The Plus-Size Guide to Safe Pregnancies and Healthy Babies
By Patricia Staino
A wave of emotions engulfed Debbie Miller as she writhed on the birthing bed, waiting for her baby's head to crown. It was Miller's first pregnancy, and the previous nine months had been a whirlwind. During her pregnancy, Miller, 40, who is single and lives in rural Ohio, worked full time, kept up with the house and yard work, and managed to complete her bachelor's degree. Now, two days after her last final exam, Miller was in labor.
In the delivery room, the drive to bring a new life into the world was as relentless as the pounding surf. Because Miller dilated from three to ten centimeters in no time flat, she missed the window of opportunity for an epidural anesthetic. Her doctor was stuck on Route 315, and Miller worried that he wouldn't make it in time. And she was scared because the staff doctor kept saying that she couldn't feel the baby's head.
Miller kept telling her that she wanted to go home ("Like that would work!" she laughs now). Despite the craziness around her, she tried to concentrate, but the two people in the room seemed to multiply into dozens of bodies running around and yelling orders. When Miller's doctor finally ran into the room, his first comment was, "Hold on Debbie, I have to get dressed!"
Only 48 minutes after Miller's tsunami began, little Jenna Lee was placed in her mother's arms. "I was 40 when I became pregnant and it was totally unexpected. I felt like it was 20 years of waiting for a child of my own," says Miller. "My daughter is a miracle because I had given up on ever having a child, and I was so very grateful to be having her."
The decision to have a child should be an exciting, happy moment for any woman. But for a plus-size woman, decisions about pregnancy are often surrounded by a swirl of questions and controversy, most often based on society's biases and misinformation.
Amanda Summers*, a 41-year-old sales executive from the Northeast, has been struggling with her concerns over the last few months as she decides whether or not she wants to get pregnant. She finds herself thinking about every possible complication that might come into play. "I worry about [problems during] pregnancy. If I need a Cesarean, will they be able to cut into my stomach safely? Will I get toxemia? Can I continue to take anti-depressants during pregnancy? All these things conspire to make me very, very nervous."
Starting a family is foremost in Summers' thoughts right now because her "biological clock is ticking quite loudly." She and her husband have been married three years, and, prior to that, she says, "there was no time in my life when I was with a man I wanted a child with."
Her husband, Glen, is far less concerned about difficulties in having a baby. He calls Amanda "Fertile Fanny" and tells her that "lots of women bigger than you have been giving birth for years." Many doctors agree.
According to Dr. Marcos Pupkin, chair of the OB/GYN department and Director of the Center for Women's Health and Medicine at Mercy Medical Center in Baltimore, plus-size women can absolutely have healthy pregnancies and babies. He adds, "Prenatal care is very, very important, and the patient needs to be diligent about following doctor recommendations."
Finding a Doctor
Health care professionals are no different than other stratum of society, in that many have preconceived notions about large people. Plus-size women often report difficulty in finding gynecologists from whom they can receive unbiased care. It's crucial that you find health care professionals who will work with you during your pregnancy - and you'll be better off if you can find a size-friendly OB/GYN before you start your family.
"You must be comfortable with the doctor, and you shouldn't feel nervous or scared to go see him; you should be excited," says Janelle Knodel, 28, a recent first-time mother from Northern California. "My doctor made my pregnancy much easier. I chose him because I heard him calling women of size 'prosperous.' He has a respect for women that you don't find in a lot of doctors today."
A supportive doctor will make the months of pregnancy more pleasant, but more importantly, s/he will not add stress to your life. This is also true of the other medical professionals you'll come in contact with during your pregnancy-nursing staff, lab technicians, nutritionists, etc. Don't be afraid to ask about their experience/opinions concerning patients your size, and if you feel you need to educate them, give it your best shot. If you ultimately feel their attitudes do not meet your needs, don't shy away from asking for different service providers. Much has been written about the connection between physical and mental health, and avoiding stress during pregnancy is a top priority. Finding the right doctor is your first step toward ensuring that your nine months will be calm and positive.
