is it true that obese women "should" have epis?

[paradise lost]

In terms of the studies (google for them, there are a bunch) the reasoning behind this article are as follows....

Obese women tend to have longer labours. That does NOT mean they are "complicated", that means that in a hospital an Ob who is twitchy to get to golf/bed/the bar will regard a normal labour for an obese woman to be a protracted one by HIS standards and then augment, CAUSING complications. The reasons for longer labours are twofold. The first reason is that having a lot of excess bodyfat tends to interfere with calcium levels in cells, and your uterine muscles (in fact all muscles) NEED calcium to contract in a strong and organised way. That doesn't mean you can't labour perfectly well, it just means you might take a while to efface and dilate, and in and of itself that is not a problem at all. The second reason is that while the cervix is dilating and the baby descending everything in the pelvis needs to get out of the way. SOME obese women have a lot of fat around their organs (although they are far less likely to than obese men) and this fat also needs to move out of the way to let the baby out. This can mean the late first, transition and early 2nd stage is a little longer for obese women too. Again, not a problem so long as mum is well-supported and allowed to rest properly between contractions.

The reason epidurals can be harder to site in obese people (obese men having spinal pain relief for injury or surgery present the same challenge) is because THE NEEDLES AREN'T LONG ENOUGH! The epidural needle is about 4inches long and has a stop on it - they insert it into the epidural space and then place the stop against the skin to stop it going deeper. If your epidural space is more than 3 inches from your skin the needle can be too short. MOST major hospitals should have needles long enough as that is hardly bloody rocket science!

I have obese friends and was about 101kg at delivery (though 181cm so not quite obese) and i have read an awful lot on this. In my view i would suggest the following for obese women:

1) During pregnancy stay active and eat well - fat around the vital organs and in the pelvic cavity is MUCH less common in physically fit individuals, and exercise is the key to keeping your bodyfat under your skin and not around your guts.
2) Have a doula or a good midwife as constant support - you might have a long labour, but your body is EVERY BIT as capable of birthing your babies as any other woman - it can be hard to remember that after several days of tiring contractions, so make sure you have really top notch emotional and practical support for your WHOLE labour experience (oftentimes you will be sent home from hospital until you're dilating and if you arrive at 4cm after 58 hours of labour it might be too LATE for the support of your ob or hospital midwife to make a difference, those early hours are valuable working time for your cervix and baby, and good support then will be invaluable - i do not subscribe to labour only being "real" when dilation hits a 4 - labour is labour as soon as you're having to work to meet the contractions, and you need support from then on).
2) Take calcium supplements during pregnancy and birth - 1000mg/day during the last month and 1000mg every 3-4 hours during labour is what my german midwife friend prescribes for her larger mamas. This will also help minimise your pain as the better tone you have and the more organised your uterus is the less "work" there will be for you to do - it will flow like a well-oiled machine.
3) Avoid spinal anaesthesia. I know this is flying in the face of him up above with the article, but really as someone else pointed out, if your labour will be long anyway, WHY would you counteract gravity and sacrifice the tone of your pelvic muscles? Obese women, like ALL women, should stay upright during contractions, ESPECIALLY once dilation is happening.
4) USE YOUR RESTS - between contractions rest as much as possible. Stay upright but resist the urge to march about trying to speed things up - a little walk every few hours is fine, but climbing up and down the stairs between every contraction for 10 hours will just exhaust you. Eat and drink for as long as you feel interested, your body will appreciate it as will your baby. An active labour needn't be an exhausting one and the more relaxed you can stay the more your body can use its energy to labour.
5) Use gravity during the 2nd stage. The birth stool, supported squats, hands and knees and so on are your friends! With bigger mamas especially lying on your back can really shut the pelvis, making it much harder work for you and babe to get to birthing. So stay upright, and have a doula, DH, DP, Midwife, bar or rope to hang from while you push.
6) Remember this bit of good news; one study i read suggested that positional problems in undrugged obese women with protracted labours are REALLY rare - your baby is very unlikely to "get stuck" due to a positional problem during labour because all that prelabour means s/he has a lot of time to get tucked up into a little ball of birthable joy.

Bx

[Midwife Melissa]

I read a letter in The Age today, written by an anaethsetist, that said the following:

- obese women are more likely to have birth complications (this I believe)
- obese women are harder to anaesthetise, especially in a rush
- therefore it is recommended that all obese women have a planned epi (or maybe other kinds of pain relief) during birth, to avoid a situation where it goes wrong in an emergency.

Maybe this anaesthetist is trying to justify another use for his/her services, thereby ensure his / her income stream?

Do your own research and come to your own conclusions. I'm waiting for the day when TENS, Calmbirth, waterbirth etc are promoted as much as epidurals are, for pain relief in labour.

