean rates in these groups.

Much of the pressure for early delivery is because of the fear of stillbirth. Providers rightly point out that the risk of stillbirth at term is higher in older mothers, and is probably higher in high-BMI women too (although some research suggests that this risk may be more limited to those with growth-restricted babies, or is particularly strong in black women).

However, while elevated, the risk for stillbirth in these groups is still relatively low in absolute numerical terms, even for the oldest mothers.  It is a concern, but one that must be kept in perspective.

This concern over stillbirth leads many providers to routinely induce all older women and heavier women at 39-40 weeks, even when there is no other medical indication for induction.  The question is whether early induction helps lower the risk for stillbirth, or whether it stresses the baby and leads to more complications than it alleviates. Certainly, it likely strongly increases the chances for a cesarean.

In other words, is the risk of continuing the pregnancy higher than the risks of an induction?  Frankly, that is not clear at this point.  Most care providers simply assume inducing early will lower stillbirths in these groups, but more research is needed.  However, there are alternatives.  For some providers, the increased risk for stillbirth is simply seen as an indication for more prenatal monitoring, with early delivery only being considered if the results are not reassuring. This will likely catch some cases where stillbirth might be preventable, but realistically, will not prevent all stillbirths.

Some women are uncomfortable with any possibility of increased risk of stillbirth, and are happy to agree to early induction or even elective cesareans, despite the known potential harms of inductions and cesareans.  And of course, that's their right.  These women will be most comfortable with the delivery protocols of most OBs, and will probably feel reassured by frequent prenatal monitoring near term.

On the other hand, many women recognize that even with a somewhat elevated risk, the likelihood of stillbirth is still quite low and they are comfortable not rushing the birth process at all.  These women are more likely to be comfortable with a hands-off midwife or OB, one who won't require delivery by a certain date on a calendar.

Either way, it is very important for you to be "in sync" with your provider's philosophy and protocols for due dates in older or heavier women.  Ask about their concerns and protocols ahead of time so there are no surprises.  Don't be afraid to switch to a provider that is more in line with your preferences.  It's better to switch now than to try and fight a protocol you don't want later on.

If you choose induction at 39 or 40 weeks, remember that inductions are more successful if done when the cervix is ripe and the baby is in a good position for birth.  Ask what your Bishop's Score is and if the baby is anterior.  See if you can hold off inducing if your Bishop's Score is low, and do what you can to ripen the cervix ahead of time.  Serial induction (doing a slow induction over several days) and avoiding breaking the water too early may increase the chances for a vaginal birth.  There is also research to suggest that more patience may be needed in the labors of induced mothers; as long as baby is doing well, make sure your provider is not too quick to intervene surgically.

If you think induction is likely because of a medical issue or a strict due dates protocol from your provider, acupuncture can help gently prepare your body for labor. That way, if an induction happens, it is more likely to be successful.  The key with acupuncture is to allow it enough time to work.  It's not like medical induction, meant to work in a short period of time. It's most effective when it's done gradually, over a period of several weeks, rather than done once or twice near the very end of pregnancy when there's no time left.

It's important to know that there are also providers who are supportive of waiting for spontaneous labor, even in older, heavier women.  You may have to ask a lot of questions and interview a lot of providers to find one, but they are out there if you want one.

Because I was healthy (no blood pressure or blood sugar issues) and my baby looked good, the midwives in my last pregnancy were comfortable waiting for spontaneous labor, even though I was 42 and "morbidly obese."  Baby was born at almost 43 weeks by LMP; just over 41 weeks by adjusted due date.  We were both fine, and it was my easiest birth by far.  However, my choices are my own and may not be right for you.

It's not easy to know what to do about due date protocols when you are in a group that is at increased risk for stillbirth.  Early intervention may sometimes save lives, but that may come at a price of a very high c-section rate and all the harms that can come from inductions and cesareans.  Bottom line, it is a question that deserves careful contemplation and great care when choosing a provider.

Be Proactive

Although no one can promise mothers of any age a perfectly healthy pregnancy, being proactive in your health habits may increase your chances of avoiding the more common complications.

