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Pregnancy

Talk about every stage of pregnancy, from early symptoms to preparing for birth.

Question for all midwives...

52 replies

dizietsma · 13/06/2009 02:04

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?

OP posts:
Deemented · 18/06/2009 12:07

It is really scary, isn't it? I guess all we can do is read up on everything as much as is possible and go prepared with facts in hand, iyswim? Just because we are overweight doesn't mean we have less of a right to the kind of birth that we want.

JamesAndTheGiantBanana · 18/06/2009 12:48

"Just because we are overweight doesn't mean we have less of a right to the kind of birth that we want"

Yes, in theory. In reality it seems to be totally out of our hands.

Clarity2005 · 18/06/2009 13:07

afternoon ladies, and here was me thinking I was the ONLY BMI 40+ lady to ever give birth!! And the only one to have to keep asking for a large cuff!!! Mind you when I had DD 8 years ago they had to trot me up to the delivery suite at every appointment as that was the only place with a large cuff! lol

I have been prodded and poked, and prodded some more and tested and tested includ GDT and scanned and re scanned and to be honest I think its almost like they are a little disapointed everything is "Fine" lol. Including the measurement scan I had last week to find, surprise surprise he is within normal limits (who would of thought it!!) And if anything is long and not Fat, but with a Daddy of 6ft 6 I didnt need a scan to tell me that, I can feel him all arms and legs in there!!

I wouldn't mind but I was over 4 1/2 stone heavier when I had my DD1 (now 8 1/2) so god only knows how I survied and managed to have a perfectly healthy fast delivery being so beached whale like and all! lol ;-)

Am 33 weeks and Csection has never been mentioned in relation to this and boy will they have a fight on their hands if they do!

trafficwarden · 18/06/2009 13:38

Re: cuffs - the Midwives should know, they are clearly marked as well but perhaps they were just lazy
I sympathise with the comments from the other ladies who have fought to have normality with a higher BMI. It's so hard to persuade other HCP's that a lot of bigger ladies are perfectly healthy otherwise and can be very fit too, even more than some skinny ones.
I guage my advice on how mobile and active someone is. If you struggle to get in and out of a normal bath maybe a pool has implications for an emergency but the benefits of supporting weight as well as all the other plus factors would sway me.
As for elective C section, madness. It is much more difficult to access a uterus if you are going through more layers of flesh (sorry if TMI) and healing can often be impaired .
I think some HCP's lose their common sense around this issue.

scratchet · 18/06/2009 14:38

I always use a large cuff for a large arm. It makes much more work for me if someone has a high bp!

James, maybe your ds was fine at delivery but there must have been a reason for needing continuous monitoring? It sounds like they needed to attatch the monitor to his head as they couldn't get a good enough trace abdominally.

niccibabe · 18/06/2009 19:38

Hi, I've ended up in tears trying to persuade MWs and a Doctor! to use the bigger cuff. I was so stressed the other day that my blood pressure did actually go up.

The same doctor asked if I would be monitored - I asked if it would be just for the afternoon - he said "This afternoon only". I was then admitted to a ward overnight - which I had NOT agreed to. I explained this to the ward staff and to another doctor that they called down to talk to me. The 2nd doctor said that if I went home it would be noted that I had done so against advice which would affect my treatment if anything happened to me or the the baby later - so I ended up in overnight beside 2 women in labour and well within earshot of a postnatal ward of screaming babies. I was supposed to have BP monitored every 4 hours - no one came near me from 8.30pm to 6.30am! Got 2 hours sleep - on reading my handheld notes when I got home - it says I agreed to stay in overnight and I slept well. That's quite a lot of outright lies in one hospital visit.

dizietsma · 19/06/2009 01:58

Dee, JATGB, so sorry to hear about the hassle you had in your births.

You CAN have a homebirth with high BMI, but you may have a bit of a fight on your hands, so read up and contact AIMS if they give you any crap, and look at the homebirth.org.uk site. Start asserting that you want one early in the pregnancy so you can get the battle out of the way before late pregnancy.

I had to really assert myself to prevent the MW attaching the scalp monitor (they thought waters were already broken). MW waited until my exhausted DH was napping to hassle me about it, but I didn't back down, and gave her my best "don't fuck with me" look. She let it go. I think it's cos I don't pluck my thick eyebrows, it makes me appear pretty intimidating when I'm pissed off, and comes in useful in these situations!

