High BMI pregnancy and birth, with Alice Keely

Why is so much importance placed on how much you weigh in pregnancy? Is a mother with over 30 BMI really at a high risk of complications in birth?

This week, I’m speaking to Alice Keely, the Heavyweight Midwife, about the stigma attached to plus size parents, what to expect in pregnancy and labour if you’ve been labelled high risk, and how to approach interactions with healthcare professionals so that you feel more cared for and in control.

Find more from Alice at www.theheavyweightmidwife.com

Join her Facebook group at www.facebook.com/HealthyPregnancyAtAnySize

Please subscribe, rate and review, so we can get this vital info to as many parents-to-be as we can!

______________________

This episode is sponsored by

iCandy

• Visit  https://discover.icandyworld.com/birth-ed to shop my favourite pushchairs!
• Follow iCandy on IG and/or TikTok for helpful advice and ‘hints & tips’ too!

https://www.tiktok.com/@icandyworld

https://www.instagram.com/icandyworlduk/

_____________________________

Hear More from Birth-ed

Join the Birth-ed Online Course https://birth-ed.co.uk/online-course-2

Join the BUMP CLUB FREE https://birth-ed.co.uk/bump-club

Follow us on Instagram https://www.instagram.com/birth_ed/

Transcript

Megan Rossiter  

Ad - This episode is brought to you in partnership with iCandy. I've been using our iCandy peach pushchair almost daily for the last seven years and counting. And I've really put their five year warranty to the test using it for both my boys on muddy walks in aeroplane holes in and out of my car boot and aside from being completely filthy, my fault not theirs. It's still going strong. I can't wait to tell you more about my experience with eye candy later in the show. 

Megan Rossiter  

You're listening to the Birth-ed podcast. I'm your host and founder of Birth-ed, Megan Rossiter. If you're looking for the evidence, the nuance the detail that's missing from your antenatal appointment, then I've got your back. The Birth-ed podcast is here to help you sort the facts from the advertising the instinct from the influences and the information you're looking for from the white noise of the internet. I hope you've got a cup of tea in hand and a notepad at the ready. Let's dive in. 

Megan Rossiter  

Hi, everybody. Welcome back to the Birth-ed podcast. Today I am delighted to be joined by Alice Keely. Alice is a UK registered midwife of over 20 years, with experience working in complex care teams home birth teams teaching Hypno birthing and everything in between. She is also a university lecturer and holds her PhD in women's experience of a plus size pregnancy care. Her published research was used by the Royal College of Obstetricians and Gynaecologists in their latest UK plus sized pregnancy care guidelines. Alice is the founder of the heavyweight midwife, where she teaches you to understand and celebrate your unique pregnant body, empowering you to understand what your body actually does during pregnancy and birth. But also to understand evidence, medical guidelines, your choices and how to make decisions, and how to ask for what you want. Having seen years of impersonal rules based care offered to women, Alice has made it her mission to change this through empowering you to advocate for yourself in pregnancy. So there really was no greater guest to have on the birth Ed podcast. As you know, this is entirely the ethos that we work from. And hopefully it's going to be very insightful hour ahead. And so today's episode is looking at what might be described as a pregnancy for somebody with a high BMI. And we're going to break all of this down and look at all of the research and things that you might be offered. So Alice, thank you so much for joining me.

Alice Keely  

Thank you for and hope I can live up to that introduction. My goodness. I hope we can break everything down and get really insightful. Yeah, I think I was just saying to you before we came on that we could chat all afternoon, probably on the kind of stuff that I know your followers and your clients have been asking you about. So yeah, I really hope that we can have spent some useful time together, there is a lot to talk about.

Megan Rossiter 

Yeah, I mean, we will we will get as much crammed into an hour as we possibly can. But I will share at the end all of the links to Alice's services and information. So we can even go deeper, deeper, deeper as we go. Now, Alice, I've called this podcast episode, high BMI, as this is the label that many women will be given as they enter their kind of pregnancy care. But I thought a helpful place to start might actually be explaining what BMI is, and maybe kind of exploring why this might actually be a problematic measure to be used on kind of individual women as a measure of their health. So do you do you mind breaking that down for us?