Primary among these is the importance of getting good nutrition and regular exercise. Older women and fatter women are both at increased risk for blood pressure and blood sugar issues, so a woman who is both older and fat is at significant risk for these issues.  The good news is that nutrition and exercise can go a long way towards reducing those risks.

For example, some research suggests that regular, daily exercise can lower the risk for blood pressure/pre-eclampsia issues.  Some research also suggests a similar effect for blood sugar issues.  The beneficial effect is marginal in average-sized women but may be more powerful in women of size, so that's even more reason for older, heavier women to be proactive about this.

Sensible nutritional hints, like avoiding large amounts of simple carbohydrates at once, eating a lower-glycemic or moderate carb diet, and eating protein with your carbs may also lower your chances for blood sugar issues. There is no need to be neurotic about this, but a sensible, moderate approach is a reasonable goal that may help reduce risks.

For those at particularly high risk for pre-eclampsia (i.e., women with a history of prior pre-eclampsia, a family history of it, those with blood clotting issues), there may be other options to consider as well.  For example, some research suggests that low-dose aspirin or supplemental calcium may be helpful in lowering the risk for pre-eclampsia in high-risk women.

For those women at particularly high risk for gestational diabetes (i.e., women with severe PCOS, a strong family history of diabetes, or preexisting impaired glucose tolerance), other choices might include considering metformin or supplements like chromium, d-chiro inositol or myo-inositol prophylactically.

However, decisions on medications and supplements are ones that should only be considered in conjunction with your care provider, since they also may carry risks as well as benefits. Discuss these carefully before proceeding with any of them.

The benefit of a strong focus on nutrition and exercise is that a reasonable lifestyle approach has many potential benefits and very little risk.  For those at particular risk for complications, further interventions may be helpful, but pros and cons have to be weighed first.  Good nutrition and regular exercise doesn't have that downside.  It's one of the strongest and most effective things you can do to increase your chances of a healthy pregnancy and baby.

If you can avoid complications like gestational diabetes or pre-eclampsia, that goes a long way towards giving you more choices during your birth.  Develop those complications, and your choices are more limited. So it is vitally important to be as proactive about your health as possible during pregnancy.

Consider Body Work in Pregnancy

There's no question that pregnancy is harder on a 40-year-old body than it is on a 25-year-old body.  Life is just harder on an older body than a younger one, so you usually have more aches and pains to deal with when you are pregnant at an older age.  However, that doesn't mean that pregnancy in a 40-year-old is all that bad.  The key is to stay as active as you can, and to not be afraid to use bodywork to help you be more comfortable.

I personally found that regular chiropractic care (from a chiropractor with special training in pregnancy, like those with Bagnell or Webster Technique training) was important in helping my old pregnant body be more comfortable. It was also key in promoting a good fetal position (which makes birth a LOT easier, trust me). I think it's especially important for those with a history of car accidents, significant falls, sports injuries, or other body trauma.  Honestly, chiropractic care was one of the most important things I did for myself as an old, fat pregnant chick.  However, as always, it's a choice up to the individual.

Prenatal massage is definitely a wonderful treat for any pregnant body, young or old, and can also help with aches and pains.  There are many massage therapists who specialize in prenatal massage, and it's well worth looking into if you can afford it.  If you can't afford it, you might be able to find a massage-therapist-in-training who would work on you for free or for a reduced fee.

If you have a history of body trauma or experience significant pain in pregnancy, gentle myofascial work may be a good addition to traditional relaxation massage.  Craniosacral Therapy is another complementary bodywork technique that many women find helpful.

Acupuncture can be useful for the aches and pains of pregnancy in an older body too. It can also be extremely effective for other pregnancy complaints like blood pressure issues, heartburn, morning sickness, and headaches. I used acupuncture in my last pregnancy and found it helpful for aches and pains, for heartburn, and for headaches. I also used acupuncture during my labor for pain relief and encouraging a good labor pattern.  Although I didn't use it for ripening the cervix, it can be helpful in preparing the body for labor, for those being pressured to give birth by a certain date, as noted above.

(Not all acupuncturists see pregnant women, so check around with your local doulas and midwives to get a recommendation for one comfortable with pregnancy.)

