Maternal Obesity and Pregnancy
Mood:  a-ok
This is my final paper i had to write for nursing school. I did an internship on a maternity floor at a local hospital and choose to write about Maternal Obesity and Pregnancy. I dont mean to offend anyone, this is all about articles i researched. I write about the results of some of those studies. Anyone can find this info on the web just like i did. This is my writing that i spent hours researching and writing, so i would greatly appreciate that it not be replicated.


Introduction

The prevalence of obesity is on the rise. Weight gain has become a hot topic lately. The percentage of Americans that are over weight continues to rise dramatically. Lately, news stories tend to focus on childhood obesity rising posing great risks for such young people. News also focuses on our increasingly sedentary lifestyle. Children tend to stay inside watching television and playing video games rather than going to play outside. As adults, our lifestyle has changed as well. We tend to have more desk jobs, eat out more frequently and pay visits to the famous drive thru windows. I have also noticed during my time spent at clinicals this past year, that there are many over weight nurses. I remember one of our first lectures telling us that we set examples for our patients by what we do and how we should strive for our own weight to be normal. I find it fascinating that a nurse can be overweight. With all the running around nurses do, I expect them to not have weight problems. I myself was hoping to lose weight during clinical, but unfortunately the opposite happened. I have theorized an explanation for this. With such tight time constraints, nurses might not make the best food choices and tend to choose quick, usually unhealthy food. Also, with the amount of stress put onto them, nurses might also eat emotionally which contribute to weight gain. Needless to say, obesity is an enormous problem in the United States of America.

My practicum was conducted at Delaware County Memorial Hospital in the maternal child health complex. This paper will discuss the complication of obesity on the pregnant woman as well as the newborn child. I will discuss how maternal obesity has effects on labor and delivery, lactation performance, cost and maternal and neonatal outcomes. I will then discuss what I have witnessed in the hospital setting pertaining to maternal obesity.

Clinical Relevance

Maternal obesity has a great deal of relevance. There are many complications of maternal obesity for the mother and for the child. It has great relevance for healthcare workers as well. It is our responsibility to educate our patients on the risk of certain behaviors. In this case, the risk not only lies on the mother, but the unborn child as well. It is also our responsibility to care for the complications that arise due to maternal obesity. These complications accrue costs that fall on to the insurance companies to pay.

Our greatest weapon in battling obesity is education. Specifically, to battle maternal obesity, we need to catch potential mothers before they conceive. Education should start then about complications that could arise if they conceive. I did not witness first hand preconception counseling of overweight women, but from the amount of publicity this topic receives and the amount of journal articles written I can tell that not much is done to counsel overweight mothers to be. The most vital piece of information that best illustrates obesity of a person is the body mass index. This will be referred to frequently throughout this paper.

BMI is calculated by using your height and weight. Your BMI is then grouped by category.

BMI Categories:
Underweight - =/< 18.5
Normal Weight - 18.5 - 24.9
Overweight - 25 !V 29.9
Obesity - =/> 30

Review of Literature

I found 6 articles that researched maternal weight and outcomes associated with both mother and child.

First is the study Maternal Pre-pregnancy Overweight and Obesity and the Pattern of Labor Progression in Term Nulliparous Women by Vahratian, Zhang, Troendle, Savitz and Siega-Riz it was shown that the median duration of labor from 4 to 10 cm was significantly longer for both overweight and obese women, compared with normal-weight women. For over weight women the duration of labor was 7.5 hours, for obese women it was 7.9 hours and for normal-weight women the length was 6.2. The prolonged labor for overweight women concentrated slower at 4-6 centimeter and for obese women it was before 7 centimeters.

The second study titled Maternal obesity: effects on labor and delivery: Excluding other diseases that might modify obstetrical management by Hamon, Fanello, Catala and Parot showed effects on labor, delivery, afterbirth, and neonatal status of maternal obesity. They stated that !?Pregnancy in obese women must be considered to be "at risk", regardless of any complications of obesity.!? They also cited many complications due to maternal obesity. Post-term deliveries were higher among obese women, as well as more frequent inductions, and the duration of the first phase of labor was longer. Cesarean section was seven times higher leading to less frequent spontaneous vaginal deliveries and lack of progress in dilation. The mean weight of the newborns was also significantly higher in obese patients.

