I'm a plus-size pregnancy specialist midwife: ask me anything!

[liftis44]

Hi, I've been a specialist plus-size UK registered midwife for 15 of my 20 year career. Nowadays I'm a PhD midwifery lecturer/researcher. I get lots of questions and worries from women on this topic, and I'm all up for myth-busting, information-giving and reassurance! ASK ME ANYTHING and I'll give you an evidence-based response ASAP!!

Not a question but this is really interesting and I'm looking forward to seeing this thread

do you find a lot of fat phobia/ bias against fat patients? An assumption that it's all entirely gluttony and not a result of trauma/ they must have repeated gd tests because 'they're fat so they must have it'

My colleagues have all said a variety of these things

Loving your name fannyfan! In response - a big mix. I've worked in big city hospitals smaller clinics, universities and I've seen fat phobia for sure! But I've met lots of clinicians who struggle with sensitive communication and want to do it well. I teach midwifery students and one thing I really try to myth-bust with them is that a) plus size women somehow need educating about how to 'eat right' when, as you allude to, the weight someone is might be the result of a whole host of factors..... but in my experience it is almost NEVER because they don't know how to 'eat right'. The other misconception I've come across a lot is that plus size women aren't aware that they are plus size and that clinicians/midwives should inform them of this (!!!) Both of these extremely patronising myths need busting right out of the water.
I also - as mentioned - meet lots of health professionals who worry about getting it right and sometimes don't discuss what they should for fear of causing offence. Women & (nice) midwives need to be allied somehow in improving open communication - and challenging nasty stereotyping.

What weight / bmi is the lower limit to be considered a high risk. My BMI was 31 and no additional care was suggested.

A good question and not a straightforward answer! The evidence here tentatively suggests that risks increase as maternal weight increases, but it depends on a number of factors - stressing lots of plus size women (and I mean LOTS) have no problems in pregnancy and birth. There is so much here that noboody understands about who might experience complications and who not. The guidance from the Royal College of Obstetricians & Gynaecologists & Royal College of Midwives (RCOG/RCM) state BMI 35 as a cut off where they recommend increased surveillance/interventions such as a glucose tolerance test (for gestational diabetes detection), extra growth scans, anaesthetic review, gving birth in a consultant-led unit etc. with further recommendations if your BMI is above 40. What happens in different NHS Trusts does vary though in different regions. For e.g. there are some Trusts which will restrict using midwife-led birth centres or water in labour if a woman's BMI is >30, others if it >35 (and FYI these are often presented as 'rules',, when in fact they are guidelines, and should be gently challenged if you want to explore options!)
So, with a BMI of >30, it may be your Trust guidelines recommended no specialist additional care, so you won't have noticed a difference.
Could I ask, did you have concerns and would you have welcomed anything different/extra and, if so, what?

Hey @liftis44

Interested in this thread!

Can I ask why weight is not monitored after your booking appointment?

My BMI was noted as 33 at booking (which was a bit of a surprise as my weight on other scales was a good few lbs less, but neverless I would have been >30) and as such I got flagged for things such as the GTT and had notes on all my scans referencing a raised BMI etc. But since then I've not been weighed at all to track how much I've gained, which I would have thought would be important?

Don't get me wrong, I don't necessarily want to be weighed every time, but it seems strange to me that your weight at 8 weeks (unless you have an extreme BMI in either direction) could be more important than the amount of weight you gain during pregnancy?

Hi! Good question! Historically, all women were weighed as a monitoring mechanism of the healthy growth of the baby, but it was identified as a very inaccurate way of doing this and scrapped some 30-40 years ago.

As for now, the guidelines state women should be weighed at the first appointment (booking) to calculate BMI, then later in pregnancy, to identify whether there are additional factors to consider for birth (36 weeks usually - but I think in fact this often does not happen or get offered).

In terms of not monitoring weight gain all the way through, at every appointment, one simple answer is what we might actually do with that info. There are a number of different reasons for weight gain in pregnancy - fat tissue gain, baby growing, amniotic fluid, increased blood volume, placenta - but also, crucially, in the UK there are NO formal guidelines for recommended weight gain. Women often ask what is a recommended 'healthy' weight gain, and midwives often quote American Institute of Medicine (IOM) guidance, but the National Institute for Health & Clinical Excellence (NICE) here in UK assessed and rejected thos,e on the basis that we have a very different population in the UK compared to the US.

So.... we could offer to weigh women throughout, but we can't then make an evidence-based recommendation with the findings, and that fundamentally underpins the lack of weighing throughout pregnancy.

Thanks @liftis44 !

I just find it interesting as I had my 38 week appointment this week and was approved for the birth centre based on my BMI 30 weeks ago.

Luckily I haven't actually gained that much, but if they had me at 33 to begin with then I could theoretically be far higher by now if I had gained the few stone that some people do. Which I'd have thought was more relevant for safety currently than what we weighed right at the start but obviously don't anymore😕

It kind of goes to show how arbritrary it is really doesn't it?
What's really important is that each woman has an individualised assessment of their health & preferences at this stage as well as at the start of pregnancy. Birth centres/water births/home births etc are recommended for women with 'uncomplicated' pregnancies according to the RCOG (obs & gynae) guidelines. You and your pregnancy can be 'uncomplicated', regardless of your BMI and that's what the discussion and plan should focus on.
All best wishes for the birth! Feel free to keep asking questions!

