Background
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To obtain practitioners’ experiences of caring for obese pregnant women,
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To identify the issues that practitioners face when caring for obese pregnant women,
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To identify how these issues impact on patient care,
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To identify possible solutions that could decrease the impact on care.
Method
Results
England | Scotland | |
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Obstetrician | 3 | 3 |
Anaesthetist | 1 | 1 |
Midwife | 10 | 6 |
Focus Group 1 | 3 midwives | - |
Focus Group 2 | 4 midwives | - |
Focus Group 3 | - | 4 midwives |
Focus Group 4 | - | 2 midwives |
Interviews | 3 midwives | - |
Interpretation: Different approaches to obese birth offer opportunities to promote normal birth | |||||
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Theme 1 | Theme 2 | Theme 3 | |||
Medicalisation of obese birth | The promotion of normal ‘obese’ birth | Complexities and contradictions in staff attitudes and behaviours | |||
Place of birth | Place of birth impacts on mobility | Antenatal education | Importance of information-giving antenatally | Use of fetal scalp electrodes | FSE used to aid mobility |
“We had a woman who wanted to sit on a ball because she was a home delivery, but had to be continuously monitored and they (staff) were unhappy to do it at first”
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“I think we should be educating them about mobility and being mobile and trying to get them to the MLU”
| “I would preferably, be able to monitor the babe, put the FSE on, to make sure that if she wanted, she could be mobile to help the labour as well”. | FSE viewed as an intervention by some but used to promote mobility by others | ||
Normailty influenced by place of birth | Antenatal education about mobility | ||||
Negative attitudes of staff | Negative attitudes about women’s size | Promotion of normality during labour | Acknowledge risk but promote normality same as anyone else | Risk of caesarean section | Risk of caesarean can influence care |
“And the delivery of those patients, I think it’s probably looked at negatively by the midwifery staff as well to an extent, because they are overweight they see them as ‘oh, this person’s going to be a problem’ |
“We should be treating them the same, if not more so promoting normality”
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“I think people tend to play safe. I don’t think I personally would agree with that….It’s best to have a normal delivery and if it can be, you know, pushed to that stage, without taking much risk, I will do that. Rather than doing something, like ding a section for example”
| Not all obese women have a caesarean | ||
Caring for obese women viewed negatively | Pro-active approach to normality | ||||
Challenges monitoring fetal heart | Technically difficult monitoring fetal heart | Promotion of mobility during labour | Promote mobility regardless of size | BMI influencing clinical management | BMI may influence decision-making for caesarean section |
“I just had to stand there and I was trying to get something and half the time you didn’t know if it was maternal pulse, it was very difficult”
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“I think basic care should be managed exactly the same. Like, cos any woman should be mobile in labour, you know, regardless of what they weigh”
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“I don’t feel that I do, but I do feel that some people probably make decisions where the lady’s weight influences their decisions”
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BMI may influence decision making positively | |||||
Fetal heart monitoring is difficult | |||||
Reluctance to mobilise | Obese women less mobile in labour | Classification as high risk | High risk classification can be detrimental | ||
“I think they’re generally more difficult. They’re more reluctant”
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“I think putting somebody in a high risk category actually doesn’t do anybody any favours because then people tread very carefully and they start to think ‘oh God, she’s high risk……I better make sure that nothing wrong happens here’”
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General reluctance to mobilise | Women view themselves as ‘normal’ | ||||
Discouragement of use of water | Water birth contraindicated because of size | ||||
“Because at the moment women are excluded from water birth aren’t they, who have a BMI over 35”
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Water birth not an option |
Medicalisation of ‘obese’ birth
Place of birth
“Nationally the recommendation is that anyone with a BMI of 35 or more should be in consultant-led” (M/W FG)
“I had a woman that had a raised BMI that wasn’t allowed on the MLU because of a certain cut off that they had a long time ago, who came in, mobilised and pretty much delivered herself” (MW Int)
Negative attitudes of staff