Third was the article The Effect of Pre-Pregnancy Body Mass Index, Gestational Weight Gain on Pregnancy Outcomes by Yekta, Porali and Aiatollahi. They studied neonatal birth weight. They broke down their group based on maternal weight in terms of low with a BMI below 19.8 and above 30. For the group having a BMI below 19.8, the median weight of the newborn was 6 pounds 8 ounces and had the least rate of Caesarean sections. For the group having a BMI above 30, the median weight of the newborn was 7 pounds 6 ounces and had the highest incidents of Caesarean.

The fourth study was Maternal and neonatal outcomes in pre-gestational and gestational diabetes mellitus, and the influence of maternal obesity and weight gain by Ray, Vermeulen, Shapiro and Kenshole. They studied pregnancy outcomes in pregnant women who had gestational diabetes mellitus and women with pre-gestational diabetes mellitus. They found that the women with pre-gestational diabetes mellitus were at increased risk (compared to those with gestational diabetes mellitus) for Caesarean delivery, shoulder dystocia or cephalopelvic disproportion, and gestational hypertension or toxemia. The offspring of these women were also at increased risk for admission to the neonatal intensive care unit, large-for-gestational-age birth weight, and preterm birth before 37 weeks. Another aspect they look at was the admission rate of the newborn into the NICU. Infants of mothers with gestational diabetes mellitus were admitted into the NICU at the rate of 46%. Infants of mothers with pre-gestational diabetes mellitus were admitted into the NICU at a rate of 84%. The risk for NICU admission was even more distinct among the offspring of obese mothers and was independent of gestational age.

Fifth is the article Obesity and pregnancy: complications and cost by Galtier-Dereure, Boegner and Bringer. They state that !?The prevalence of obesity is currently rising in developed countries, making pregravid overweight one of the most common high-risk obstetric situations. Even moderate overweight is a risk factor for gestational diabetes and hypertensive disorders of pregnancy, and the risk is higher in subjects with overt obesity.!? Mothers who are overweight have a higher risk of cesarean deliveries and a higher incidence of anesthetic and postoperative complications in these deliveries. Low Apgar scores, macrosomia, and neural tube defects are more frequent in infants of obese mothers than in infants of normal-weight mothers. Maternal obesity also increases perinatal mortality. Long-term complications include worsening of maternal obesity and development of obesity in the infant. The average cost of hospital prenatal and postnatal care is higher for overweight mothers than for normal-weight mothers. Women whose pre-pregnant BMI that was more than 29 stayed in the hospital an average of 4.43 days longer than women whose BMI was lower. The infants of overweight mothers also require admission to the NICU more often than do infants of normal-weight mothers. The article also stresses the importance of preconception counseling, careful prenatal management, tight monitoring of weight gain, and long-term follow-up.

Lastly is the article Is Maternal Obesity a Cause of Poor Lactation Performance? By Lovelady. She refers to an study by Rasmussen and Kjolhede that investigated the role that hormones may play in the relationship between obesity and lactation initiation. They hypothesized that obese women may have higher levels of progesterone than normal-weight women due to the concentration of this hormone in adipose tissue. Normally, progesterone concentrations decline immediately postpartum, which signals the onset of milk secretion by the mammary gland. In addition, they hypothesized that obese women may have differences in insulin concentrations that may affect lactogenesis.

Comparison

While at DCMH I saw a couple of women who would fall into the overweight and obese category. One woman was having her fourth child. This woman had a BMI over 30. During labor, the baby!|s shoulder was stuck. We thought that this would be a major obstacle. The nurse I was following was so concerned she rang the emergency button to bring in other nurses. The doctor, fortunately, was able to maneuver the baby to deliver the shoulder. Even hours after delivery, the baby was not able to move her arm. She was able to grasp with her hand. The nurses assured me that this was a good sign. The baby will need to be followed by her pediatrician.