Bodywork is one of the kindest things you can do for your body in pregnancy, especially as you get older.  If your budget allows it, it can be a wonderful addition to your prenatal care.  If your budget is strained, remember that many bodyworkers will utilize a sliding scale fee or bartering if asked, because they feel it is so important for pregnant women to receive this work.

Other Issues to Think About

Older women and heavier women may be more prone to thyroid issues during and after pregnancy, so ask your provider to watch your thyroid levels carefully, especially if you have a history of depression or PCOS.  Thyroid levels can quickly go out of whack in pregnancy or postpartum in some folks, even those who never had a problem with it previously, so it's worth monitoring for carefully.

If you tend towards depression and are concerned about post-partum depression (PPD), some people swear by placenta encapsulation for preventing PPD.  However, this is a little more on the "alternative" side of the spectrum, so you might want to choose a midwife if you are interested in this.

Final Thoughts

Don't let the scare-mongers frighten you away from being an older mother or a fat mother.  It's definitely doable, and many of us have done it.  You can too.

Certainly, it's important to be aware of the possible risks of being an older mom (or a heavier mom), but remember that being a member of a group at risk for something doesn't guarantee anything for an individual's outcome.

However, it is a call to be particularly proactive about your self-care and your choice of provider.
  • Find your tribe by finding a care provider who aligns with your birth preferences and will honor your birthing choices
  • Be an educated consumer by doing your research on prenatal testing, delivery protocols, and birthing choices
  • Be proactive in your health habits, with special emphasis on nutrition and exercise
  • Look into bodywork for making pregnancy more comfortable and your body optimally functional during this important time
Best wishes to anyone out there thinking about becoming a mother.  Although it can be scary to read about risks, remember that most mothers, regardless of age or size, do just fine.

Be aware of the risks, but focus your energies on proactive behaviors and the knowledge that most women will have good outcomes, whatever their risk factors.

Old or fat or both, you CAN do this. Enjoy your new direction in life, and don't spend much time worrying about what-ifs.  Being a mom can be a tumultuous journey, yes, but it's also one of life's greatest blessings.  Don't be afraid to embrace it whole-heartedly, whatever your age or size.


**Do you have any experience as an older mom of size?  Do you have any great websites with information for older moms?  Share your stories or resources in the comments section.

Friday, December 7, 2012

Friday Fluff: Sleep Eye song

Friday Fluff, anyone?

Remember those days trying to convince the baby to go to sleep?  I sure do.  My first was very colicky and always had a very difficult time getting to sleep.  Too bad I didn't know this song then!

Here is a lovely video called, "Sleep Eye" by Elizabeth Mitchell.  It's from the album, "Little Seed: Songs for Children by Woody Guthrie," which was nominated for a Grammy.  It's available from Smithsonian Folkways Recordings, or from her website, www.youaremyflower.org.

It's not your usual lullaby. It's very cute and sweet, but with a little bounce in it, like when you jiggle your baby to soothe her, or dance around a little to help him settle down.  Enjoy!


Monday, December 3, 2012

Cesarean Incisions in Women of Size: Supraumbilical?



We previously discussed cesarean incision choice in women of size ─ specifically, the choice of vertical (up-down) incisions vs. low transverse (side-to-side) incisions.

The gist of those posts is that for years many doctors were erroneously taught that a vertical (up-down) incision was best in very fat women.  They were taught that the area under a fat woman's belly (called an "apron", "pannus" or "panniculus") was far too prone to infection, so it was best not to do an incision there.  Instead, many were taught to do a vertical skin incision, which often turned into a vertical or "classical" incision on the uterus as well.

High-BMI women were told that this vertical incision would lessen their risk for complications like wound infection, wound separation, bleeding, etc., but when researchers finally got around to actually studying this, they found the opposite ─ that outcomes were not improved with vertical incisions, that vertical incisions actually worsen outcomes in many cases.  Furthermore, classical uterine incisions have poorer outcomes, both short-term and long-term, and therefore should not be undertaken lightly.

Despite the evidence that vertical incisions do not improve outcome and may worsen it, many doctors are still promoting the idea that an incision under the belly is far too prone to infection to use.  As recently as 2006, one OB-GYN wrote, "In general, there is a lot to be said for an incision not buried under the pannus of fat, so that fresh air can help keep the wound dry."  And the illustration above is from a 2009 article, which also highlights the supposed dangers of an incision under the belly.