@GlitteryGreen I'm really interested in your posts as I'm on my 3rd pregnancy with a BMI hovering around 35 at all my booking appointments and I'm weighed at every midwife appointment and was for my previous 2 pregnancies as well. So very surprised to discover this isn't actually national guidance!

@liftis44 is this something which could differ across trusts or is it a personal decision of my midwife? (Same midwife for all 3 pregnancies)

I'd also be interested in your view on weight management in pregnancy classes? I attended them for my first pregnancy and found them a total waste of time. Like you say, an assumption that we were all fat because we were too stupid to know how to eat right. Also some of the advice was outright wrong in my opinion. One gem that really bothered me "reduced salt stock cubes are still quite high in salt so you might as well buy the normal ones". Yes, they're still quite high, but not as high as regular! Sorry, little rant there, but I'd be interested to know if you feel these type of classes have a positive impact or if they're just a way for the trust to look like they're doing something to help fat pregnant women

DM me if you want to follow me on Instagram x

@GlitteryGreen I'll get back to on the weight management - hold the line! (But broadly, yes I agree!!)

@satelliteheart I will respond! Watch this space!

@satelliteheart OMG the stock cube anecdote is depressing! And illustrative of how poorly things are done in many cases.
There have been a number of large intervention studies evaluation 'healthy lifestyle' promotion or 'weight management in pregnancy' programmes (UPBEAT and LIMIT being the largest, if you're inclined to have a Google. None - none - of these have been shown to have a impact on weight gain in pregnancy or any other key outcome measures (birthweights of babies). We do not have weight gain recommendations and we don't have tailored dietary advice for plus size women. Most women seem to find advice etc. patronising, which sounds like it chimes with your experience!

Can I post my Instragram name here or will it get removed??

Do you have to be weighed when you are pregnant? I have a history of a restrictive ED and would find it really triggering (I don't want to be blind weighed either as a) I would still see it somehow or someone would mention it and b) it would become an obsession). What would the response be?

random question! What weight would you lose after birthing a 6.5lb baby and then the extras. In 9 months I started at 104kgs my weight in Hospital for my c-section was 85kgs. I kept being told I’m not big not to worry etc! I lost 19kgs while pregnant but I wondered after giving birth would I have been like 78kgs? 80kgs

reason I lost weight is because I had GD.

I’m 40 and plus size, I’ve read they offer early induction, is this a thing? And any benefits to this

@Havehope21 Fundamentally, you do not have to anything at all when you are pregnant. Everything is offered/recommended and should be evidence-based or justified. And just like for you, this is a big deal for a lot of people, getting weighed.
Ask your midwife what it's for - why does she want the information? Have a chat about your concerns? Another thing some women do is consent to being weighed but make it clear they do not want to know their weight or their BMI calculation. It's got to be right for you. This is your pregnancy and your care. The midwife should be at your service!
I'm happy to discuss in more detail if you want to DM

What support would you have offered to a woman such as myself with a history from young adulthood of high BP (at various BMIs) who was pregnant at BMI >35 and was very aware of her pre-eclampsia risk from the start (made sure was on correct BP meds, aspirin, sought advice and monitoring etc)

I ended up developing it in labour which led to a cascade of intervention and trauma.

Also am another who experienced judgement that gtt results couldn't have been correct as baby was measuring large, so was made to have a second gtt which was also normal. Was offered healthy eating advice late in my third trimester. (All stuff I'm aware of! My weight gain is due to more complex issues!)

@Ineedtoletgo83 This is a reaallly tricky one as it is all so individual. But for sure you don;t just lose the weight of the baby when you give birth. There's placenta, amniotic fluid, a little bit of blood loss, plus your body spends the next week or two breaking down the extra 1.5 extra litres or so of blood it made too circulate whilst you're pregnant (most people find they wee A LOT after having a baby and this is partly why). So it depends on so many factor about your own health, diet, lifestyle, medical conditions and birth etc. Sorry I can't be more specific!

@Room4onemore Changed my name to my Instagram name!!
So, you may be offered induction based on your age and weight, however, this should be an individualised assessment based on your history, health, pregnancy and wishes. Age & weight are factors which may increase the risk of complications, HOWEVER, they are not complications in and of themselves, so things like if you've had a baby or babies before and how that went as well as many other factors should have a bearing on the plan which you come to and the choices you make.
Short answer, it is a thing, but it should not be routine and not something you should necessarily anticipate.

@liftis44 Thank you so much for your message. It has given me SO much reassurance. It was a huge worry for me when thinking about starting a family (even though it might sound silly to some). If only all midwives were as kind and compassionate as you.

Hi @Rainbowgoth It is really difficult when complications develop in labour and it doesn't go smoothly. And as you say you were really aware of the risks as it sounds like you had or have essential hypertension (pre-pregnancy). Clinical maternity staff are extremely careful when it comes to BP and I hope you felt your care was good
Re. GTTs, your story is quite a common one unfortunately. Women really do feel very judged and patronised. It's been my goal for a long time now to promote wellness, not focus on risk and restriction and try to acknowledge and neutralise the stigma around these discussions. I do wish clinicians would stop presuming women simply need to be told what to eat, to be educated! It's so patronising - most women I meet are total experts on all things food!

@Havehope21 Instagram: theheavyweightmidwife
I'm touched by your words! Very best wishes.