Raised Body Mass Index (BMI) in pregnancy, birth and afterwards

Raised Body Mass Index (BMI) in pregnancy, birth and afterwards An Information Leaflet September 2011 Every Patient Matters

MAT148 2 We want to help and support you during pregnancy and birth, and also to encourage you to look after your health in the long term. What is BMI? BMI means Body Mass Index. It is worked out using your body weight and height. A healthy BMI is 18.5 24.9. Pregnant women who have a BMI of 24 or more are known to be at a higher risk of developing problems during their pregnancy, labour, birth and after giving birth. The higher your BMI, the greater are your risks of having complications. Obesity is the medical term for being significantly overweight (i.e.. when your BMI is 30 or above). Almost 1 in 5 (20%) of women have a BMI of 30 or above at the beginning of pregnancy. Your BMI is calculated at your first antenatal booking appointment. If it is 30 or above, you will be weighed at each antenatal visit. This is in order to help you keep your weight gain in pregnancy to within healthy limits. You will be given information and advice on diet and exercise to help you achieve this. This leaflet aims to: Give more information about some of the possible effects of having a raised BMI. Describe positive steps you can take to avoid or minimize these. Help plan your care, in discussion with your midwife and doctor. What are the potential risks of having a raised BMI? Remember, not all women with a raised BMI experience problems. But being aware of the possible complications can help you to a better understanding of what is happening and why you are being offered particular care, treatment and advice. We hope this information will encourage you to follow guidelines on healthy eating and exercise in pregnancy and also to seek advice and support after you have had your baby, in order to achieve a healthy BMI before becoming pregnant again.

MAT148 3 These problems may include: For you: Raised blood pressure and pre-eclampsia, diabetes (high blood sugar) in pregnancy and a higher risk of thrombosis (blood clots in the legs or lungs). For your baby: if you have a BMI of 30 or above at antenatal booking, this can affect the way your baby grow in the uterus (womb).when you are overweight, it can also be more difficult to see clear images of your baby on the scan, so it is more difficult to diagnose problems with growth or development. There is an increased risk of Miscarriage: the overall risk of miscarriage under 12 weeks is 1 in 5 (20%) which increases to 1 in 4 (25%) if your BMI is 30 or above Stillbirth: the overall risk in the UK is 1 in 200 (0.5%) but if you have a BMI of 30 and above your risk doubles to 1 in 100 (1%) Neural tube defects (problems with the development of the baby s brain and spine): in the UK, approximately 1 in 1,000 babies is born with a neural tube defect. If your BMI is 40 or above, your risk is 3 times that of a woman with a BMI of below 30 There are also other risks for you and your baby linked to having a raised BMI: Difficulties in checking your baby s growth and position, when the midwife / doctor palpates (feels) your tummy, so you may be offered extra scans. A higher chance of labour being induced and / or your labour progressing slowly so needing acceleration using a drip. Complications during labour and birth, increasing the chances of forceps, ventouse (vacuum cup) or an emergency Caesarean

MAT148 4 Section to help deliver your baby. About half of women with a BMI of over 40 are likely to need a Caesarean Section. Anaesthetic problems Your baby s shoulders becoming stuck during labour due to the increased size of your baby; risk of injury to the baby at delivery due to his/her increased size. Bleeding that is heavier than normal after your baby is born. How will I be cared for during my pregnancy? Women with a BMI of 35 or more will be referred for Consultant led care. This means you will come to Stepping Hill for some of your antenatal appointments. You may also have more frequent check-ups, in particular to monitor your blood pressure and to detect early signs of pre-eclampsia (a complication of pregnancy where the BP rises, there is protein in the urine and swelling develops). Pre-eclampsia is more common in women with a raised BMI. Your midwife will explain and discuss a healthy diet for pregnancy. You are not advised to lose weight during pregnancy but your midwife can help you keep your weight gain to a safe minimum. You will be given written information - the balance of good health food plate. It is very important to cut out sugary, fatty foods which have little or no nutritional value Your midwife will give you information about appropriate exercise. The advice for pregnant women is the same as the advice given to the population as a whole: 30 minutes of moderate exercise (e.g. walking, swimming) daily If you are not used to regular exercise, you should build up gradually. For example, start by walking for 15 minutes, 3 times a week and increase the length of time and frequency of your exercise over a period of weeks. You can discuss this with your midwife.

MAT148 5 Referrals If you smoke, we strongly advise you to stop as this will reduce the risk of complications during pregnancy, labour and afterwards. You will be offered support and a referral to the Stop Smoking Midwife. We will see you in clinic when you are about 28 and 34 weeks and consider extra scans to check your baby s growth. Women who have a BMI of 30 or more will be: Offered a glucose tolerance test (GTT) at 26 weeks. This is to check your body s ability to handle glucose in pregnancy and detect any tendency to diabetes. Referred to the Anaesthetist at 34 weeks, to discuss your particular needs and plan for labour and delivery. Assessment of your risk of developing a blood clot so you can be given the correct treatment before 36 weeks Scans Scanning the unborn baby of a woman with a high BMI can be more difficult, as much of the power of the ultrasound waves may be absorbed into the mother s tissues. The pictures obtained may therefore not be as clear as those from a woman with a lower BMI. This may mean a reduced ability to detect problems, for example at the 20 week scan.. More anomalies are missed because of poor scan quality. Additional scans may also be necessary to check your baby s growth or position, for the reasons explained above. Labour and birth We advise you to book to have your baby on Delivery Suite, where there is a Consultant Obstetrician (doctor specialising in complications of pregnancy and birth) available 24 hours a day to help if there are complications in your labour. We have specially designed beds and equipment available to help care for women with a higher BMI.