“The minute you see somebody come through delivery suite who’s very large you hear people ‘oh, I don’t want to look after her, don’t give her to me…..so immediately they are negative…..so I don’t know how they’re going to be when they get the woman in the room” (MW Int)
“They’re already feeling negative about caring for her, so I don’t know how that would then come across to the woman….” (MW Int)
Challenges monitoring the fetal heart
“I can’t remember it [obesity] being one of the things that we put down as an indicator for continuous monitoring” (Obs Int)
“Continuous monitoring…I don’t think there is any evidence that says so” (Obs Int)
“…Continuous monitoring, that’s going to put somebody on a bed before they’ve even started” (MW FG)
“Even intermittent auscultation is more difficult for the midwives to physically perform when the women are obese….You end up having to do ultrasounds to locate the heart….” (Obs Int)
“I just had to stand there and I was trying to get something and half the time you didn’t know if it was maternal pulse….it was very difficult” (MW FG)
Women’s reluctance to mobilise
“It’s hard to get them up, it’s hard to move them about” (MW FG)
“I think sometimes that the very biggest ladies do tend to be a little bit more reluctant to do that [mobilise], only because you can see it just takes so much more effort for them to move” (MW Int)
“I don’t think they like being immobile. I think they find it embarrassing” (MW FG)
Discouragement of water birth
“No I don’t think they are allowed in the pool” (MW FG)
“I had a large lady a few weeks ago and she said to me ‘oh I was told I could have a pool birth’ and I said ‘no, because it would be difficult to hear your baby and to get you out in an emergency” (MW FG)
“One of the difficulties that people with high BMIs have is difficulty in changing positions….and to have somebody like that buoyant in water takes all the pressure off their pelvis……” (Obs Int)
“That’s the difficulty with water birth isn’t it? Because they are the ideal sort of group to benefit….the weightlessness” (MW FG)
The promotion of normal ‘obese’ birth
Antenatal education
“It’s also about education isn’t it? So that she knows what’s coming, that she needs to be doing all the right things” (MW FG)
“I think we should be educating them about mobility and about being mobile and trying to get them to the MLU” (MW Int)
Promotion of normality
“I think we should be encouraging them to have more of a normal birth” (Obs Int)
“Rather than sitting back and just saying the guidelines say this; let’s encourage it, let’s promote it” (MW FG)
Promotion of mobility
“I’d try to keep her either active on a ball or active over the side of the bed…I would keep her as upright as possible” (MW Int)
“I think possibly if you keep obese pregnant women upright and mobile you’re probably going to get a better outcome, you’re probably going to get a nice delivery” (MW FG)
“I think it wouldn’t be difficult to promote, I think it’s the best thing to promote mobility in that population, they need to be upright” (MW FG)
Complexities and contradictions in health professionals’ attitudes and behaviours
The use of a fetal scalp electrode
“Unless they’ve put an FSE on, which is very interventional really, isn’t it, when you’re trying to promote normality” (MW FG)
“They tend to end up with fetal scalp electrodes on and you’re automatically medicalising labour in a group of women that we know, probably don’t labour as well, so would benefit greatly from being more mobile” (Obs Int)
“Although theoretically if you’ve got a scalp clip on you are supposed to be more mobile, but I don’t necessarily see that transferring into practice” (Obs Int)
“We tend to use FSEs quite a lot if we’ve got somebody that’s on continuous monitoring, so that we can get them up” (MW FG)
“Put an FSE on, to make sure that if she wanted, she could be mobile” (MW Int)
Risk of caesarean section
“I do feel that some people probably make decisions where the lady’s weight influences their decision. So whether they don’t do a caesarean as soon as they should do because they are trying to avoid doing a caesarean ….or they do it sooner than they should do because they want to do it when the consultant staff are available” (Obs Int)
“No I think we’d give it the same, in fact I might even give it longer, it’s not much fun doing a caesarean section on a very obese patient, so no, I don’t think we jump in early” (Obs Int)
BMI influencing clinical management
“I do feel that a woman’s size can influence your management and it’s very difficult to do that because obviously the woman’s safety is paramount, but it probably does then affect the way you manage her” (Obs Int)
“I would suspect it is a way in which we manage their care and I suspect we do see them as a problem…” (Obs int)
Classification as ‘high-risk’
“They are at higher risk of complications of labour, so I would think yes, yes they are [high risk] (Obs Int)
“I think putting somebody in a high risk category actually doesn’t do anybody any favours” (MW FG)
“I think a lot of them come in and they’ve been told, the risk is this, the risk is that, so they have the mindset, then that’s what’s going to happen to me” (M/W Int)
“I know the risks are much higher, but they don’t all and if you get it across to people that, think positively, you know” (MW Int)