Question for all midwives...

[dizietsma]

Why do so few MW seem to know that when measuring blood pressure in pregnant women with high BMI you need to use a big cuff to avoid inaccurately high readings?

It makes a real difference to the care received by pregnant women with high BMI, and could end in unnecessary early induction for non-existent "pre-eclampsia".

Inductions are correlated with worse health outcomes for mother and baby than spontaneous birth, so surely this is a measurement it is vital to get right?

In my pregnancy, every MW needed to be informed of this and reminded each time to get the big cuff. Many of them tried to convince me just to use the normal one. The one time I reluctantly agreed, my bp read as elevated. I then insisted they get the big cuff to check, hey presto my bp was perfectly normal again!

So how come this happens MW's? Don't they teach you this?

I got this alot, I think because normally the medium cuff is attached and it's abit of a faff to change cuffs so they try and get away with the other one (even when the velcro is tearing they just hold it!)

Yeah, but if it will seriously change the health outcomes for the mother and baby, i.e. possible induction, isn't it a little bit... negligent to not use a bigger cuff just cos you can't be bothered with a "bit of a faff"?

I didnt even know that there was different sized cuffs, thank you for enlightening me.

I'm very suprised every midwife you had needed to be reminded of this. I'm a first year student Mw and we were taught this along with learning how to do obs in the 1st month of uni, every MW I have seen and worked with knows this.

me23, I can vouch for what dizietsma is saying. I just sacked my MW for thiseven though I TOLD her I needed the bigger cuff, she insisted it didn't make a difference. I even told her about my friend who ended up with an induction due to false high BP from a too-small cuffshe brushed me off anyway. NHS Clinical Knowledge Summaries and my GP say I'm right! I'm glad to hear student midwives are being trained properly though. My (former) MW is supposedly quite senior amongst the community midwives in my area--hope she doesn't have responsibility for supervising people.

So what does it mean when you have a high BMI, but your blood pressure is measuring perfectly fine on a normal sized cuff? The highest my BP has been is 110/68 on a normal sized cuff, and I'm far from the perfect BMI range.

SWBL, your arm size might be 'normal' enough for the standard cuff, despite having a high BMI. NHS guidance on arm circumference for different cuff sizes here.

Other possibility is that you have low-normal BP and any error introduced by the standard cuff doesn't put you over the 'normal' limits. For me, I measured 140/70 with the standard cuff, but only 110/70 with the large cuff.

me23, I have no idea why they all needed reminding, it was very frustrating! I'd get looks like I was being a bit precious, and was told on many occasions that it didn't make any difference. I had to insist several times, and often made the MW grumpy at my insistence.

Being a student I am glad to hear you are getting taught the correct way to take bp, but I would be interested to hear what you see when you get to sit in on a MW surgery in general practice, whether or not the MW are quite so careful about the right sized cuffs. I assume that's a part of your training? Or is it mostly hospital clinics?

Great thread, dizietsma. As I said on the other thread, this happened to me a lot, and I really think that they just couldn't be bothered to fetch the larger cuff, which when you consider the potential implications of an incorrect reading is really irresponsible.

Plus many larger mums won't even know that different cuff sizes exist, or the implications of using the smaller one, so they won't think to question it and will accept their diagnosis of high blood pressure because lets face it, they'll already have been bollocked lectured about being fat and pregnant anyway, so it's natural they'll get hbp too right?

"will accept their diagnosis of high blood pressure because lets face it, they'll already have been bollocked lectured about being fat and pregnant anyway, so it's natural they'll get hbp too right? "

Exactly JATGB. The assumption of ill health in pregnancy if you have a high BMI is so high from most HCP, that I suspect there's a bit of seek and ye shall find at work.

I also think that from a purely psychosomatic standpoint, it's very unhelpful for HCP to hassle pregnant women about how their weight will make their pregnancy "higher risk". Unless it's actually relevant, in that there appear to be complications in the pregnancy, WTF is the point in having a go at them? As I said in another thread, I think it achieves nothing apart from giving the HCP a sanctimonious kick. After all, it's always nice to tell the disgusting fatties how gross they are, right?

