Showing posts with label belly. Show all posts
Showing posts with label belly. Show all posts

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 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.


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.

Monday, May 30, 2011

Honoring Our Bellies Month: Healing Through Belly Art

As May ends, it's time for some final thoughts on "Honoring Our Bellies" month. 

My thanks to all the wonderful women who have been willing to share their thoughts and their pictures with the rest of us.  You may never know what a service you have done for future women of size contemplating pregnancy, and perhaps even in helping non plus-sized folks see the beauty and the wonder of pregnancy in women of size too. 

As we end this month, let's discuss a few final thoughts; a few more ways to honor our bellies, our selves, and our journey; and let's feature a few more pictures of pregnant bellies and related belly art.

Document Your Journey

First, if you are pregnant, please please please take the time and effort to document your pregnancy and your motherhood in pictures. 

 Too many fat women are missing in action from their family's photo albums because they are self-conscious or too embarrassed to be photographed much. What a tragedy this is!

The truth is that our pregnant bodies are beautiful. And they deserve to be seen in all their glory.

No one cares if you are not stick-thin with a bump; certainly your children don't care.  They only know that you are that most beloved of people ─ mommy ─ and if mommy isn't in the pictures of their childhood very much, what does that say to them?  Be present in your children's lives, both in the moment and in their archives.

If you don't get pictures of yourself pregnant, you will be losing such a wonderful memory.  Every pregnant woman is beautiful, and we all deserve to have our pregnancies documented in pictures. 

Sweet moments like these are so incredibly precious later on.  If you miss the chance to document it, that opportunity is gone forever.  Remember, you can always throw away or delete the really terrible shots, but you can't go back and get pictures you never took. 

Don't be the gaping black hole in your child's baby album.  Take pictures of yourself both in pregnancy and as a mother, and make sure your existence is documented, both for your child and for yourself. 

You deserve it.

Honor The Normality of Ambivalent Feelings

Remember, it's normal to feel some ambivalence about the changes happening to your body.

The truth is that your body will never be quite the same again...but that's okay. Life is change, and change is hard sometimes.  Often, we want everything to stay the same, forever, but that just doesn't happen.  Change is the norm in life, but it's not always easy. It's okay to acknowledge that.

And when that change is reflected on the body, it's normal to mourn those changes, whether they happen because of pregnancy or accidents or just plain time.  You're not a "bad" fat-acceptance person for having smidgens of dissatisfaction or body ambivalence.  It's just a normal part of dealing with changes in your body.

And few changes are bigger or more fast-acting than those wrought by pregnancy! So it's very normal to have mixed feelings about changes in your body around pregnancy. 

Just don't stay in that place of ambivalence.  Recognize its normality, recognize the challenge to your sense of self-confidence and worth, and actively find ways to work through it. 

Don't stay stuck in negativity. Do the work you need to do to get back to a place of self-acceptance and self-love.

Find a Way To Honor Your Body

Even as you process normal feelings of ambivalence about these changes, it's important to  honor your belly for all the amazing work it's doing in pregnancy, and one way to do that is through belly art.

There are many types of belly art you can do to honor your body in pregnancy.  Look around online and see which type calls to you.

[No, not all the images below are of women of size; but some are.  Others are presented just for ideas. Links to sources of some of these pictures are presented near the end.]

 We've already discussed belly henna, temporary tattoos using henna, which starts as a dark paste on your belly (like above)......

................and then turns to a reddish-brown hue like this when it rubs off, lasting for about 2 weeks or so.

Another beautiful and fun thing to do is belly bump painting.  This can run the gamut in quality and subject matter (depending on who your artist is!), from toddleresque to whimsical to seriously artistic.  It all depends on what you want.

A lot of people enjoy doing silly baby bump painting.  And what better Halloween costume can there be than a pumpkin baby bump? I've also seen baby bump paintings of watermelons, basketballs, and even a beachball!  It certainly doesn't have to be fancy.

You don't have to be a skilled artist to create some of these.  I am very artistically-challenged, but even I could probably manage a basic pumpkin or ladybug like the ones above. 

For those slightly more skilled, relatively easy themes might be butterflies or flowers.

There are a lot of whimsical ideas for belly painting, from turtles to speed bumps to Hello Kitty to the "She's Got The Whole World In Her Hands" riff above.