You can get your pregnancy off to a good start by preparing your body. According to Dr. Lisa Domagalski of Women & Infants' Hospital in Providence, R.I., many of the same lifestyle recommendations made to women during pregnancy are equally important prior to conceiving. "The most important things...are to have a complete physical exam and find an obstetrician with whom they feel comfortable," she suggests. "Any woman considering pregnancy should eat a healthy diet, have a regular routine of low to moderate aerobic exercise (like walking), take vitamin supplements containing folic acid and try to eliminate as much stress as possible in her daily life."
You may already be eating a healthy diet, but if you aren't, making changes now is a great way to establish habits that will continue throughout your pregnancy. Good nutrition ensures that your baby gets the nutrients it needs in the weeks after conception, when you may not know you are pregnant. Your daily intake should include protein, grains, and green and yellow vegetables. Angle recalls, "I really watched what I ate to make sure it had nutritional value," said Angle. "I ate like I was feeding the baby."
Folic acid, or folate, is a B vitamin that helps in the development of the baby's spinal cord and brain. The March of Dimes and the Centers for Disease Control recommend that women planning to become pregnant add natural folate to their diets and supplement that with at least 400 micrograms of folic acid daily. Once you are pregnant, they recommend you increase the supplement amount to 600 micrograms. Folate can be found in bananas, spinach, orange juice, fortified cereals and red kidney beans.
Even with a healthy diet, you still may not be getting all the recommended daily allowances of vitamins. Because maintaining the right balance of supplements can be like walking a tightrope (you might not get enough of one vitamin, while too much of another could be dangerous), doctors often recommend specially formulated prenatal vitamins.
"Prenatal vitamins are a supplement to a healthy diet," stresses Dr. Domagalski. "By consuming both, a woman should get all the amounts of vitamins and minerals she needs with one exception--calcium. There is very little calcium in the vitamin, so women must supplement their diets with an over-the-counter calcium source if they don't get about 1200mg in food sources." Calcium is important because it helps a baby's teeth and bones develop, and can also prevent leg and muscle cramps in pregnant women.
First-time mom Janelle Knodel is a firm believer in "taking care of your insides" to have a healthy pregnancy. When she and her husband, Will, found out she was pregnant, they went right out and bought a treadmill for regular exercise. "I had not been much of water drinker before, so I worked on drinking six eight-ounce glasses of water a day, plus milk and orange juice or decaf tea," she says. "I also began taking prenatal vitamins, and I added extra folic acid."
In addition to ensuring your baby's health by getting all the right nutrients, you should do everything you can to make sure your delivery is trouble-free. Labor is a very exhausting process, and in Dr. Pupkin's experience, larger women tire sooner than those of average size do. Dr. Domagalski concurs, saying, "Exercise during pregnancy does seem to shorten the duration of labor and delivery, and give women more stamina for the pushing stage."
"When I realized I was pregnant," recalls Toni Angle, a 40-year-old Midwesterner who works as a buyer for the U.S. Government, "I read up on pregnancy issues and how to have a happy, healthy pregnancy and baby. Having had two babies already, I knew what I was in for!"
"I walked as much as possible to help with the weight, and to build the stamina and lung capacity I knew I would need for the delivery," recalls Angle, who was average size when she gave birth to her other two children. "I think the walking helped quite a bit, [resulting] in a short labor and easy delivery. My water broke at 1:27 AM and little Scottie-man was born at 3:24 AM."
Many women of size are concerned with the weight gain that is inevitable during pregnancy. The women who were interviewed for this article gained amounts that were comparable to what a smaller woman would gain during pregnancy.
While all women's bodies change shape during pregnancy, the downside for very large women is that the big event isn't as obvious to passersby. "I realized my worst nightmare when I was pregnant-nobody could really tell since I only gained 13 pounds!" relates Angle. "My neighbor came over after the baby was born and said in her cute little perky way, 'Wow, I didn't even know you were pregnant!' Of course, she's about 5'2" and weighs 112 pounds!"
While it's always important to find a doctor who knows you can be healthy at any size, it's even more important during your pregnancy. This is not the time to go on a diet, and run - don't walk - away from the health care professional that encourages you to lose weight during pregnancy.
"If I tell a patient to lose weight [before they get pregnant], how much do I tell them to lose?" reflects Dr. Pupkin, who reports that he frequently delivers babies to patients weighing 350 to 400 pounds. "How long will it take? And maybe it will cause other side effects."