Now some doctors are promoting another choice for cesarean incisions in very heavy women ─ one done above or near the belly button. This is called a "supraumbilical" (above the belly button) incision.  This incision is not new, but is gaining new traction among some OBs. While not extremely common, it is being promoted by some doctors as beneficial in supersized women.  But is it?

So today, let's talk about supraumbilical incisions and their pros and cons.
Trigger Alert - This post discusses the difficulties associated with surgery on the bellies of very fat women.  Some graphic details are included, and the tone of the research cited is often quite judgmental.  Therefore, readers who might find this triggering may wish to skip this post.
Supraumbilical vs. Low Transverse Incisions

The difficulty in doing abdominal surgery on very heavy women is the barrier that a large amount of belly fat presents.  If you cut through the middle of the belly, you are going through the thickest part of the belly, which takes longer, increases the risk for excessive bleeding, and inhibits healing because of decreased vascularization of adipose (fat) tissue.

Thus, surgeons have come up with 2 approaches to avoiding incisions in the fattest part of the belly. The first is a low transverse incision, under the belly, and the second is a supraumbilical incision, above or near the belly button (umbilicus).

The low transverse incision (usually Pfannenstiel or Joel-Cohen) has repeatedly been shown to have superior outcomes to other incisions, even in obese women.  However, doing it in women with very large bellies is not easy.

Low-transverse incision made under the belly
by pulling back the panniculus

In the picture just above, the woman's overhanging belly is pulled back via a strap or tape towards the mother's head.  This exposes the area under the panniculus (which tends to be thinner) and a low transverse (side-to-side) incision is made there.

Again, many doctors have erroneously been taught that this area is hot, moist, and "a veritable bacteriologic cesspool" (yes, actual quote from the medical literature) and thus highly prone to infection.  In addition, an assistant is sometimes required to hold back the belly during a cesarean, and this can be very physically tiring.  Therefore, some doctors have sought an alternative.

The supraumbilical incision has become popular in some obstetric circles as a possible alternative, especially for women with extremely large or "droopy" bellies.

The $64,000 question is whether this improves outcomes over low-transverse incisions.

Types of Supraumbilical Incisions

In most women, a supraumbilical skin incision translates to a vertical (up-and-down) incision in the skin above the belly button, as in the picture below (repeated from the top of the post). This then is usually accompanied by a vertical/classical incision in the uterus underneath.



This differs from the usual classical incision, which is a vertical (up-down) incision also , but done from the belly button down to the pubic bone.  This also involves a uterine incision in the upper segment of the uterus.



The main difference between a supraumbilical incision and the usual classical incision is that the supraumbilical is done above the belly button, not below it.

Sometimes a supraumbilical incision is done side-to-side (transverse above the belly button, on the upper uterine segment), a picture of which can be found here

However, in a few women with extremely voluminous and droopy bellies, a skin incision above the belly button translates into an incision into the lower segment of the uterus, as in the picture below.

A supraumbilical skin incision,
but with a low uterine incision

[Sorry for the blurry image above; it is from a medical study and is very small. When enlarged, the text becomes blurry.  The words from L to R are "panniculus", "umbilicus", "projection of the pubic symphysis", "abdominal and low uterine segment incisions".]

In other words, in a few women the belly droops down low enough that it pulls down the alignment of the skin over the uterus, so that the skin area above the belly button sits near the the pubic bone (pubic symphysis), over the lower uterine segment instead.  In such a case, a supraumbilical skin incision can translate into a low transverse uterine incision. Since lower-uterine segment (LUS) incisions have fewer complications, this combines the advantages of easier surgical access with a supraumbilical skin incision and the better long-term prognosis of a LUS uterine incision.

However, most of the time, a supraumbilical skin incision means a uterine incision in the upper uterus, which carries more risks, both short-term and long-term.  

Patterson (2002) and Bakhshi (2010) compared outcomes in women who had classical incisions vs. low transverse incisions.  They found that women with classical incisions had more infections, more hysterectomies, more blood transfusions, longer operating time, and more intensive care admissions.  They also had far more uterine scar separations in future pregnancies.  Therefore the decision to do a supraumbilical incision potentially has far-reaching implications.