One of my favorites for sheer creative simplicity is this snowman.  Not very hard to do, yet it certainly brought a smile to my face!

And hey, who says you can't have fun with belly art, even if you can't paint?  Wouldn't this picture be a great conversation piece in a photo album in years to come?

Or you can have someone document your baby's position for you, late in pregnancy, with belly mapping.  This can be educational as well as fun, as you discover how fetal position can influence labor.   You can learn more about this at (this picture is from their site), or buy their book about it here

Or ditch your artistic and educational pretenses entirely and just let your kids go wild.  As I shared before, it can be a lot of fun to have your older children paint your belly, whether or not it turns out pretty or artistic.  My kids and I had a grand old time bonding over painting my belly, and it was a nice way to distract myself at the end of pregnancy number four.  If you are artistically challenged, just do it as a fun kid activity, not to turn yourself into a modern Renoir painting.

On the other hand, if you are the more artistic type, you can aspire to something more lofty. You can even hire someone well-versed in fine art to paint your belly for you.  Isn't this an amazing work?

There are a lot of fun examples out on the internet of different images women have painted onto their bellies, like some of these that I've pulled for us.  Some artists even specialize in this art form, or offer tips on how to do it.  There are even blog sites and flickr accounts to dig through for ideas. 

The possibilities for beauty and whimsy are endless. Let your imagination and your creativity run wild!

Create a Lasting Keepsake

Another way to honor your pregnancy belly is to create lasting keepsakes of it.

You can do this in many ways.  Photography is one of the best. 

Having professional or high-quality photographs of your pregnancy or family is one of the most beautiful keepsakes ever.  Almost without fail, women who have done this are glad that they did.  If you can't afford to have professional work done, try it yourself at home. Don't be afraid to experiment with it and try different things.

Pictures that use black-and-white tones, sepia tones, or that use lighting in an artful way can be some of the most striking pictures. Give that a try.

Then, be creative with your images.  Artsy them up with photoshop and see how they turn out.

Or focus on whimsical, fun shots.  Do whatever makes you happy.  The trick is to just do it. 

Remember, you are not obligated to keep every shot.  Take lots of shots so you are more likely to get a good one among them, and then discard the others.

Another fun idea is belly casting.  In this, you make a plaster cast of your belly in the latter stages of pregnancy.  This takes your memory of pregnancy from 2-D photos into 3-D sculpture. How cool is that?

This is a photo of someone having a belly cast done. You slather your belly with lubricant (like Vaseline, olive oil, or Crisco), then use quick-setting plaster strips (like Rigid Wrap), available at most big craft stores. You just wet them down in a pan of water and apply. There are kits available to buy online, or you can gather your own supplies fairly cheaply. 

You can do as much or as little of your body as you want.  You can do belly only, part of the belly, belly and breasts, or even the whole torso and upper legs.  Furthermore, you can be as demure or not as you prefer.  If you don't want your nipples to show, just wear an old bra under the casting, cover them with Saran Wrap, or put an arm over your breasts.  If you don't want any belly sags to show, don't cast that part of your belly.  It's completely up to you and there are no "right" or "wrong" ways of doing it.

When done, your belly cast can be left in its plaster state, like this one....

.......or finished and polished, but still with a plaster-like look, like this one from Molded Moments............

.....or it can be finished and painted for hanging on your wall, such as this one by artist Bethany Farrell....

......or personalized, like this one by artist Tina Killackey..........

........or decorated with added pieces, like this one from artist Nic Hohn.......

.......or given elaborate designs, like this one from my friend Amy Swagman of The Mandala Journey........

........or this beautiful but simpler one from Massage-ology.

You can even take a picture of your newborn nestled in the inside of the bellycast, just like they were positioned in the womb, which makes a wonderful piece of memorabilia for baby albums.  Or put paint on your baby's feet and do footprints on the inside (or outside) of the cast, to commemorate all that fetal kicking!  Or write a letter to the baby and tape it to the inside of the cast, to be given to them when they are older.

It can be as detailed or basic as you prefer ─ the possibilities are endless ─ but what a lovely keepsake to have forever.

There are any number of websites available that discuss how to make a bellycast, how to finish and display them, and which offer many images and ideas to choose from for decorating them. 