Most women who are overweight already feel dreadful about it, adding to those feelings by guilt-tripping in pregnancy too is very likely to increase stress and self-hatered. If their pregnancy is progressing normally, why stress them out? That's not going to improve their health, is it? It may actually harm it!

Sorry, rant over

I think basically the hcp's need to realise the difference between making people aware of the real risks that you run, and being downright insulting or attempting to scare the patient as "punishment" for getting pregnant whilst fat in the first place (How very dare we? don't we know how ill we are bound to get??)

Hmm, I've just been browsing around different sites and just read this little nugget off rcm.org.uk : "Elective CS is unavoidable for the very obese (BMI over 40), in view of the impossibility of access for the treatment of shoulder dystocia or for vaginal examination and instrumentation."

Obviously I just dreamt my perfectly normal vaginal delivery at bmi 53.

'impossibility of access'??? If you have a BMI over 40 do you grow some kind of fat flap across your fanjo? Without 'access' in that area, how do any of us get pregnant in the first place???

FFS

No one has said anything to me about elective CS (BMI 41). Am 30 weeks now. Very interested to see if it gets mentioned....

The treatment of women with higher BMI is very disheartening. My BMI is not far off 40 and the idea that a c-section would be 'unavoidable' is such a pile of crap! The medical profession should be doing everything they can to encourage women with high BMI's to give birth vaginally - far less complications and risks. I wish somebody would do a study in to whether anxiety about weight on the part of the medics is actually causing more complications than otherwise. There is a real vicious circle it seems to me - fat = more tests just in case = tests are ok but you needed to have the tests because you're fat and we're sure there will be a problem = intervention because you had all those tests, there MUST be a problem = more interventionleading to a birth finally = oooh now you're pregnant again (assuming you go for it again) and look at all the tests you had to have last time = better do some more tests as we're sure there will be a problem, after all the problems you had last time!

fab thread, my bmi with dd was 42 and i was made to feel like an awful person and a terrible mother for being over weight, was even told at 40+1 that i needed as a section as baby was breach, i said not a chance - i would have felt her turn, was told that it not poss due to my weight!!!!!! demanded scan and she was perfectly head down, delivered later the same day no problem!!!!!

i also was refused a homebirth for the same reason, if i have DC3- i will def go for HB if all goes well, i am 25 yrs old, had two straigh forward pregnacies and 2 very fast deliveries(1hr56 with DS) (5Hours with DD)

i also had to ask for bigger cuff when measuring Bp every time!!!!!!

sorry rant over!!!!lol

"i also was refused a homebirth for the same reason"

They didn't go as far as refusing me a homebirth, but I was sent to a consultant for a ticking off!

Funnily enough, the consultant was one of the few HCP I met who seemed totally relaxed about the whole thing and the appointment was basically a normal listen for the heartbeat and bp measurement with a "I have to advise you that we don't advise homebirth with high BMI" addendum. I just said, I understand that, understand the "risks" and he was perfectly OK with that and I was "allowed" to be booked for HB.

He was an older consultant, and I wonder if his greater experience was the reason he was OK with it?

The idea that you can't feel them turn because of your weight! WTF? Being fat doesn't destroy nerve endings FFS! This is part of the whole being fat makes you other, inhuman, bullcrap that happens with stereotyping.

God if ONLY I felt less because I was fat, that would've made labour a whole lot easier!

High BMI is used to restrict access to homebirth and to midwife led units. Leading to more medicalised births and the question once again - was it the BMI which caused the problems or was it the medical approach to BMI which caused a cascade of interventions?

"was it the BMI which caused the problems or was it the medical approach to BMI which caused a cascade of interventions? "

That was exactly what I started to wonder during my pregnancy, NL. I believe that high BMI is correlated but not necessarily causal with more complications in pregnancy and birth. It is my opinion that this is mostly due to a hightened chance of this cascade of interventions phenomenon, driven by the negative expectations of HCP.