Another obese mother had a caesarian section. The baby who weight 7 pounds 7 ounces was fine and had no complications except for a blood sugar of 46. The mom on the other hand complained for about a day of intense pain and was not responding to the pain medication as well as the doctors hoped.

I saw other mothers who were more slender who did fine tolerating pain after a c-section. Another mother who would be classified as obese was all set to be discharged. The baby, however, would not be going home. He was doing fine, until that morning, and was admitted into the NICU due to tachycardia.

There was also a young woman who was obese and had a third degree tear as well as a peri-urethra tear. For these mothers, I do know that none of them gain more than 20 pounds during pregnancy. Of course I did not witness prenatal visits with overweight or obese mothers to be. I do not know what kind of counseling the doctors gave to them.

Research

From what a witnesses, research was not active in the maternal child complex. According to their website, !?Delaware County Memorial Hospital supports an active research program. While most of our research is in the areas of cancer prevention and treatment, we also take part in some studies from other specialties.!? DCMH!|s Institutional Review Board approves all research done at or through the h hospital. They are a group of people who review research studies to protect the rights of the subjects. This Committee is composed of Physicians, a Pharmacist, a Social Worker, a Nurse, a Minister, a DCMH Board member, and a member of the local community who is not an employee of DCMH.

Recommendations for clinical practice

First, let us take a look at how the extra weight of pregnancy is divided.
This is an approximate breakdown of the extra weight of pregnancy:

Baby 7 to 8 pounds
Larger breasts 1 to 3 pounds
Larger uterus 2 pounds
Placenta 1 to 2 pounds
Amniotic fluid 2 pounds
Increased blood volume 3 to 4 pounds
Increased fluid volume 2 to 3 pounds
Fat stores 6 to 8 pounds
Total 24 to 32 pounds

Second, I would like to review some recommendations that are already in use.
Below is recommended total weight gain during pregnancy. They are divided into categories based on pre-pregnancy BMI.

Pre-pregnancy BMI
Recommended Total Weight Gain

Underweight - =/< 18.5 28!V40 lbs
Normal Weight - 18.5 - 24.9 25!V35 lbs
Overweight - 25 - 29.9 15!V25 lbs
Obesity - =/> 30 15 lbs


There are some general recommendations that we can encourage our patients, not just overweight and obese patients, to promote a healthy pregnancy. We can inform and council women about the health risks associated with overweight and obesity. Nurses can encourage a healthy diet. Diets that restrict particular food groups are discouraged, especially during pregnancy.

Screen for hypertension and diabetes mellitus in women who are at risk and this includes overweight women and obese women. We also need to encourage women to consume adequate folic acid, iron and calcium and to get regular exercise.

The American college of obstetricians and gynecologists also has recommendations regarding exercise. In the absence of either medical or obstetric complications, more than 30 minutes of moderate exercise on most, if not all, days of the week is recommended. Exercise may be beneficial in primary prevention of gestational diabetes
Exercise may also be !?a helpful adjunctive therapy!? for gestational diabetes mellitus.

We need to Discuss recommended weight gain during pregnancy and keep a record of weight from the start. Also, there is a need to council women to return to a healthy weight after pregnancy. As nurses we should also encourage breast feeding. This not only is healthy for the baby, but also helps to shrink the uterus and it burn calories.

ACOG also offers guidelines for women who are pregnant or may become pregnant and are obese. Record height and weight at initial prenatal visit to calculate BMI. Discuss guidelines for recommended weight gain during pregnancy.

Preconception counseling is important to educate patients about maternal and fetal risks of obesity in pregnancy. Offer nutrition consultation and encourage an exercise program to the patients. We should Consider screening for gestational diabetes during the first trimester, and repeat screening later in pregnancy if initial results are negative.

You may also want to conduct an anesthesiology consultation before delivery because of increased risk of emergent cesarean delivery and anesthetic complications such as difficult epidural and spinal placement.

We also need to take into consideration the growing number of women of childbearing age who have had bariatric surgery. These women should also be assessed and possibly take supplements of vitamin B12, folate, iron and calcium. We might also want to implement the use of graduated compression stockings, hydration, and early mobilization during and after cesarean delivery.