Some doctors are far too quick to resort to supraumbilical incisions on "morbidly obese" women, and at BMIs that don't truly require it. Since most supraumbilical incisions result in classical uterine incisions, doctors are putting these women at considerable risk, whether it's because they don't want to deal with the mechanical challenges of a low transverse incision, or because they have erroneously been taught that the risk of infection is higher in an under-the-belly incision.

Cosmetic Considerations

Another problem with supraumbilical incision that scarring that accompanies it.

The negative cosmetic and psychological impact of a giant scar above the belly button in women of size must not be underestimated.

Research on supraumbilical incisions never considers this, as if the surgeons believe that the bellies of women of size are already so repugnant that a giant scar in the middle of the belly is of no consequence.  Yet, as with midline vertical incisions, the potential psychological impact of such a disfiguring scar is tremendous.

I have a friend who had multiple cesareans ─ not because she wanted them but because of the fat-phobic ignorance of her first OB.  That OB had been taught that a low transverse incision was too prone to infection in obese women, so her first cesarean was supraumbilical, with a classical vertical incision on the uterus. Her next two cesareans were low-transverse repeat cesareans with a different OB, since she could not find anyone who would  let her try a VBAC with a prior classical incision. Her subsequent OB was very frank that the decision to do a supraumbilical incision was totally unnecessary in her first cesarean, and very sympathetic to her frustration that this arbitrary decision by the first OB had totally taken away all her options in subsequent pregnancies.

Even as time lessened the scarring, she found the supraumbilical scar far more disfiguring than her low transverse scars.  She wrote:
I had a supraumbilical incision, so I have this huge scar about 1 inch wide in the middle of my abdomen.  Not very pretty.... 
As far as cosmetics go, my LT [low transverse] incision is so far down it starts right above my pubic hairline...so it's barely noticeable, and in an area no one else but [my husband] would see.
The scarring from a supraumbilical incision is noticeable, and it does matter to women of size.  Just because their bellies are large doesn't mean that cosmetic considerations are irrelevant.

Oh, and those subsequent low-transverse incisions my friend had?  No infection issues at all, despite what her first OB was taught.  But the psychological impact of that first, supraumbilical scar has stayed with her for years. And the doctor's choice for a supraumbilical incision denied her any choices in her future births, any chance at a VBAC, and exposed her to the risks of classical cesareans, not to mention the risks of the subsequent repeat cesareans that were mandatory with the doctors in her area.

The cosmetic considerations of such a disfiguring scar in such an easily-seen place should not be underestimated when making the decision about incisions in women of size.  Just because a woman is obese doesn't mean these cosmetic considerations are moot.  Nor should the limitations supraumbilical incisions place on future pregnancies be shrugged off lightly.

Supraumbilical Incisions: A Summary

To be fair, supraumbilical incisions have certain advantages from the surgeon's point of view. They offer easier accessibility to the uterus in women with very large amounts of belly fat.  They are also less demanding on the O.R. staff, who often have to "pull back" and hold the pannus away from the lower uterine segment, which can be difficult and tiring. One can appreciate and sympathize with the technical demands of doing abdominal surgery in heavy women.

However, given the downsides of supraumbilical scars, this is not enough.  Supraumbilical incisions need to be shown to result in clinically superior outcomes, and they have not been.  Although researchers expected that supraumbilical incisions would improve outcome in very fat women, the data showed that they did NOT actually improve outcome.  Outcomes were actually similar among women with low transverse incisions and supraumbilical incisions.

Again, most of these supraumbilical incisions result in uterine incisions in the upper uterine segment, which is MUCH more risky, much  harder to recover from, and which has profound implications for any future pregnancies.  It also essentially ensures the woman must always have repeat cesareans in the future. Furthermore, they leave a large, very disfiguring scar on the upper abdomen of women after the surgery is over.  A low transverse skin incision is also scarring, but is far less obvious and far less disfiguring in most cases.

The whole premise of doing supraumbilical incisions was to improve outcome for obese women. If they do not improve outcome while simultaneously placing the woman at extra risk and being quite disfiguring, there is no good reason for doing supraumbilical incisions in most cases.