Alice Keely 

No, I'll certainly do my best. So yeah, so BMI is kind of always a lot of things. It's kind of, so it's a clinical category, isn't it? But it's also it has a different meaning in, in our sort of social world. So it's, it's kind of it's loaded with judgement. And it's, it's full of problems. And it's sort of like, I think, a little bit of a red herring as well in some ways. Because, I mean, what it does is it categorises women into something that is also a really big problem, which is these kinds of binary high risk and low risk categories. So straightaway, it's opening up a can of worms. For us, it is a clinical category, that's that's sort of got a controversial history. It stands for body mass index for anyone who doesn't know, and it is a calculation that's made after measuring someone's height and weight. And it's got quite a broad, broad ranges. So kind of what what is what is termed as a normal in inverted commas, BMI range, or any other BMI range is quite quite a sort of broad. It's got broad numbers within it. So there's, there's quite a range of height and weight, you can be within each within each category or section. But nevertheless, it's it's it's full of problems in terms of the fact that it is used in the context of maternity pregnancy care as an indicator of health. So it's sort of oversimplified. It was invented to look at patterns of health amongst, amongst other things across populations. So it doesn't really tell you anything about your individual health. It was also developed, obviously, for population health, on male populations. So it's very far removed from an individual pregnant woman who's kind of thinking about our own our own health and well being at the start of during pregnancy. And I think it's argued by health professionals that, you know, nobody says it's perfect, but it's the best, it's the best that we've got. And it certainly might be used as an indicator. But I think on the ground in individual consultations within clinics every day of the week, it is used to kind of make judgments about people's health and well being and it's just totally inappropriate for we I mean, we could probably do a podcast on the on the BMI. But that is that is that is an overview

Megan Rossiter  

It is that yeah, absolutely. And I think that I think what you've started to touch on, there will be a theme that goes on throughout all of the conversation that we're about to have is that, you know, once somebody ticks this box on a piece of paper, or gets a specific number attached to them, if that number is higher than the box wants it to be, suddenly they can feel like this forms, they just become like a walking tick box, they become a walking risk factor. And that forms the kind of basis of every conversation that they have their forward, and that is definitely something that we're going to touch on kind of as we go.

Alice Keely  

It's something that it just labels somebody based on this one calculation and is obviously just, you know, reducing someone's house to a number doesn't tell you anything. So it's kind of it's, it's a bit of a symbol of you know, everything that's wrong with the way that healthcare is arranged. You know, I always shy away from blaming kind of individual midwives, or doctors, they were really fabulous ones and they were really rubbish ones, in terms of their approach to these things, you know, the organisation of stuff is, is is definitely a lot of where the handle of the problems lie. Now, the brilliant practitioners are operating often within systems that are really, really restrictive and difficult. But just on that point about, you know, you can make a really fit, and you can have a BMI, you know, a high BMI, and you can be put into that category. And I think that's true. But I also think that, you know, as a population, what I want to deal with is kind of, you know, a really, I'm keen to to counteract, you know, to promote positivity for everybody. And the simple fact is that as a population, our sort of collective BMI and our size is going up and we get you know, we are more rovers will be labelled obese in inverted commas, by health care, and more of us are carrying more body fat. There's a kind of hidden failure of healthcare to acknowledge loads of issues around how we could help people who are carrying extra weight, and how can help them with their well being not sticking them on the scales and giving them a BMI, but kind of acknowledging and trying to neutralise stigma and trying to actually help them individually with whatever is important to them helping them to feel good during their pregnancies.