Continued nutritional counseling and encourage exercise program after delivery is also necessary and recommend consultation with weight loss specialists before attempting another pregnancy.

Conclusion

It is our responsibility to council over weight and obese patients. This is most important for mother to be. The counseling should begin before conception. Women need to be aware of these risks they pose to themselves and their child. I am in nursing school and did not realize all the complications that can arise from maternal obesity. I am sure that obese women do not realize the ramifications either. It is our duty to serve our patients and give them all necessary information. In closing, I will end with a quote from Galtier-Dereure et that sums up the responsibility of healthcare workers. !?Preconception counseling, careful prenatal management, tight monitoring of weight gain, and long-term follow-up could minimize the social and economic consequences of pregnancies in overweight women.!?


BIBLIOGRAPHY

Galtier-Dereure,Florence, Boegner,Catherine, Bringer,Jacques. (2000) Obesity and
pregnancy: complications and cost. American Journal of Clinical Nutrition, 71,
1242S-1248.


Hamon, C, Fanello, S, Catala, L, Parot, E. (2005) Maternal obesity: effects on labor and
delivery: Excluding other diseases that might modify obstetrical management. J
Gynecol Obstet Biol Reprod (Paris), 2, 109-14.


Lovelady, Cheryl A. (2005) Is Maternal Obesity a Cause of Poor Lactation Performance?
Nutrition Reviews, Oct, 352-355.


Ray, JG, Vermeulen, MJ, Shapiro, JL, Kenshole, AB. (2001) Maternal and
neonatal outcomes in pregestational and gestational diabetes mellitus, and the influence of maternal obesity and weight gain. QJM: An International Journal of Medicine, 94, 347-356.


Vahratian, Anjel, Zhang, Jun, Troendle, James F. , Savitz, David A., Siega-Riz, Anna
Maria. (2004).Maternal Prepregnancy Overweight and Obesity and the
Pattern of Labor Progression in Term Nulliparous Women. Obstetrics &
Gynecology, 104, 943-951

Yekta, Zahra, Porali, Reza , Aiatollahi, Hale. (1999) Effect of prepregnancy body mass index and gestational weight gain on birth weight. The Internet Journal of Health, 49, 23- 5.
BMI Chart Retrived from http://www.consumer.gov/weightloss/bmi.htm.
http://www.marchofdimes.com/files/MP_MaternalObesity040605.pdf

http://www.mayoclinic.com/health/pregnancy-weight-gain/PR00111

http://www.crozer.org/CKHS/Left+Nav/Hospitals+and+Facilities/Delaware+County+Memorial+Hospital/Research/

http://www.acog.org/



http://nhlbisupport.com/bmi/
Vahratian, Anjel, Zhang, Jun, Troendle, James F. , Savitz, David A., Siega-Riz, Anna Maria. (2004)

Hamon C, Fanello S, Catala L, Parot E. (2005)

Hamon C, Fanello S, Catala L, Parot E. (2005)

Yekta, Zahra, Porali, Reza , Aiatollahi, Hale. (1999)

Ray, JG, Vermeulen, MJ, Shapiro, JL, Kenshole, AB. (2001)

Galtier-Dereure,Florence, Boegner,Catherine, Bringer,Jacques. (2000)

Galtier-Dereure,Florence, Boegner,Catherine, Bringer,Jacques. (2000)

Lovelady, Cheryl A. (2005)

http://www.crozer.org/CKHS/Left+Nav/Hospitals+and+Facilities/Delaware+County+Memorial+Hospital/Research/

http://www.crozer.org/CKHS/Left+Nav/Hospitals+and+Facilities/Delaware+County+Memorial+Hospital/Research/

http://www.mayoclinic.com/health/pregnancy-weight-gain/PR00111

http://www.consumer.gov/weightloss/bmi.htm.

http://www.marchofdimes.com/files/MP_MaternalObesity040605.pdf

http://www.acog.org/

Galtier-Dereure,Florence, Boegner,Catherine, Bringer,Jacques. (2000)