Yes, supraumbilical incisions are easier to perform and are easier on the operating room staff.  Yes, low transverse incisions are harder in supersized women and can present many technical and physical challenges.  However, the bottom line is that the surgeon's convenience should take a back seat to the best interests of the mother and baby (and future babies).

Of course, there may occasionally be situations where such an incision might be useful, such as in a woman with extreme obesity, a woman with an extremely large and droopy belly, or a woman with a complicated placenta previa (low-lying placenta).  No one is saying that supraumbilical incisions should be absolutely banned, only that they should be kept for very rare cases where they are truly needed.  They should not be done routinely, even in high-BMI women.

Fortunately, most cesareans being done today are low-transverse incisions, even in women of size.  However, there are some doctors who use classical or supraumbilical incisions as a routine alternative to low transverse incisions in "morbidly obese" women, and their threshold for using it is far too low in some cases.  The mean BMI for a supraumbilical incision in the Tixier study below was 47, which is near my own BMI.  Many women of this BMI (including me) and a lot larger have had low transverse incisions with no problems, so any routine use of supraumbilical incisions in this size is highly questionable.

A supraumbilical incision can be a useful tool under certain extreme circumstances.  It's worth documenting the technique for that reason. Even so, it must be pointed out that supraumbilical incisions do not improve outcome over low transverse incisions, and they should never be used routinely or because they are easier for the O.R. staff.

An incision like this has far too many implications for maternal health and future pregnancies. Only under special, extreme circumstances should a supraumbilical incision be utilized.


*Images from "Delivery and postpartum concerns in the obese gravida" (Phillips, Obmanagement, Feb 2009), Gunatiake and Perlow 2011, and the Tixier 2009 study below.

References

Supraumbilical Incisions

Houston MC and Raynor BD. Postoperative morbidity in the morbidly obese parturient woman: supraumbilical and low transverse abdominal approaches. American Journal of Obstetrics and Gynecology 2000 May;182(5):1033-35. PMID: 10819819
OBJECTIVE: Our purpose was to determine the differences in postoperative morbidity in obese women who had a supraumbilical or a Pfannenstiel incision at cesarean delivery. STUDY DESIGN: A case-control retrospective review was conducted of all patients who were at greater than 150% ideal body weight when undergoing cesarean delivery between 1989 and 1995 by means of either a supraumbilical or a Pfannenstiel incision. Patients were excluded if medical records were unavailable. A total of 15 women who had a supraumbilical incision and 54 who had a low transverse incision were included in the analysis. Antenatal complications were examined, as were age, weight, and training level of the surgeon. Postoperative complications were then compared. RESULTS: The groups were similar in age and antepartum complications. However, mean weight and percentage of ideal body weight in the supraumbilical group were both higher (P less than .00001 and P less than .0001, respectively), with the supraumbilical group 83 lb heavier on average. No significant differences were seen in any postoperative complication. CONCLUSION: Postoperative morbidity in morbidly obese women undergoing cesarean delivery does not differ between a supraumbilical approach and the low transverse abdominal incision.
Tixier H et al. Cesarean section in morbidly obese women: supra or subumbilical transverse incision? Acta Obstetrecia et Gynecologica Scandanavica 2009;88(9):1049-52. PMID: 19639463
The obstetrician is more and more frequently faced with the decision to perform a cesarean section in obese women. We describe a technique of supra or subumbilical transverse cesarean section (depending on the height of the projection of the upper edge of the pubic symphysis) specifically designed for morbidly obese women with a voluminous panniculus. We evaluated feasibility and associated morbidity in a retrospective descriptive series of 18 patients operated between 2003 and 2008. We assessed the quality of access to the lower uterine segment and facility to extract the fetus. The mean body mass index was 47.7 kg/m(2) (range 40.1-60.8). The incision was subumbilical in 13 women (72.2%) and supraumbilical in 27.7%. With this technique, the exposition, the section of the lower uterine segment, and extraction of the baby are simple. It can be easily generalized and quickly learnt.
J Reprod Med. 2007 Mar;52(3):231-4. Cesarean birth in the morbidly obese woman: a report of 3 cases. Porreco RP, et al.  PMID: 17465294
BACKGROUND: Primary and repeat cesarean births are a frequent occurrence among morbidly obese women. Technical difficulties encountered in caring for these patients, coupled with physiologic differences, affect their operative management. CASES: Three morbidly obese women (190-296 kg, body mass index 56.7-93.6) had cesarean births utilizing a supraumbilical incision and internal retention abdominal wall closures. Alternative anesthetic management was required in 2 patients. Bariatric operative and postoperative equipment was required in each case, and varying thromboprophylaxis strategies were employed. CONCLUSION: Careful planning along with appropriate specialty consultation is required for a safe and successful cesarean birth in the morbidly obese woman.
J Obstet Gynaecol. 2002 Nov;22(6):691. 'Classical' caesarean section at or near term in the morbidly obese obstetric patient.  Nicholson SC, Brown AD, MacPherson HM, Liston WA.   PMID: 12554273  [no abstract available]
"Morbidly obese obstetric patients undergoing caesarean section with a large, protruding panniculus present major technical problems to the obstetrician and anaesthetist and significant operative risk to themselves...It is our practice to perform a high transverse abdominal incision, avoiding the subpannicular fold, thereby reducing the risks of wound infection, necrosis, and dehiscence."   
Kmom summary: Case report of 2 cesareans in morbidly obese women (BMI 58 and 70) with a large panniculus.  Surgeons used a high transverse abdominal incision just below the umbilicus.  The lower uterine segment could not be accessed, so they did a classical fundal uterine incision.  They briefly discussed alternatives to this subumbilical transverse incision, including supraumbilical midline incisions and a panniculectomy (surgical removal of the pannus, which can be associated with many complications) before the cesarean.  They completely dismissed the fact that low transverse incisions have been used successfully on women of this size in the past.
Successful Low Transverse Incisions Used on Supersized Women