At shift change an evil bitch of a MW waltzed in, turned off my music without a bye-your-leave, and was about to break my waters without my permission, or even notification, until DH who had (bless him) been paying attention in the NCT class figured out why she asked him to fetch her the instrument that looks like a "long crochet hook", and he told her "Er, isn't that for breaking the waters? We already said we don't want ARM unless it's absolutley necessary." My hero

Nasty MW then tried to pressure us into agreeing with her, walked out the room in a huff saying she'd have to speak to the Paediatric doctor to see if I was "allowed" not to have them broken! Whilst she was out the room my waters broke (HA!), and I went into transition. I remember moaning "I don't want her back, I don't like her." DH, man of the hour, went out and told her to bugger off. At that point I got a good MW, and pushed DD out promptly.

See, here's what I think helped us- being armed with all the information, expecting the worst and hoping for the best, DH being an awesome, proactive and protective birth partner willing to listen to me and my instincts first, attending both NCT and NHS classes, having a doula.

Actually, our doula didn't come with us to the hospital as I transferred when she was getting some kip, and the hospital then refused her entry without even asking me if I wanted her there, the douchebags. I still think having her helped, though. She was there pre-natally when I was getting hassled at clinics, and for most of my labour. All that helped me feel supported, more in control and able to assert myself.

Have any of you guys considered a doula to help you get the birth you need? In this situation, where it feels like HCP aren't listening to you or working in your best interests, it could be really beneficial to have backup.

Scratchet, why can't they use handheld dopplers? The first 27 hours of my labour at home the MW had no problems getting a heartbeat with the handheld ones, when I got to hospital it was all of a sudden imperative I had continuous monitoring... Tethering a labouring woman to the bed is not very conducive to a good birth IMO.

nicci, what bullshit. Don't be afraid to stand up for yourself, it's your body, your baby and your choice about what tests to get, when and if you are admitted.

This- "it would be noted that I had done so against advice which would affect my treatment if anything happened to me or the the baby later"- is absolutely outrageous! WTF do they mean by that? "affect your treatment"? The only thing that should affect or change your treatment is good clinical judgement based on factual evidence of your state of health, end of!

Next time you feel stressed out and they try to push you into a bp test, just say "I'm not going to have that test today, I'm stressed out and I think it would be unrepresentative of my health." Or just, "I wont have that test today, thank you." Be calm, but firm. Don't enter into it with them, just say no. They can't make you. You can refuse any and all treatment, remember that. Obviously, it's in your and your baby's interests that you have medical care, but you decide that, NOT the HCP. I really think a doula could help you, nicci, you need someone in your corner.

OP posts:
scratchet · 19/06/2009 10:01

Hand held dopplers do not provide a continuous ctg trace. As i am sure you are aware, a CTG is recommended by NICE in certain situations. This is to ensure maternal and fetal wellbeing. You are entitled to refuse this, however, a ctg trace has, on many occasions picked up a fetal problem that needed to be acted upon.

From a midwife perspective, a ctg makes a lot more work for me and i do prefer to listen in intermittently. If a ctg is clinically indicated i have to inform the woman of this and the implications of having or not having one throughout labour. I also inform women that they do not need to lie down just because they are being monitored.

melissa75 · 19/06/2009 10:33

I have learnt a lot from this thread..so thank you very much! I did not know the size of cuff can make a diference to BP reading!
I fell pregnant when I just started on Weight Watchers, so although I have still tried to remain eating healthy, plans changed because I was execting. I have had normal BP readings in all my appointments pre 12 weeks, but they have changed to bigged cuffs, as I do have bigger arms, but my last few appointments, they have not, and I had higher readings, I am now 27 weeks and thus have been told to take it easy and go down to part time work (I am a teacher and have gone down to three days a week due to medical advice). I am making an appointment as we speak to have my BP checked again.

I too am sick to death of the medical profession being so unhelpful/unsupportive etc etc..because I may have a higher BMI. I know I need to lose weight, but I can't do that very easily if I am pregnant can I!?

melissa75 · 19/06/2009 10:48

niccibabe...I am totally outraged by your experience, and how they treated you...thats terrible.
I had the same situation pre pregnancy...was in A and E and had unexplained headaches...so they kept me in, I too was told that if I refused to stay, and then were to come back again another time I would be refused treatment (total crap, not to mention against the law I have now come to learn). Anyway, they had nowhere to put me, so put me on the maternity ward with the screaming babies...which really helped my headaches
My first night, I did not sleep a wink...I rang the bell onsistently for pain meds, noone came, noone even acknolwedged my existence...the next day, someone came to see me in the morning, left my notes within reach so I had a read and it too read "patient slept well all night and was comfortable" I nearly had my eyes bulge out of my head. Just goes to show, this obviously happeneds a lot, and it is SO important to have someone advocating for you in your corner. I had DH come in the next morning, and he does not suffer fools gladly, and there was a lot of strongly worded conversations!

dizietsma · 19/06/2009 11:47

"As i am sure you are aware, a CTG is recommended by NICE in certain situations."