Megan Rossiter  Yeah, absolutely. And so once somebody has ticked this box, what does that mean for their antenatal care? So if they were to know absolutely nothing about their rights and choices at all, what are the kind of recommendations that they might face that they might not have otherwise have done if they hadn't ticked this box just as an as a kind of aside From the the yes, this the stigma and the kind of emotional care now might be very different. What's the difference in the kind of on paper care?

Alice Keely  

So let's so let's say that somebody goes along to their antenatal, they're first booking an appointment, you know, and I know that lots of women who thinks that maybe they're overweight, they feel worried about going along to that first appointment, and there's like a booking an appointment, so he can take that hypothetical scenario, what they really need is a lot of reassurance with a midwife that and what they often get is a kind of big list of things that they might get offered or recommended because of their BMI. So, as a quick kind of summary, the cuts are the sort of crude cut offs with your BMI, the BMI ranges, and all of this is, is in inverted commas that you might have, it's around about BMI, BMI 19 to 25 is considered normal 25 to 30, is considered overweight. And above that 13 above is considered obese, very much in inverted commas. And that's another word that could fill a series of podcasts. So above a BMI of 30. There are various recommendations that you may get from your midwife. So one, one thing that will have big implications for your care is that you might be recommended to If your BMI as well 35, you might be recommended to see a consultant obstetrician during your pregnancy. So we'll come back to that in a sec. What you might be recommended also, there's there kind of flowcharts and algorithms around things like whether or not you're recommended to take a low dose of aspirin during your pregnancy. So aspirin is thought to lower the risks of developing preeclampsia in pregnancy. And a raise BMI across a population of women with raised BMI as has been shown to increase the chances a bit of developing preeclampsia. Unfortunately, preeclampsia is a is a relatively common complication across all pregnancies. So and what happened is that your health care provider will look at a should look at a sort of flowchart of different risk factors for that, and they might recommend you to take aspirin. So that's that's an explainer for that, but ask questions as to kind of why that's being recommended. So you'll also be recommended to take a higher dose of folic acid possibly depending on what your BMI is calculated as, and that is recommended from before you get pregnant. So if you as with anybody, if you're trying to conceive, you're recommended to take folic acid. And you'll be you'll be recommended to take an increased dose If your BMI is raised. Now, that is to help to prevent neural tube defects. So the most common of those is Spinal Bifida. Now to put that in context, preeclampsia that, unfortunately, is relatively common. It affects around about one in 20 pregnancies worldwide, spinal bifida is extremely rare. So all these things, you know, you probably wouldn't even get that impression from things that from these things being discussed with you in most of your appointments. So I'm always really keen that you get the information that you need. And you you know, how to make the right decisions for your health and your baby. But also that you're reassured about how you get that in context, it's not just your high risk. So therefore this isn't this, that you get that reassurance. So an increased dose will be would be recommended. This is all according to the Royal College of Obstetricians and Gynaecologists national guidance. And that's what you know, that's what's being followed, it's easy to recommend to you. 

Megan Rossiter  something that I really like about the work that you do in the work that you share, is that it? It does put everything into context with the reassurance that the vast vast majority of people who tick this high BMI box will go on to have a healthy pregnancy and birth and that these things are, you know, you we talked a little bit about the kind of the emotional care that you're getting, and the way that you're potentially now failing. And because of this, this risk back to that has kind of been ticked, it suddenly feels like that's the only conversation it's like, well, now you've got a risk of this and you've got a risk of that and you can walk around being like oh my god, I'm like a ticking time bomb like waiting to go off. Yeah, but actually the chances are for the majority of people, it's going to be a healthy.

Alice Keely  

Yeah. But and I'm sure we'll come on to this in actual fact, the way that care is provided sort of makes these complications, particularly in terms of when it comes to actually gave birth and inductions and etc, etc. You know, ironically or not we, we as a system and sacrifices make those things more likely to happen. So you know that by discussing, but by by emphasising this this high risk. And I see on that, you know, seeing it on on the ground all the time, because I'm teaching student midwives, I know how things happen in practice, I've worked in, I've worked in the NHS for 20 years. So I, you know, I know, I know how much people learn and how much they understand in general. You know, there are, as I say, there are some really brilliant practitioners out there. And I wanted to talk as well about kind of what your listeners can do in terms of their, how they can be positive in terms of their expectations. But just to Bob back, as I said to you, with AD, we'll just jump around, and please make me go back in the end. 