I personally did not have the nerve to do a bellycast in my first 3 pregnancies, but decided to do one in my last pregnancy. I really had to challenge myself to go through with it ─ but now I'm very glad I did. Alas, I've never found the time to actually have the cast finished ─ maybe by the time she graduates high school! ─ but what we did was sort of like the picture below. 

My husband put his hands on my belly, then I put my hands atop his.  It was difficult to differentiate between his hands and mine with plaster strips, but you can see it if you look for it.  Then later, after the cast dried a bit, we added a cast of my other children's hands too.  Doing them one at a time, later on, helped us make this work, since my kids would never have had the patience to do it otherwise.  Eventually, we will paint each person's hand a different (but complementary) color, and then finish the whole thing with beautiful uniting color and perhaps the outlines of my daughter's feet in the middle.

For now, my belly cast sits in its unfinished-but-still-inspiring-state in my office, looking down at me as I work, giving me inspiration as I write.  Even though it's not finished, I still treasure it and am immensely glad I took a chance on trying it.  I would always have regretted it had I let body self-consciousness get in the way of making this one-of-a-kind gift to myself.  Now, even if it's never formally finished, it's still a treasured memento of a very special time in my life, and of a very special child of my heart.


It's really not unusual for women of all sizes to experience body image issues during and after pregnancy.  There are huge changes happening to the body, and any pre-existing image issues can get magnified in uncomfortable ways as a result.

But while it's very normal to experience body ambivalence, that doesn't mean we have to stay in that murky place.  Rather, see it as an opportunity to work through and heal yourself in new and deeper ways.

One great way to work on healing pregnancy body ambivalence is through belly art. Photography, belly painting, henna, belly casts....all of these and more are good ways to honor ourselves, our bodies, and our babies.

It doesn't really matter which form you pick, but do find some way to document the experience.  It is only a brief moment out of your life, but it is such an important and memorable one.  It (and you) deserve to be honored in a special and unique way.

Don't let your size or body image keep you from memorializing this so-special moment in time in some way.  You will treasure it later, trust me!

*For more ideas and images of belly casts, belly painting, and henna tattoos, click here.

Friday, May 20, 2011

Welcome, Maceo: Newborn Video

In our last post, we shared pictures of pregnant women of size to show the diversity of bodies and belly shapes for Honoring Our Bellies Month and for our Plus-Sized Pregnancy Photo Gallery

I'm happy to report that one of those women who shared belly pictures, Theresa, gave birth exactly one week ago to her son, Maceo.  She sent us a video of Maceo's first moments in the world, just after he was born.

The video is about 3 minutes long, doesn't have any graphic birth footage, and is mostly just sweet sweet pictures of baby Maceo with his mommy and daddy.

Beautiful, just beautiful. Thank you for sharing, Theresa.

Here is an abbreviated version of her birth story.  To me, it illustrates the importance of maternal mobility in labor as a way to deal with the pain without drugs, and probably as a way to help correct any position issues with the baby (in this case, possibly a hand by the baby's head). 

Can you imagine how hard it would have been for her to deal with the pain if she was tied down to a bed, flat on her back, not permitted to move around much, like most women (and especially women of size) are in hospitals?  This is why the epidural rate is so high in hospitals, even among women who want to go without drugs.  Such restricted movement just makes it incredibly hard to deal with the pain; free range of motion and unlimited mobility makes it at least doable for many.

Notice how much Theresa moves around in her birth story, and notice how many positions she uses for labor and pushing.  Notice also how she switches positions at the last minute.  This frequent movement and re-positioning was probably very important in helping the baby out, yet it's something that's rare in many hospitals.  How many problems could be avoided if women were just encouraged to have free range of motion like this?

Here, then, is Theresa's birth story.

"Suddenly instead of five people in our bedroom, there were six."

Okay, so Thursday I started having what I can only describe as gas pains..It wasn't painful, more like the kind of sensation that makes you want to wrinkle up your nose. Also I noticed when I was in the "library" that I had started to let go of the mucus plug.  I had an appointment to go see the midwives that morning and luckily I had asked [my husband] Moonie to start his leave a few days early because I didn't want to drive to the midwife's by myself (good thing, too!)

Everyone agreed my gas was likely early labor but it could be really early and start and stop or maybe it WAS just gas. Anywho, the appointment went well, my BP was great, my urine was fine and about an hour later the sensations subsided.  [I took] an afternoon nap (good thing, too). 

