There is a lot of controversy about weight and pregnancy. Not gaining enough weight or even losing weight can leave a parent feeling stressed out about their options for plus-size birth.
It can be hard to suss out VBAC facts in a sea of misinformation, and this is even more true when it comes to plus size pregnancies.
Add to that, entering pregnancy with a BMI over 30, classified as obese, adds an additional element of pressure from providers, hospital staff, and even friends and family members.
So, what’s the big deal about being plus-size and pregnant?
While a plus-size pregnancy does have some increased risks, they are small increases to already low risks. There are many things we can do to mitigate that risk. People of all sizes have healthy pregnancies and outcomes, and being a woman of size does not automatically exclude you from a VBAC or vaginal birth.
As a plus-sized mom of four, I am excited to dig deep into the reality of plus-sized pregnancy, birth, VBAC, and Cesarean. In this article, I will answer all your questions and leave you with resources you can use to further explore and take charge of your birth.
Is plus-size birth high risk?
Being plus-size or obese does not automatically make a person’s pregnancy high risk. While being overweight does increase your chances of some common pregnancy concerns, most women of size go on to have healthy, uncomplicated pregnancies.
While having a BMI greater than 30 does increase the risk of certain ailments, the scale used to calculate BMI has flaws. One of those flaws is the assumption that having a higher BMI automatically means you are unhealthy, which it does not.
The BMI scale does not take into account many factors that have a big impact on a person’s well-being. Things like muscle mass, fitness level, visceral fat vs subcutaneous fat, age, economic status, health history, or ethnic background, along with any health conditions, have to be considered.
With that being said, being overweight heading into pregnancy can increase your risks of getting gestational diabetes, having a bigger baby, developing preeclampsia, and can increase the overall length of your labor. We will discuss all of those things below.
Plus size VBAC
The biggest issue a pregnant person will face with VBAC, in general, is finding a supportive provider, and even the most supportive VBAC providers can have a bias against weight.
Being overweight alone does not exclude you from TOLAC (trial of labor after Cesarean), but it is especially critical that you have a size-friendly and VBAC friendly provider.
It can be challenging to find supportive practitioners, but you owe it to yourself to search for a provider that will provide evidence-based care for you — one who won’t put a lot of focus on the numbers on the scale.
Potential complications in plus size pregnancy and labor
There is some increased risk for obese parents during pregnancy and labor, most of which can be minimized or managed if you are aware.
Most of the concerns related to parents of size and birth are cultural and deeply rooted in the belief that being overweight means a person is unhealthy, and being thin means they are healthy.
I attended a birth once where an anesthesiologist outwardly thanked the mother for being so thin after giving her an epidural because the few before her had been “hard sticks.”
It is not uncommon for a provider, especially in the hospital, to screen for gestational diabetes in parents with a higher BMI in the late first trimester. This test determines if you are already pre-diabetic or diabetic. You will also be tested again at the end of your second trimester or early third trimester.
I want you to know that while you always have the right to decline any procedure, this is an extremely common test. This particular screening is done with the intention of protecting the health of yourself and your baby.
However, if your provider tells you that you will for sure get gestational diabetes based on your size alone, that is a red flag. It is also not evidence-based for a provider to want to test you monthly.
Getting a second opinion or switching to a provider that is more friendly to women of size might be an option for you to consider.
Following a diet that is rich in nutrients and low in sugar and carbs will be beneficial in preventing and controlling gestational diabetes. This advice is actually something we recommend for ALL pregnant people, not just those who are plus-size. VBAC with gestational diabetes may still be an option.
A whole food diet mainly focused on vegetables, meat, fish/seafood, eggs, protein, dairy, nuts, seeds, complex carbohydrates, beans, and legumes is essential for pregnancy nutrition. Even a short brisk walk 3-4 times a week has been shown to prevent gestational diabetes.
If you’ve been with us for a while, you already know how we feel about big babies. If not, you will learn real fast.
Just being real here, as plus-sized parents, we already have a larger belly coming into pregnancy. So, it is not uncommon for our fundal height to measure larger than typical for our gestation.
A size-friendly provider will account for this, as you are more likely to measure ahead. This is perfectly normal and is not indicative of having a baby that is too large to birth vaginally.
Parents with gestational diabetes are more likely to have larger babies, but the risk goes down when it is controlled by diet and exercise.
The biggest worry about larger babies is the likelihood of shoulder dystocia. While the risk of shoulder dystocia increases with larger babies, the risk is still relatively low.
It is also important to note that maternal obesity is NOT an isolated risk factor for shoulder dystocia.