Megan Rossiter  

That's fine!

Alice Keely  

Just to go back to what to expect if you're so if you are getting if this is your first appointment going along to a booking appointment, you will probably be recommended to have a glucose tolerance test a little bit later on in your pregnancy. So when they're tested earlier, for diabetes, this is a test for diabetes, specifically gestational diabetes, so diabetes that develops as a result of being pregnant, because unfortunately, pregnancy does increase his risk of developing diabetes, it's, it is due to hormonal changes in pregnancy. So you might be tested early in pregnancy. But that would only be because it's to kind of exclude whether or not to detect whether or not you already had diabetes. So diabetes, as a result of pregnancy only develops really after 20 weeks. So that's when you would get your what's called a glucose tolerance test. And you might even have a recommendation to have more than one some people, some people's characters well, except the don't stay till dipo. 

Megan Rossiter  

I know. You must do. Yeah. 

Alice Keely  

So again, it's a really bad. Gestational Diabetes is a really, really complicated one. But it's a nice example, that I, when you're talking about reassurance that I use quite a lot to reassure women aren't gestational diabetes, it is the complication of pregnancy, that being plus size kind of increases the chances of vermin, because if you're looking at kind of crude analysis of across populations, you know, it's there's no doubt that statistically, your chances are increased, although it is something that pregnancy causes due to hormonal changes is very, very nasty in complicated condition. But again, you get this sort of high risk, high risk, high risk, and everyone's wanting to test some people every time they walk in the door, all plus size women, and depending on where you get your stats from about 80 to 90% of plus size, women will not get gestational diabetes. So even despite that, that increased chance, that's what should be emphasised to you, you know, we want to offer you this, this test, it's important to pick up diabetes if it does occur. And also you know, that most people that develop diabetes, it's a spectrum, there are loads and loads of ways of staying healthy with it. And you know, not seeing it as something that's definitely going to negatively affect either baby's growth or your health or etc, etc. is low loads of positive stuff around it. That could and should be emphasised. So you're so yeah, so you'll have a back and have a gestational diabetes and text recommended. And one thing that confuses a lot of women. Yeah, so a lot of lot sizes, women have told me over the year, so the ghost scene obstetrician, which is kind of nerve wracking, because that's a doctor, you know, a supremacy doctor, that women with complications get referred to. And then when they go along to that appointment for many of them, you know, nothing really happens. And they're like, Oh, what was that for? And it's, it's because it's kind of the sort of ticking a high risk box because of their BMI. But actually, their pregnancy isn't complicated. So that's another mantra is, is your BMI, being plus size, whatever it is that your perfect health professional, or you might call it, it's a consideration for you for your care and for your pregnancy. It's not a complication itself. And it gets treated as such. So often, you know, women will go along with what was the point of that? And really, it's just a consultant kind of is going to have a look and see if there are complications in your pregnancy and your health and for most people, their answers like know that they're sort of they're sort of just casting their eye over your your maternity notes and asking you some questions. Just that's just so you can expect that to have that might happen that that the midwife will kind of probably the the guidance in terms of what your your BMI is calculated as one tip I would just I would just say as well because for loads of people and this is really not acknowledged Each I think I referred to this a little bit earlier on, is this kind of oh, just just pop on the scales, and we'll calculate your BMI, you know, pumping on the scales for a lot of people is a massively problematic thing to do. There are so many people who have extremely complex, but you know, I think probably, I'd argue everyone's got a complex relationship with their own body. And lots of people, you know, they don't want to be weighed, they might have a history, or history of eating disorder or an active eating disorder. It's treated as unproblematic as pop onto the scales. And it's really, that's really, it's really, it's dangerous. I think it's just it's, you know, it's really wrong, that we treat it as a kind of simple test is often done in public, you know, so if it's often you get like a healthcare system that might do some way. So please, when you bid if you if you're going along to your booking appointment, and I would anticipate, they might ask you what you weigh, but commonly, you would be asked to be weighed, you don't have to be weighed, you can ask for a personalised approach. So you don't need to be weighed. In you know, nothing in your pregnancy care is compulsory at all, nothing in health carriers, if you want to, you can ask to be waived, but they don't tell you what you were and tell you what your BMI calculation is, you know, you can, I would always encourage you to expect really kind respectful treatment when you go along to any appointment. But to go up, go there with your priorities in mind. So, if you're worried about being weighed, or about your weight, or about how you'll be treated, then as far as you can, I would really encourage you to write that down, take somebody with you that can support you, and just tell that person when you arrive. These are my concerns. I think people wait too much they think they think that the healthcare professionals it is in control in charge, in fact, that as well as these sort of more invasive, more kind of complex clinical tests that might be done. There is this initial calculation of your BMI. And that's, you know that right from the off, that's something that you can be thinking about, you know, do I want my What are my options around that? What's What's that for? 