Totally unaware, what situation are they recommended in then?

The MW I had told me I had to lie still and on my back with the monitor. I had a walking epi so I could be a bit more mobile and wanted to lie on my side, latterly when I got more feeling I wanted to get on all fours, but the MW scolded me for it, and I was so knackered from 29 hours labour and battling to get what I needed that I let it go. It's at that point I wished my doula was there

When I was in transition, and I got the good MW, I was moaning that I wanted to kneel upright on the bed, and she was really helpful about moving all the wires etc, but previous to that all the hospital MW wouldn't budge on it.

OP posts:
treedelivery · 19/06/2009 11:55

Nice guidelines on CTG

guidance.nice.org.uk/CG55/Guidance/pdf/English

Although this is the full intrapartum guidence, so doesn't cover antenatal indications such as reduced movement, cholestasis, preeclampsia etc.

CTG monitoring would be indicated in prematurity, when syntocinon is used, preeclampsia [as it affect placental function], meconium, audible deceleration on listening, prolonged labour [as this is as hard on the bubba as mother in some situations], maternal temp, there are others but these are off top of head.

Deemented · 19/06/2009 12:06

'CTG monitoring would be indicated in prematurity, when syntocinon is used, preeclampsia [as it affect placental function], meconium, audible deceleration on listening, prolonged labour [as this is as hard on the bubba as mother in some situations], maternal temp, there are others but these are off top of head. '

Bloody hell - i had none of those, yet they still insisted on putting the monitor on. I suspect it was to make their job easier rather then anything to do with the baby.

StripeyKnickersSpottySocks · 19/06/2009 12:32

I aways use a big cuff on a bigger arm.

Our hospital has a new policy which really annoys me. We now have to reweigh women at 36 weeks and recalculate their BMI. Of course this isn't a true BMI as its not the woman's body mass index but ratehr her body mass index, the baby, placenta, fluid, etc. But if at 36 weeks a lady has a BMI of 35 or over then it is hospital policy that they are continuosly monitored.

treedelivery · 19/06/2009 12:39

Cor blimey that sucks Stripey!!

What a wierd thing to do. Risk assesment gone mad me thinks.

I realised at 38 weeks I was high risk as my weight was 100kg. I think that they managed me correctly, whilst we said out loud during labour that my uterus might contract less well, and that there may be a disposition to distress as a result, we would do 4 hourly base line ctg's and only monitor if there was an obvious need. I liked that - it didn't ignore the clinical facts of my presenting history, but it also allowed my labour to be individual and take it's path.

Never got to 2nd trace as delivered

YanknCock · 19/06/2009 13:13

The midwife I 'sacked' after the BP cuff incident just phoned me! Still not admitting she did anything wrong, but did say they would be having a large cuff available now. I have started a ranty thread about her here if anyone is interested.

scratchet · 19/06/2009 14:36

Deemented, there are numerous reasons as to why someone is put on a ctg, some obvious some not so obvious. Believe me it was probably not to make your midwife's job easier. If anything having a ctg instead of intermittent monitoring makes our jobs far harder.

treedelivery · 19/06/2009 14:44

Agree with scratchet. Maybe some find them reasuring but I don't! They just sit there churning out the trace just worrying me! But that's not fair on the CTG as a whole - obviously they have a huge role in avoiding fetal distress, and have made many a complex labour safer for the pasenger. PITA for the pregnant one though. I had a scalp electrode with dd1 and found that much easier for me, as I could move about a bit more.

sarahmikeharryandrosie · 19/06/2009 17:22

this thread has made me realize its not just me who felt terrible for being pregnant with a high BMI, i am so pleased to hear that so many of you have had to fight the same battles i did, even though it is totally not fair!!!!!

niccibabe · 20/06/2009 00:12

Hi everyone,

Thank you for your kind words - means a lot to me that it's not just me that thinks what happened was out of order.

Had another hospital appt today. On DH's advice I had added my own notes about what happened to my hand-held hospital notes. The MW checking my BP noticed and asked about it - and was very nice.