Moonie made us some dinner about 6pm and we watched a movie and my "gas pains" started to return.  I finished eating and felt like I really needed to go take a leak and Moonie helped me up off the sofa and followed me to the "library" but I was to do no reading here for a while!  As soon as I got in I got an EARTH SHATTERING contraction that made me grab the over toilet towel rack and moan, "Ohhhhhh AHHHHHHH"   We had been discussing that maybe I wasn't in labor and we didn't want to go getting excited over nothing especially since first labors are usually long.  Moonie just said, "Yeah, kid I think you really are in labor!"  and called the midwives to put them on alert and I tried to go back to watching the movie but all you moms probably can figure how well THAT worked out! 

By 8pm I was seriously in first stage. The midwifery student came over an hour later and I was just dealing with each contraction as it came. [I was] sitting on the exercise ball, using the sock warmers (socks filled with rice and warmed in the microwave), and Moonie was timing my contractions as we played my "Relaxing" playlist on iTunes and tried to veg out to the visualizer. 

Soon after the student came she started inflating the baby pool and I could no longer sit and deal with contractions I was walking around moaning and chanting OM while doing belly dance moves and pelvic stretches.  Walking it off was really the only way I could deal with these harder contractions, the thought of laying down was uncomfortable. I did try to lay down through one and it felt all wrong so I scrapped that idea.  

For me the contractions weren't painful per se, they were more like the most intensely uncomfortable sensations ever mostly because I couldn't lay down, I couldn't sit and standing and walking all felt crappy.  Then one thing that only one mom ever mentioned to me was the flu-like sick feeling you can get. Boy did I EVER get it!  I threw up that dinner like nobody's business and I felt like was gonna hurl up everything I had eaten since I was 2 years old. I felt really sick to my stomach between contractions and that continued until the end pretty much.

Later that night...the midwives came.  The midwifery student had been helping me through the contractions because the sensations were so STRONG that they scared me at first and I would [think], "Oh another one! What do I do???" I couldn't believe how close they were and she just hugged me and let me lean on her and reminded me to breathe and helped me through it.

I tried to sit in the pool which was filled by a hose hooked up to the shower head.  The water seemed too hot and there wasn't enough of it. Also it was on my hard living room floor so kneeling in the pool sucked. I couldn't SIT for love or money and leaning on the side just made it sink down and overflow.  I tried a second time during the labor but it just felt wrong and so I scrapped it. 

We all ended up in the bedroom and to be honest, I'm surprised my neighbors didn't call the police. I was told that I wasn't so very loud because I was moaning instead of screaming.  I was on all fours on our bed and it seemed like forever! I was getting these MASSIVE pushing contractions one at a time and felt sick as dog in between along with the front of my hips hurting like Satan was cracking my bones so in between loud moans I just yelled "SICK SICK! I'm not gonna be sick I FEEL sick!" and "DAMN IT MY HIPS HURT LIKE HELL!"

My midwife wanted me lay on my back to try and examine me but there was no WAY I could lay on my back!  I just instinctively knew that would make everything worse. She thinks Maceo's hand was up by his head because I had been pushing for a bit and the head would come out and go back. So she did a clear of my cervix which I  was told I complained about loudly (I have no memory of this) and then switched positions.  They suggested I try the birth stool. I got up off the bed and then another massive contraction came (they were now two or three pushing urges in a row then a break), and I just grabbed my rickety bedside table and got into a squat and yelled. I got into the birth stool and pushed there for a bit. Got back on the bed and pushed there, yelling about how my hips hurt in between while they kept repeating, "Push it out and it'll all be over!"  I remember being covered in sweat and seeing Moonie's face and holding his hand and crying.

"This is taking so long!!!" I yelled and they said something and I remember saying, " I just want to get the baby OUT!!!" I slid off the bed to the birth stool and  had the most massive contractions ever and pushed with all my might with every ounce of strength I had in my entire being and the midwife said, "It's coming!" and Moonie dove to the floor to help her catch baby and he said "I see the head, baby! I can see it, it's almost here!" I said "You do?!" and then pushed Maceo out into the world and suddenly instead of five people in our bedroom there were six.  The midwife and Moonie both caught baby.