Megan Rossiter  

You know, and once that's been offered the first time, which when when we're talking about booking an appointment, that's usually somewhere around kind of eight to 10 weeks, isn't it? And should this ever happen? Again, should women be asked if they can be weighed at any other point in their pregnancy? 

Alice Keely  

Yeah, this is a really interesting one, because I see that what I see is that vastly different things happen throughout the UK and elsewhere. I mean, I know in the US that's, there's a lot of there's a lot of weighing and measuring throughout, throughout pregnancy. And I would challenge any, any doctor or midwife to tell me why they're doing that. Why are you doing that? Why are you offering that? So, you know, obviously there is this there is this very crude measure of a BMI that's calculated at the beginning of pregnancy. And that's, as you know, as we've talked about making that it's very problematic to, to make some sort of sweeping judgement about someone's health, or prognosis, pregnancy progress based on this number. But it's something that you can you can offer. And you can argue that it might give you a bit, it might give you a broad idea about some things that you might offer, and you can offer it to people. And then you know, people women can decide whether or not they want it to have that BMI calculation. Years ago, I think probably around the time that I started training, so I was training in the 1990s. That sort of just done away with weighing people throughout pregnancy, because they used to do that to reassure themselves that babies were growing adequately. So you know, there are other ways in accurate ways to measure more high tech ways via scanning to measure growth. But they also realised that around that time that it was really not an accurate way to measure, reassure about a baby's growth and stop doing that. So traditionally, what we did was we were way or calculating a BMI, the beginning of pregnancy. And it's not the guidelines to where to weigh women or to offer to weigh women throughout pregnancy at all. But nevertheless, I do know that it happens.

Megan Rossiter  

I know where I where I trained. And I did not question this at the time. And now I look back and it's absolutely outrageous. Women were coming in labour and the first thing they were asked to do was to stand on the scales. And this was only like less than 20 years ago. And like people with uncomplicated pregnancies, you'd be like sent to go and get scales to bring them into the room for them to go even on like a birth centre stand on the scales and like now I'm like this seems insane. And I've heard from women who have had their BMI recalculated at 30 something 40 Something weeks of pregnancy. Yeah. And you're like hang on, you've got a whole baby water placenta, of course you Of course, your BMI is going to be higher at the end of pregnancy than it would have been at the beginning of pregnancy. 