[Kmn]

I think that the anaesthetist is just writing based on what they see, and trying to reduce the distress of their patients.
The patients (obese and otherwise) who get through labor with heat, cuddles, TENS, gas and peth are not patients who are on the radar of an anaesthetist. The patients they see are the ones who are not coping and are distressed. And their job is to minimise additional distress to the patient.

So if you were an anaesthetist who kept seeing distressed, large women who were difficult to help, you might also develop this view, based upon a very biased sample.

There's no shortage of work for anaesthetists, they don't need to create extra!

Maybe the advice that should be given to large women is "It will be harder to get an epi in if you need one, so if you aren't managing with the gas/heat/etc then let us know earlier rather than later".

[mummy of many]

Hi ladies, I`ve had four natural births only one of them i had an Epi,the rest i had no pain relief,but my 5th birth i needed a c-section due to medical reasons. There is no reason why a larger lady can`t give birth in the manner she chooses,I refuse to be bullied about the birth choice i make, unless it effects myself & bub. I don`t understand why us larger women are sometimes treated so differently to a slimmer person,but during my pg`s i have found that most Dr`s & midwifes aren`t that friendly towards us plumper girls.No wonder we leave hospital only a few hours after giving birth.it seems like no one really gives a toss,I`ve never stayed more than 10 hours in hossy after my births except when i had my c section,then i sighned myself out on day three.Just didnt like the some of the nurses attitudes.

Tenar- I wouln`t read to much into the article you read,sounds like a scare tactic,to me!!!!

[tenar]

Actually I talked to my ob about this today.

She said that in her opinion the comments might be sensible of very obese women (BMI over 45), who are giving birth in the crowded public system. The rationale being that it is better to plan to have an epi given by an expert, during the daytime, than to have a registrar doctor trying to get a tricky thing right in the middle of the night if you really need one then.

Given the reports in the press about the state of public hospitals in Melbourne at the moment, and the fact that epis seem to be harder to get right for obese people in general, the ob's comments actually make sense to me.

[AliBaby]

This is why that whole BMI thing is a load of crap!!!!

It is so not an indication of your health and how much fat you actually carry.

I am not skinny, I am actually quite healthy, I am a size 14-16 (mainly because of my massive assets up top) and usually carry no weight around my middle section. I mainly carry weight on my legs and arms. I also have muscles (which we all know weigh more than fat). My midwife doesnt weigh me as she thinks I am looking great but according to that BMI thing I am obese! WTF!

I think that anaethetists are jsut trying to make mroe money by scaring women into booking in epi's and I dont buy it at all.

Thanks to all the women who have told us about their positive experiences (whilst still being classed as obese even though I am sure you are not). It is very good to hear that you could still have great labours without needing epi's or without having problems having one if you wanted it.

[sunshine_sieben]

I have NEVER heard this much BS. Actually, that is not true, this kind of BS comes up all the time.
Yes, it is more complicated to anaesthetise an obese woman. This is why they should AVOID and epi. As epis increase the risk of things going wrong and a general anaesthetic and c/s becoming necessary.
Your BMI is not an accurate indication of whether or not you are obese and high risk. It is however and easy way to "measure". But there are so many factors involved. Like your fitness level, your body fat percentage, your muscle mass, your general health, your attitude and mindset and last but not least your environment.

I have been told by a close family friend who's an anaesthetist to try and avoid an epi if at all possible because you can twist it however much you want: no epi means less risk than having an epi. It's a simple fact. Epis reduce pain, not risk.

I am obese judging by the BMI and I was when I fell pregnant with DD. I managed not to put on too much weight during my pregnancy and ended up having a beautiful complication free all natural water birth at a birth centre (link to birth story in my siggie, if you want to read it).
I was 85kg when falling pregnant the first time andgained around 12 kg during my pregnancy. I am 171cm tall.

Saša

[dust]

im obese never had any epi or tear.. not a single stitch. ive also never used any pain meds as im a control freak and the thought of my head spining from gas doesnt float my boat!

sorry but the generalisation in any sense is complete BS! Im obese would have been easy 110 at 169cm at both births. No pain meds, No epis, No forceps or salad scoops, No tear, full public service midwife only, birthed squatting & birthed on birth bean bag & very quick births (including all stages)

there was never a suggestion of epi, gas or otherwise.. one crazy midwife who wanted 2 get my personal details check my BP etc kept on going on about water injections in my back.. which ive never heard of b4 but after a internal stopped insisting as i was 8cm dilated.. no crap! i go to the hospital to deliver not to have a chat over tea.. grr

i hate that despite my perfect record of wonderful births & healthy babies that im classified as "high risk" its like telling cathy freeman she may have won gold at running but no she cant run 4 ****.. WTF?!!!