Depending on your current health, family history and other circumstances, there are numerous tests and screenings that a doctor may recommend for women of any size. However, there are a few others that are recommended for most plus-sized women.
An ultrasound can be used throughout your pregnancy to determine such things as the number of babies, your due date, and the size and position of the fetus. Smaller women usually have one ultrasound around the eighteenth week of pregnancy. Dr. Pupkin says he recommends a series of ultrasounds for plus-size women, so the size and development of the fetus can be monitored for "Big Baby Syndrome." Larger women are more likely to have larger babies, which can pose challenges during delivery.
There are two types of ultrasounds, vaginal and abdominal. With a vaginal ultrasound, the transducer is inserted into your vagina. With an abdominal ultrasound, the transducer is run across your belly. According to Dr. Domagalski, all women should have vaginal ultrasounds in the first trimester. "It is the only clear way to see such a small fetus," she explained. "After that, with all women, the fetus is best seen with abdominal ultrasounds."
An alpha-fetoprotein test, or AFP, is a blood test that screens for birth defects such as spina bifida and Down's Syndrome. Proteins that are produced by the fetus are measured through the mother's blood sample. If the levels are off, your doctor will recommend further testing to diagnose if there is a problem. Some mothers-to-be prefer not to have this test, feeling that they will have the baby whether or not the fetus has health problems. The decision to have the AFP and other diagnostic testing is yours, although Dr. Domagalski says she recommends this test for all mothers-to-be, not just plus-size women.
Glucose screenings and glucose tolerance tests can diagnose gestational diabetes, which occurs when your body cannot produce enough insulin to counteract the placental hormones and keep your blood sugar level within normal range. Dr. Domagalski and Dr. Pupkin agree that women of size are more at risk to develop gestational diabetes, and both recommend this testing. While gestational diabetes is a serious condition, it can usually be controlled with the proper diet and exercise.
By her eighth month, Janelle Knodel had had three ultrasounds, a one-hour glucose test and regular blood tests to watch all her levels. "All of the tests my doctor did on me, he does on all women, of all sizes," she notes. "[But] because of my size, he watched me closely for diabetes, toxemia, phlebitis and weight gain."
On the other hand, Angle had no special testing during her pregnancy: "I had the ultrasound to determine the baby's size and to establish a due date, but I had that with my first two [when I was average size] as well."
While there are some differences between childbirth for women of size and childbirth for smaller women, eating right, staying active and building your stamina can help to make your delivery trouble-free. Just as with other areas of plus-size pregnancy, planning ahead is the key.
"Actually, the birth process was very easy for me," relates Miller. "I was induced at 39 weeks because the doctor didn't want the baby to get too large at the very end. I went in at 7 AM and nothing happened until about 9 PM. I had very mild contractions. At 11:10 PM my water broke and everything went fast after that. She was born at 11:58 PM. It wasn't too bad, really. I can't say if the process was really any different because of my size."
Larger women are more at risk for large babies, which is why doctors recommend the serial ultrasounds to monitor growth. If a baby is too large, or if additional fat in the vaginal area makes the baby's passage more difficult, a caesarean delivery may be required. But don't assume that your weight means your doctor will automatically schedule a C-section. Attend childbirth classes and prepare yourself for a vaginal delivery. Dr. Pupkin advises that you discuss all your options and all the possibilities with your doctor during one of your last regular visits. There is an excellent chance you can deliver the baby naturally and vaginally.
"I think this birth was very normal. I don't think anything was any different due to my weight. I did have a worry, though, about what if I collapsed [when I went into labor]-who would carry me to wherever I needed to go?" laughs Angle. "All in all, everything was textbook for me this last time, just as it was in my first pregnancy, where I was not a [plus-size] mom."
Finally, don't forget about the physical parameters of your birthing room. Dr. Domagalski says that any good hospital should have the equipment necessary for large-size patients, but for your own comfort, either you or your labor coach should ask ahead of time. Be sure your birthing room will have blood-pressure cuffs, fetal monitors, gowns, bathrooms and beds that accommodate your size. You deserve to be as comfortable as possible during your labor and delivery.
Miller concludes, "So [here] I am, a plus-size woman raising a baby. It is wonderful. Every minute of it. I look into [Jenna's] little brown eyes and think, I've been blessed. And I have been."
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