"Is it a girl?" I asked and she said, "It's a boy!"  and I said "Oh it's Maceo!" and I just repeated his name over and over again.  The cord was around his neck but she just slipped it off and handed him up to me.  We waited what seemed to me like five seconds but was an hour we clamped the cord and the student cut it. 

Then we waited for the placenta to come out but it had stage fright I guess. I tried coughing and pushing but to no avail. I took a few doses of Angelica tincture  and still nothing. The midwife suggested we move to the toilet because it might come out easier. I sat there and sat there and nothing and finally the midwife said, "You know if you can't get it out we'll have to go someplace where they can take it out."  Then before I could even say "Oh" I had another contraction and this was actually a little painful or maybe it was just that it was stronger than I expected and it was over before I even knew what happened and out it came.  I looked at it when they put it in a specimen bowl and was like "uh-huh" and thought about how tired I was.

I went back to the bedroom and Maceo was in his Poppi's arms and the student took some photos. Then I had him again and we took some more photos.  Then the midwives started cleaning everything up and sump pumping the pool and deflating it, loudly.  Finally that crap was over and we had quiet time. I just laid in bed with Maceo and Moonie was totally enraptured with us both.

Our midwives examined me and I had  no rips but something called a skidmark which is like a little scrape on the taint and they were all so happy (so the hell was I).

I think I just laid in bed and dozed with Maceo and Moonie just laid diagonally at the foot of the bed, completely dressed with glasses and everything and slept for the next four hours until his parents got there and brought us breakfast.

Sunday, May 15, 2011

Honoring Our Bellies: Pregnant Belly Diversity

May is Honoring Our Bellies Month at Well-Rounded Mama.  We had a Belly Blog Carnival where we shared blog entries from various moms of size, talking about their feelings about their bellies during and after pregnancy.  We've shown pictures of Belly Henna and how it can be used to honor your belly during pregnancy.  Now it's time for some more pictures!

One frequent anxiety about fatness and pregnancy for many women of size is wondering what their pregnant bellies will look like. 

And the truth varies.  Fat bodies do not all look alike, so fat pregnant bodies won't all look alike either.  Some women just get much more apple-shaped, some look pear-shaped with a small bump, some get a really big belly, some hardly look pregnant at all, some get a double-roll belly, some look like the classic basketball just never know what your body will look like until you actually ARE pregnant. 

Here are some pictures sent into me for the Belly Blog Carnival.  They represent some of the diversity possible among pregnant women of size.  I've re-used a couple of pictures, but most are new.  For the sake of privacy, I identified some of them only with an initial (and even that may have been changed). Others contain first names. All were used with permission.

Please note that the copyright of these pictures belongs to the mothers and this post; do NOT copy them and use them elsewhere.

I've included here the ones submitted to me that identified exactly how far along they were.  All pictures are of women of size, but of varying sizes of large. I've put them in order by gestational dates. Since most people take more pictures at the end of pregnancy than the beginning, late baby bumps are far more represented than early baby bumps.  Finally, I ended with a couple of pictures of labor, newborns, and nursing, just for a sense of closure.


This is "L" at 6 months pregnant.

This is "Sh" at 28 weeks pregnant (about 7 months).

This is "J" at almost 8 months pregnant.

This is Arwen at 8 months.

This is Issa at 33 weeks.

This is "T" at 35 weeks.

This is Angela at 37 weeks.

This is "A" at 37-38 weeks.

This is Cassandra at 38 weeks.

This is Lexi, at approximately 38 weeks.

This is "A" at 40 weeks, 1 day.

"E" at 41 weeks, 3 days.

"Ch" during pushing phase in labor.

"M" pushing during labor, baby starting to crown.

"E", skin-to-skin, after birth.

"J" nursing, 8 months post-partum.

Thank you to all the moms of size who so generously shared their pictures.  You rock!  You totally look beautiful, and you have done a real service for future moms of size who wonder if fat women really do get pregnant, and oh-my-goodness-what-am-I-going-to-look-like-if-I-do?

Yes, Virginia, fat women really do get pregnant, we do have baby bellies, our baby bellies vary as much as our pre-pregnancy bodies do, but whatever unique shape and size we end up having, we are beautiful. 

*This is the second publishing of this post.  Blogger went down shortly after it posted originally and all recent posts were deleted.  So we're putting it back up to make sure everyone has the opportunity to see it, and so that it stays in our archives.  Apologies if you are seeing it a second time on a feed or newsreader.