According to ACOG (American College of Obstetrics and Gynecology), a suspected big baby is not an indication for early delivery and only rarely is an indication for Cesarean delivery. They recommend that a C-section is reserved for estimated fetal weights of at least 11 pounds in women without diabetes and at least 10 pounds in women with diabetes.
Cesarean and anesthesia
Some plus-size parents may face difficulties when receiving an epidural. Excess fat in the back region may make it harder for an anesthesiologist to find the right area to place an epidural. It may take multiple times to place it properly. However, a more experienced anesthesiologist is less likely to have such issues. w
While there are some benefits of a natural birth — regardless of your body type — sometimes a Cesarean is inevitable.
When performing a C-section, it is not uncommon for larger women to have their bellies lifted and taped so the OB-GYN has easy access to make an incision. While this isn’t painful, it can be a little disconcerting.C-Section for Plus Size Women, Plus Size Birth
Some parents even have two small holes on either side of their incision to allow for draining, or may even have a more formal drain inserted. Check with your provider on this and see if it is something you would like to explore.
Cesarean birth for parents with a BMI over 30 does show a small increased risk for complications related to the procedure such as postpartum hemorrhage, infection, and thrombosis which can all be reduced with good nutrition and exercise.
These risks increase as BMI increases. It should be noted that neither ACOG, RCOG, SOGC, or the APA recommend an automatic Cesarean for parents with a BMI greater than 30.
We hear about parents being diagnosed as “failure to progress” often and for parents of all body types. Some studies show that parents with a higher BMI on average have longer labors by about an hour and a half and are more likely to stall between 4-7 centimeters. However, there is no significant time difference during the pushing stage.
This bias that plus-size parents will have longer labors does lead to increases in interventions like augmentation of labor (Piticon) and even Cesarean birth when patience and time are likely all they need. A labor that is progressing slowly is not an automatic need for interventions.
There are other things that can impact the length of your labor. The position of mother and baby is important as well as having coping tools, like hypnobirthing, to manage the discomforts of labor. Having a supportive birth team will also decrease your stress levels which helps labor progress naturally.
According to a review in 2019, as BMI increases, so does the risk for preeclampsia. Women with a BMI greater than 35 have a 30% increase in the risk of developing PE.
Furthermore, maternal obesity along with [other] factors, such as nonesterified fatty acids, may contribute to excess lipid accumulation in the placenta. This can interfere with placental development [including] nutrient transport between mother and baby, resulting in increased oxidative stress and inflammation at the maternal-fetal interface. These placental injuries often characterize PE pregnancies. The localization of many pro-inflammatory factors… led to the understanding that obesity presents a state of low-grade systemic inflammation. The connection between maternal obesity and PE is hypothesized to involve immune cells within the mother’s adipose tissue and in the placenta contributing to impaired placentation.
Can I have a vaginal birth?
Please don’t let anything I talked about above deter you from attempting a vaginal birth. It is important to remember that, while there are increased risks in plus-size birth, the level of risk is small. Most often these risks can be reduced or mitigated with a healthy diet and regular light exercise like going for a brisk walk 3-4 times a week.
It is important to remember that most plus-size parents go on to have healthy and successful vaginal births! There is no need to automatically schedule a Cesarean simply due to your weight. Anybody that tells you otherwise is misinformed.
I love this quote by Plus Mommy:
You do not have to be able to run a marathon to give birth vaginally.
Finding support: Next steps to prepare for plus size birth
There are a lot of stigmas attached to women of size. We are often made to feel like our bodies are broken and incapable and need highly medicalized births.
It is important to remember that you are not broken! You ARE capable! Plus size does not equal unhealthy and we need to start reframing how we speak to plus-size parents about their pregnancy and birth.
Pregnancy is a great time for all parents to make healthier choices that will increase their chances of having the birth they want.
When considering vaginal birth, VBAC, or Cesarean, remember, it is a very personalized choice and needs to be considered and discussed with those you trust. Finding a provider that will support you in your birth goals is very important.
If you ever feel like you are being shamed due to your size, you have the right and the freedom to seek care elsewhere. Everyone has an opinion about which birth option is best, but you must decide for yourself based on your unique needs and situation.
Here are some resources to further help you on your journey:
We have so many stories on our podcast about plus-sized women who go on to have vaginal births after Cesarean. Tune in now and listen to their inspirational stories!
Interested in becoming a doula to help women through their VBACs?
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This online, self-paced video course is accessible anywhere at any time, making it a convenient way to get the training you need to go out there and make a difference for VBAC mothers.