Alice Keely  

Yeah, I mean, this, it's, yeah, it's crap. It's crackers, crackers. So the the national guidelines are and and I'm always mindful that when I read these guidelines, so And if anybody wants to look at the guidelines, they're all freely available. So the, the Royal College of Obstetricians and Gynaecologists, the ICLG, their guidelines for all sorts of complications, complex care, during pregnancy, they're all freely available on the internet, they're all called green top guidelines, a warning that they do, the guidelines do contain the O word in their, in their in the title, if you want to look up, I know, it's actually that the latest version, which is five years old now talks about care of women with obesity, in pregnancy, that's what's called, whereas the previous incarnation was management. So they've, they've sort of that's their, that's their lip service have changed. And then, but it does, so in there, it says something about May. So there's, you know, whenever they say sort of May or might, or you might want to do this, might want to consider this, the kind of just isn't very strong evidence around your other don't really know. And I like the green top guidelines, because they do really clearly Grey is the evidence that they use. And it's interesting that they've got about three out of all the kind of dozens and dozens of recommendations that they've got in there, which are interesting to read, and they you know, nothing is is sort of, you know, these are experts, and I know some of them. And they're brilliant in their field, you know, and when you got when you got a complication, and you need help you flip and well, you weren't and I was one of those people on your side, you know, you want them around, but and they carefully grade the you know, they look at evidence very scientifically and in a very sort of medicalized way. And that gets extrapolated into sort of popular in the internet world, in sometimes in in different and in difficult and inaccurate ways. So they've got out of there dozens and dozens of recommendations, they've got like three that's got the highest quality, you know, systematic review and meta analysis, absolutely. tonnes and tonnes of evidence for this recommendation. And then the guy's got lots of stuff that's, you know, it's, it's, it's, it's, there's some evidence, and some of its just to the best of our expertise, we'd recommend this. So what they recommend is that you might want to consider weighing somebody at I think it's either 36 or 38 weeks, if you think that they're very, very plus sized. And if you think that there might be things like drug dosages to consider, and things like equipment, so blood pressure, cuffs, things like that. So think so it might that they might want to waste them. And I would say, there's a small number of drug dosages that that might apply to it, it's certainly not going to be justifying what you were talking about, like this, wheeling out the scales when everyone logs into the hospital. And I just, I mean, what it called, what it sort of prompts me to caution people to do is just take a deep breath and ask like, well, so why is this what so why is it that you're recommending this? Or why do you want to do this because, you know, often it's good to not be feeling to make to be saying no, or making a decision on something based on defensiveness or fear or, you know, the best place to be is in a position of mutual trust and respect within a conversation or interaction that you're having. That you know that you you've been totally open about what's being offered, what your concerns are, they come into a decision that takes on board their expertise, and also kind of your wishes and your priorities. So the folic acid example that was going to refer back to that's a nice example because they've across the world they've looked at, they think that if you plus size, it's it's going to be more beneficial to take a higher dose of folic acid is an enormously inflated dose. But they acknowledge that they don't really know what the best dose is. And that's quite a nice example of honesty on the on the part of the medical community. You know, from the evidence, it looks like it might be better if you plus those to take a higher dose of folic acid. But we don't we can't see from these, these trials. This research what what the best steps is, but you know, so we're going for this, we think five milligrammes is a good, a good dose. So, you will probably be recommended to have growth scams as well, if you have a BMI above 35. That's the the national guidelines in the UK. So the recommendation is that measuring for a baby's growth, so adequate growth is really really important during pregnancy, because the main reason being in terms of restricted growth so that, you know, someone may get problems with the placental growth and function and obviously that has repercussions for babies. And that can happen sort of most commonly If preeclampsia happens, so there are really important reasons why scans are helpful. And, and they're not perfect by any means. And they also can help to measure whether the babies are growing a bit bigger. And that's often in the presence of gestational diabetes or diet, but other diabetes, which is also important to detect, but it's more difficult to take scans of, they're really good at detecting smaller babies, and because they can look at blood flow and things like that. So they don't just look at the growth and the measurements, those are things that there's some margin for error. And it's difficult to make predictions. So they're problematic, you know, they're not perfect, and they are sort of subject to user bias in a way. So some, some operators might think that they see a bigger woman, and they think a bigger baby immediately. And that's, again, that's just not, that isn't at all, a causation. It's not, it's not something that you should expect to happen at all. You will probably be offered a growth scan at around about 28 weeks and around about 34 weeks. And that's because the guidelines say that measuring with a tape measure on your tummy is less accurate if your tummy is bigger if you're plus size. So a lot of women like this because they get extra scans. And you know, scans are, I think they're sort of they're mixed by the complicated, I think they cause anxiety. And they give reassurance. So anxiety before the fact. 