MAT148 6 There are some complications during labour and afterwards which occur more frequently if you have a raised BMI. We explain these below to help prepare you for what may happen if you do experience them. They do not happen to every woman. You may be offered compression stockings to wear plus medication to reduce your risk of having a blood clot. Shoulder dystocia involves your baby s shoulder getting stuck behind your pubic bone during the birth. This is an emergency and one of the reasons we advise you to have your baby on Delivery Suite, so the obstetric team is on hand to help. If your baby is born with the help of forceps or ventouse, or if you have a Caesarean, you tend to lose more than average amount of blood after the birth. Sometimes you may need a blood transfusion. If you have a Caesarean, forceps or ventouse delivery, we will encourage you to get up and moving as soon as possible to help reduce the risk of clots developing. It s therefore important that you ask for additional pain relief if you are uncomfortable. There s a slightly higher chance of getting a water infection (urine infection) or wound infection. Support from anaesthetic doctors If you need an anaesthetist during labour, it can be at a time when it is difficult to take in information and make decisions! While you are still pregnant, you will be given a leaflet which explains what having an epidural, a spinal or a general anaesthetic involves. Your appointment at the anaesthetic clinic at 34 weeks of pregnancy (for all women with a BMI of over 35) is a good opportunity to talk through any issues you have. We would encourage you to attend so that you are fully informed before your labour begins.

MAT148 7 Epidural pain relief If there is an increased risk of complications in your labour, you may decide to have an epidural for pain relief. If you need to have a Caesarean, the epidural can then be topped up. Sometimes an epidural is more difficult to place if your BMI is high, so again it is very important that you come to the anaesthetic clinic so that your particular needs can be discussed, and any questions answered. Pain relief for caesarean section In general, it is safer for you and your baby for you to be awake for the operation. You will be offered an epidural or a spinal anaesthetic, rather than a general anaesthetic, and you will be pain free. Your baby can be put skin-to-skin soon after birth and you can start breastfeeding sooner. With an epidural or spinal anaesthetic: There are less likely to be any breathing problems during or after the operation than with a general anaesthetic. You are awake when your baby is born. Your birthing partner can be present. Pain relief after the operation is better. The good pain relief provided by an epidural or spinal also means that you can be up and about faster. This reduces complications like blood clots and chest infections. What happens after the baby s birth In the short term, the most important aim of your care will be to prevent any of the problems described above. You will be assessed for your risk of developing blood clots. The higher your BMI, the greater your risk of having a blood clot, both during and after pregnancy. If your BMI is over 30 and you have another risk factor (for example you are aged over 35), you will

MAT148 8 be measured for and given compression ( TED ) stockings and advised to wear these for at least 6 weeks. After your baby s birth you may also be advised to have injections to help prevent blood clots by "thinning" the blood. All women who have emergency Caesarean Sections are given these injections. These blood-thinning injections are prescribed for at least 7 days and you will be shown how to self-administer the injections In the long term, losing weight after your baby has been born improves your overall health and significantly reduces the risk of developing: Problems in your next pregnancy Diabetes in the future. It s therefore important that you ask for help to do this. You can see your GP, Practice Nurse or Health Visitor after your pregnancy to make a plan to help you achieve this goal. Your Consultant Obstetrician may also feel it s appropriate to see you before your next pregnancy to discuss issues relating to your pregnancy and put a plan in place to help reduce risks in a future pregnancy. In the short term, the most important aim of your care will be to prevent any of the problems described above. Feel free to get in touch with us if you have any particular concerns or for any further information. You may contact Stepping Hill on 419 5291. Supervisors of midwives Need extra information, support or advice? Contact a Supervisor of Midwives by ringing the main switchboard at Stepping Hill Hospital: 0161 483 1010. A Supervisor of Midwives is available 24 hours a day. Supervisors are concerned with ensuring the safety and well-being of mother and baby and with the provision of high quality midwifery care.

MAT148 9 References: ACOG Committee Opinion No 315 Sep 2005: Obesity in Pregnancy BJOG: an international Journal of Obstetrics & Gynaecology June 2005, Vol. 112, pp. 768-772 Outcome of pregnancy in a woman with an increased BMI CMACE "Saving Mothers Lives" Report 2006 2008 CMACE/RCOG Joint Guideline on Management of Women with Obesity in Pregnancy, March 2010 Journal of Obstetrics & Gynaecology (2004) 190, 1091-7: Obesity, obstetric complications and caesarean delivery rate A population-based screening study NICE Antenatal care: routine care for the healthy pregnant woman, London: RCOG, 2008 NICE Diabetes in pregnancy, London: RCOG, 2008 NICE Hypertension in pregnancy, London: RCOG, August 2010 RCOG Green-Top Guideline No. 37. Reducing the risk of thrombosis and embolism during pregnancy and puerperium. London: RCOG, 2009 SIGN: Prophylaxis of thromboembolism: Pregnancy & the puerperium Our smoke free policy As per the smoke free law, smoking is not allowed by anyone anywhere on the hospital site. For further information, please read the patient information leaflet 'Policy on Smoke Free NHS Premises'.

MAT148 10 Produced by Stockport NHS Foundation Trust Review Date: September 2014 If you would like this leaflet in a different format, e.g. in large print, or on audiotape, or for people with learning disabilities, please contact PCS. Your local contact for more information is Patient and Customer Services at Poplar Suite, SHH, Tel: 0161 419 5678 or www.stockport.nhs.uk