Obstet Gynecol. 1978 Apr;51(4):509-10. Cesarean section in the massively obese. Ahern JK, Goodlin RC.   PMID: 662236
"The case histories of 4 massively obese patients who underwent cesarean section are summarized. In all, a Pfannenstiel incision was made beneath the patient's huge panniculus, and a lower segment cesarean section was easily accomplished. There were no postoperative wound infections and all of the women had an essentially benign postoperative course." 
Kmom Summary: Case report of 4 women who each weighed more than 400 lbs. and were delivered via a Pfannenstiel cesarean incision underneath the panniculus.  The surgeons were surprised by the ease of delivery ("no more difficult than in women of only half their weight") and felt that the Pfannenstiel/low transverse incision was the reason for their good outcomes. They disagreed with earlier statements by other authors that "only a novice" makes a transverse incision under the panniculus.
Anaesth Intensive Care. 1999 Apr;27(2):216-9. Anaesthesia for LSCS in a morbidly obese patient. Patel J. PMID: 10212725
Kmom SummaryThe management of a morbidly obese parturient with a body mass index of 88 is reported. She developed asthma during the pregnancy. Lumbar epidural anaesthesia was successfully used for an elective caesarean section and tubal ligation.  Special note: A lower-uterine segment Pfannestiel incision was used with NO problems or infection in this woman who was nearly 500 lbs. at the time of her cesarean.
N Am J Med Sci. 2012 Jan;4(1):13-8. Cesarean section in morbidly obese parturients: practical implications and complications. Machado LS. PMID: 22393542
...A Medline search was conducted to review the recent relevant articles in english literature on cesarean section in morbidly obese women. The types of incisions and techniques used during cesarean delivery, intra-operative and postpartum complications, anesthetic and logistical issues, maternal morbidity and mortality were reviewed. Morbidly obese women with a body mass index (BMI >40 kg/m(2) are at increased risk of pregnancy complications and a significantly increased rate of cesarean delivery. Low transverse skin incisions and transverse uterine incisions are definitely superior and must be the first option. Closure of the subcutaneous layer is recommended, but the placement of subcutaneous drains remains controversial. Thromboprophylaxis adjusted to body weight and prophylactic antibiotics help in reducing postpartum morbidity....
Retracting the Panniculus for a Low Transverse Incision