Was advised by different doctor that she would recommend induction at 40+0 due to my BP being high. I said I wanted to wait for the baby to be ready, but that even if I refused I knew they would do the induction anyway. Doctor said they would not do that, but I had to understand the risks. Nice MW came in and saw I was upset and talked me through what would happen if I wanted to take it further. MW asked for a consultant to come and speak with me, and if it would be okay by me for the consultant to look through my notes first. I said okay.

Turned out that consultant who was on only had time to look at my notes and could not understand why I had not been told it would be monitoring overnight. She also couldn't understand why I hadn't been put on medication and wrote a prescription for me before being paged back to the labour suites. Consultant recommended that MW made an appt for me with my own consultant to discuss situation - so that's happening next week.

When I got home, DH reminded me that my own consultant whom I've seen once had put in my notes that my 40 week appt is for a sweep - and did so after me telling him that I wanted to wait for the baby and not do anything in advance. So we'll see how it goes...

Maybe the BP medication will do its job and the doctors will back off a bit??

JamesAndTheGiantBanana · 21/06/2009 00:31

By scratchet on Thu 18-Jun-09 14:38:59

James, maybe your ds was fine at delivery but there must have been a reason for needing continuous monitoring? It sounds like they needed to attatch the monitor to his head as they couldn't get a good enough trace abdominally.

Scratchet, I don't think there was a reason for the continuous monitoring other than my bmi at all to be honest. I did not have high blood pressure, the labour was progressing nicely (11 hrs start to finish, I was admitted at 4cm, had baby 4 hours later) and I wasn't told of a reason for them needing to do the internal monitor other than "the stomach monitor won't stay on"

But you don't HAVE to have constant monitoring, do you, so why insist on it in a woman who is getting on with it and has no other health issues? My waters hadn't broken when she tried to fit it and as I said (sorry to repeat myself) she didn't bother to ask that they hadn't gone, so broke my waters with her nails, which was excruciating.

I think that because they weren't getting a great trace on the stomach monitor, they assumed there was a problem, and didn't put it down to the fat on my stomach getting in the way.

This sounds silly until you consider that the same midwife kept measuring my fundal height at my antenatal appointments as massive, warning me that this baby would be big just by putting a hand on my stomach and scheduling more and more growth scans, when it was quite obvious that she wasn't making allowances for the fat on my stomach whilst measuring the fundal height. Or maybe I really was 50 weeks pregnant, who knows. All I can say is, I had a normal sized 7lb baby, a normal amount of fluid surrounding the baby, but an abnormal amount of fat on my abdomen. You do the math!

Deemented · 21/06/2009 12:11

Hafta say i totally agree with you there, JATGB

scratchet · 21/06/2009 12:51

James, didn't you ask re the need for continous monitoring? I would never do a ctg for no reason.

You are right that if you have excessive fat on your abdomen a trace may not record well and therefore cannot be interpreted correctly i.e if there is lots of loss of contact, who can say what the fetal heart is doing at that time, it may be fine, then again it may be decelerating.

me23 · 21/06/2009 13:01

sorry I've been away from this thread. I've been so busy with exams and placements.

I have done placement in midwives clinic in gp surgery for 5 months and I've been fortunate to work with mws who are aware of when to use larger size bp cuffs and that it does affect readings. Also on antenatal ward and labour ward when I'm doing shifts there the mws have used appropriate cuffs.

I think it's terrible that the from a lot of your experiences mws are neglecting to do this!

JamesAndTheGiantBanana · 21/06/2009 23:16

To be honest Scratchet, throughout my pregnancy and labour I was quite apologetic about my weight, quite meek because of it (for want of a better word) and pretty much agreed with everything the medical staff told me to do.

I didn't argue with the internal monitor being fitted because I assumed that it was necessary and something was wrong, but I wasn't given a better reason other than the stomach one not staying on. Maybe there was a better reason, all I can say is they didn't give us one, so it makes you wonder.

When I got in there and she did a VE, she thought he was breech because his head was swollen after 3 days of mild contractions (I knew he wasn't breech as I could feel kicking in my ribs and an enormous skull on my bladder, he'd been engaged for ages) so she insisted on giving me a scan which she couldn't interpret, and told me I would need an emergency cs. Then the consultant came in, looked at the scan and told her the baby wasn't breech. But by then they had an IV in ready for the cs, and the monitoring happened after that.

But again an incorrect diagnosis of breech presentation shouldn't mean I'd need an internal monitor. Perhaps it would be enlightening to get hold of my notes prior to having my next baby, as I feel quite worried about it, to the point I'd rather ask for an elective to try and regain some control.