It would certainly be an interesting subject study.

Yes it was my experiences that made me think that dizetsma - my consultant wanted me to have a GTT - my BMI was the only indication for this - therefore I refused as I didn't think it was warrented and I had doubts about the validity of the test as a mechanism for improving outcomes in any case. The midwife we saw the same day told me (after we'd told the consultant to forget it) that she felt just having the test was used to label high BMI women as high risk and once you'd stepped down that path it was very hard to extricate yourself even if you were in fact progressing in a perfectly healthy and normal way.

I wish somebody would do some research on this! It's so sad to read all the posts you get on here from women who have been made to feel like they can't carry and birth without complication - and that they are of course 'to blame'

ooops

I had no idea you could refuse the GTT, or that it would impact on decisions that were made further down the line even if it came back negative for GD. That's outrageous!

I sometimes wonder if the reason that ladies with high BMI's are treated so appallingly by their HCP is because they actually dared to have sex in the first place.

As a woman with a BMI of approx 42, i have deighned to get pregnant again, and tomorrow i have my booking in appointment with the midwife. I intend to tell her that i want a homebirth and fully expect to be told no in no uncertain terms. But this is my baby, and my body, and unless they can come up with a bloody good reason for me not to have baby at home then i'm sticking to my guns.

deemented, did your first birth go ok? are you currently pretty healthy apart from your bmi? if so they shouldn't have too many grounds for refusing you, especially if you live fairly close to the hospital in case you need to transfer.

I'm not currently pg but hope to be next year, and I have to admit it's all so daunting. I simply cannot go through the pain I had last time again (forced flat on my back so I could have an internal monitor, consultant accidentally broke my waters with her nails during a contraction. I was in so much pain I couldn't think to ask for anything stronger than gas n air) I'm almost thinking of asking for an elective cs just to save them sharpening knives at the end of the bed again, just to have some element of control.

My first pregnancy ended in an emergency csec at 28 weeks, but that was due to the fact that it was twins and one of my babies was very very ill in utero - no infection, ect.

With my dd, i was told that because i'd had a previous c-sec, then i had to have another. No questions, no arguments. I fought this hard, and they did agree to a vbac, but on their terms. They wouldn't let me use the birthing pool at all, and they insisted that they break my waters and put monitor on baby's head, because i was 'so big they couldn't get a proper trace' which meant that i had to stay in bed, and as dd was back to back it was very very uncomfortable. I ended up with a 3rd degree tear and lots of stitches.

This time I want to be in control, yunno?

Wow your first birth sounds traumatic. Your second could be mine, although I don't think/know if he was back to back. Basically I wasn't really told anything about the birth as I was so out of it.

I really felt like I had no control over the birth at all after the said to lie flat on the bed (I was coping well stood up but like you they insisted so they could monitor me, and I think because of my size too, even though I wasn't leaning on any of them!) and as I said, she broke my waters with her nails whilst fitting the internal monitor. Ds's scalp is still scarred from that and it was pointless as he was fine, but I think because they'd insisted on giving me so many growth scans (which all came back normal by the way, dead on average size and he was 7lb 2oz at birth) they assumed I would be having a big baby who would need monitoring.

I did have a tear, probably due to pushing hard on my back as they were arguing over whether it was an emergency situation or not (consultant thought it wasn't, happy to let me do it at my own speed, cowbag midwife going "PUSH AS HARD AS YOU CAN we need to get this baby out NOW" - who was I going to listen to?) he came out with very high apgar scores so I'm still confused as to why the midwife panicked me like that.

I'm so scared of it all now, I really don't know what to do for the best next time, I don't feel I have the same choices as normal bmi women, and even with an elective I run the very real risk of an infection in the scar due to it being "under" my stomach. My sil had a serious infection (similar bmi) and she was very very ill.