J Am Coll Surg. 2001 Oct;193(4):458-61. Caesarean delivery and celiotomy using panniculus retraction in the morbidly obese patient. Thornton YS.   PMID: 11584977   [no abstract available]
Kmom SummaryCase series of successful low transverse incisions in 47 morbidly obese pregnant women and 9 obese gynecologic patients, all of whom weighed between 208 to 500 lbs, with BMIs between 33.8 to 76.4.  Shows in pictures their technique of using cloth tape across the abdomen and from both sides of the lower abdomen to the upper body (described as the "suspender" method) to pull the panniculus towards the head and expose the lower uterine segment so that a classical vertical or supraumbilical approach was not needed.  They noted that this technique used materials on hand at most hospitals (instead of specialized bariatric instruments), gave "excellent exposure of the operative field without piercing the skin," and took away the need for a surgical assistant to constantly hold back the panniculus during the operation. Despite the incision being in the "moist subpannicular fold" so vilified in the literature, there were NO wound infections or dehiscences, even in the most obese patients.
MedGenMed. 2006 Feb 21;8(1):52. Preventing a surgical complication during cesarean delivery in a morbidly obese patient: a simple apparatus to retract the abdominal panniculus. Viegas CM, Viegas OA.   PMID: 16915182   Free full text here (includes illustrations not for the faint of heart).
"This case report highlights an unusual intraoperative complication that has medical and medico-legal implications. A simple apparatus designed to retract the panniculus of an obese patient might reduce complications when performing abdominal surgery in such cases." 
Kmom Summary: Case report of a cesarean performed on a morbidly obese mother (BMI 54) who was also a very heavy smoker (which impedes healing).  They induced labor by breaking her waters, but as a result, the baby presented in a brow position and developed fetal distress during the prolonged induced labor.  An urgent cesarean was performed under general anesthesia.  A medical student was drafted to manually hold back the large panniculus during the cesarean.  Her incision healed up well afterwards, but the patient developed severe ulcers at the pressure points where the medical student held back her belly (picture available at the full text site; it's very graphic, be warned).  In response to this case, the authors invented a special apparatus to hold back the panniculus in heavy women during cesareans, using a bar over the surgical bed, chains hooked to the bar and then connected to a Doyen's Retractor, which is used to hold back the panniculus. A picture of this device is available in the article.  The authors state they've used it successfully with no problems since, but do not present any data on this claim.  
Risks of Classical Cesareans 

Obstet Gynecol. 2002 Oct;100(4):633-7. Maternal and perinatal morbidity associated with classic and inverted T cesarean incisions. Patterson LS, O'Connell CM, Baskett TF.  PMID: 12383525
OBJECTIVE: To estimate the maternal and perinatal morbidity associated with cesarean delivery involving the upper uterine segment compared with that of low transverse cesarean delivery. METHODS: A 19-year review of a perinatal database and the relevant charts was used to determine the maternal and perinatal morbidity associated with low transverse cesarean, classic cesarean, and inverted "T" cesarean deliveries. RESULTS:Over the 19 years, 1980-1998, there were 19,726 cesarean deliveries: low transverse cesarean, 19,422 (98.5%); classic cesarean, 221 (1.1%); and inverted T cesarean, 83 (0.4%). As a proportion of all cesarean deliveries, the rates of low transverse cesarean and classic cesarean have remained stable, whereas the rate of inverted T cesarean has risen from 0.2% to 0.9%. Maternal morbidity (puerperal infection, blood transfusion, hysterectomy, intensive care unit admission, death) and perinatal morbidity (stillborn fetus, neonatal death, 5 minute Apgar less than 7, intensive care) were significantly higher in classic cesarean compared to low transverse cesarean. Some maternal morbidity (puerperal infection, blood transfusion) and perinatal morbidity (5 minute Apgar less than 7, intensive care) were also significantly higher for inverted T cesarean compared to low transverse cesarean. CONCLUSION: Classic cesarean section has a higher maternal and perinatal morbidity than inverted T cesarean and much higher than low transverse cesarean. There is no increased maternal or perinatal morbidity if an attempted low transverse incision has to be converted to an inverted "T" incision compared to performing a classic cesarean section.
Am J Perinatol. 2010 Nov;27(10):791-6. Epub 2010 May 10. Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision. Bakhshi T, et al.  PMID: 20458666
We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P < 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.