[Early that night on the ward, we had a patient with a “shoulder
dystocia” — a scary situation in which the baby’s head delivers, but the
shoulders are too big to pass through the birth canal. Shoulder dystocia is
strongly associated with obesity and excess maternal weight gain during
pregnancy, and can lead to permanent fetal injury, neurological disorders and
even death.]
By
Claire A. Putnam
 |
|
Credit Jing Wei
|
BERKELEY, Calif. —
ONE recent night on my delivery shift, eight out of 10 of my laboring patients
were too heavy, with two weighing over 300 pounds.
Over two-thirds of adults and about one-third of children in
America now are overweight or obese. An obese pregnant woman is more likely to
have a very large baby, weighing roughly nine pounds or more. And babies of
obese mothers are more likely to grow up to become overweight or obese
themselves.
Maternal obesity causes more immediate problems as well. Obese
pregnant patients are more likely to have elevated blood pressure, gestational
diabetes and babies with birth complications. They are more likely to need cesareans.
And they are more likely to have serious complications from the surgery, such
as infections, hernias or life-threatening bleeding.
Early that night on the ward, we had a patient with a “shoulder
dystocia” — a scary situation in which the baby’s head delivers, but the
shoulders are too big to pass through the birth canal. Shoulder dystocia is
strongly associated with obesity and excess maternal weight gain during
pregnancy, and can lead to permanent fetal injury, neurological disorders and
even death.
But the biggest emergency unfolded in the early morning. A
24-year-old, 300-pound diabetic woman, who was pregnant with her first child,
had developed pre-eclampsia. Pre-eclampsia is a complication of pregnancy
marked by elevated blood pressure, swelling and mild to severe organ
dysfunction. If untreated, it can lead to the mother’s having seizures, stroke
and liver rupture, and is a leading cause of maternal death. Although
pre-eclampsia can occur in any pregnancy, it is three times more likely in obese
patients. New research suggests that babies born to women with pre-eclampsia
may have a significantly higher chance of autism or developmental delay. The
only treatment for it is to deliver the baby, so this patient had been given
drugs to induce her labor.
At 5 a.m. I was urgently called to her bedside. She was having
seizures from the swelling and elevated blood pressures. Her baby’s heart rate
dropped from 100 beats per minute to 70 to 40, and then the signal was lost —
the monitor had come off.
As we worked to treat her seizure, we moved her to the operating
room. We needed to sedate her, but struggled to find a vein. We needed to
intubate her, but her airway was obstructed from the obesity and the swelling.
Just moving her onto the operating table required an additional team: the table
was too narrow and the straps too small.
Once she was safely secured to the table and intubated, I
checked for the baby’s heartbeat. There was nothing on the monitors. Nor could
I see the heart with the ultrasound, as the mother’s abdominal wall was too
thick and swollen. There was nothing I could do but deliver the baby surgically
and hope that it would survive. Quickly, I cut straight through her swollen
abdomen and uterus. I reached through her placenta, wrapped my hand around the
baby’s head and pulled it firmly out of the incision. As I gently extracted his
body and untangled his legs from his pulsating cord, he clenched his fists and
gasped.
Later that morning, when I left to go home, I was deeply
grateful that all my patients and their babies were safe. There were many close
calls.
Obesity is a sensitive subject, even for doctors. In a JAMA study from 2011, only 45 percent of
patients with a body mass index of 25 or greater (defined as overweight) and 66
percent of patients with a B.M.I. of 30 or greater (defined as obese) reported
having been told by a doctor that they were overweight. Notably, those who were
told were more likely to have tried to lose weight.
There are many reasons doctors don’t speak up, including short
office visits and a lack of training. But one growing problem is the role of
“patient satisfaction scores,” which can be tied to doctors’ compensation and
job security. If you offend a patient, you may never see her again.
But these conversations are crucial, especially for women who
are, or want to become, pregnant. Obesity in mothers is strongly linked to
their own compromised health, and to that of their unborn babies and our nation
at large.
For doctors, the issue has become an everyday challenge. In the
last year alone, three of the doctors I work with have been significantly
injured while treating severely obese women. One even dislocated his shoulder
while performing a cesarean on a 400-pound patient. We recently had two
patients with B.M.I.’s of 53 and 60 in labor at the same time. B.M.I.’s above
50 are now classified in a new category: “super-obese.” It is frightening to
think that this might become normal.
Policy makers need to pay attention. We should consider creating
special labor and delivery centers for severely obese patients that are
equipped with automatic lifts, specially designed monitors and appropriately
trained teams.
We also need better prenatal programs that assist women in
achieving appropriate weight goals during pregnancy, through better exercise
and nutrition. The adage of “eating for two” is damaging. Thankfully, under the
Affordable Care Act, more women and children have access to nutrition and
health services than ever before. But we should be managing obesity even more
aggressively, as we do elevated blood pressure and diabetes.
Above all, we need to end the taboo against talking frankly
about obesity. Doctors need to be sensitive and nonjudgmental, and patients
should not take offense, especially when their health, and their children’s
health, is at stake.
Claire
A. Putnam is an obstetrician and gynecologist at a Kaiser
Permanente hospital.