Alice Keely  

And they're also a little bit that what a lot of people find themselves unexpectedly in this scenario, of, Oh, this 28 week scan was measuring the baby was measuring a little bit small, or was measuring a little bit big. And now it's 34 weeks, and baby's measuring a little bit smaller, a little bit bigger. So there's this kind of, or maybe your baby has grown loads in the last six weeks, or maybe your baby's growth has tailed off in the last six weeks. But nobody quite knows because there's a margin for error. So it's nice to see baby, it's reassuring. But these are screening tests, they are there to to imperfectly measure the baby's growth and blood flow and and other things. So that is there's just a kind of bear that in mind, really that's that's what if you want you know when you're thinking about what those are offered for. The other thing to say about Rosecrans is that really broadly, women in the absence of gestational diabetes, women will tend to grow a baby that is the right size for their body to give birth to. So the figure is put into people about baby's shoulders getting stuck, so having a big baby and baby's shoulders getting stuck. So it's a really, it's quite a it's a very in a very much a justified fear. So it's cold shoulder dystocia. And it's where a baby's heads born. But the baby's shoulders get stuck because of the position of the shoulders, a shoulder get stuck behind the front of the baby's pillow that the moms rather than the moms pelvis and becomes difficult to deliver. Now, although doctors and midwives will always emphasise and again, I teach us a lot. midwives and doctors are highly skilled at helping women to deliver a baby that's whose shoulders have got stuck. And we were always taught and we always tell people that is it is impossible to predict it is unpredictable and unpreventable. Okay, shoulder dystocia, and it happens to babies of all sizes. Nevertheless, women are routinely being recommended to have an induction based on the fact that they might have a big baby, and they might have a shoulder dystocia. And it's just not evidence based. And also, neither is induction as a as a treatment for or as prevention for that. But that's not known to be preventative at all. So there's a debate there's a debate around elective caesarean sections for that reason. But again, it's it's a really, really tricky one. The reassurance that I'd give you because as you know, I always try to reassure is that it's a very, depending on where you look how rare Shoulder Dystocia is, you'll get very different stats on it. It is a very rare occurrence of the reason that I think that it's, it's difficult to talk about numbers is that quite often, there are shoulders that become a little bit stuck or may or or, or a baby's born, and it's it takes it's a little bit slower for the shows to be born. So there's a there's a sort of big, maybe around lots of births. But that kind of speaks to the fact that when baby's shoulders are diagnosed as being a shoulder dystocia they are stuck. About 80% of those cases, more than 80% of those cases are just solved and the baby's born straight away just by helping the mum to move her legs into a sort of bent knees position. It's really easy to solve that problem. Or if the mums standing up into a different position, squatting down, etc. It's really rare for it to pose a big problem and it's really really rare for me II, lasting damage should be done for a mama for a baby. So it happens in maybe one in 100 cases. And of those, you know, 80% it's it's really, it's really, really easily resolvable and doctors and midwives are really skilled in helping so windy that right back to kind of why you have these scams and why. And what happens as a result of that. Just be aware that those scams often do lead to conversations that oh, we think your baby is a bit this a bit a bit big bit small, but this, that maybe the growth is this or that. And maybe even extra scams again, that it's not always just about nice opportunities to see baby and get reassurance again. 

Megan Rossiter  

Yeah, absolutely. We've got a really good podcast episode towards the end of the last series that is all about like screening tests and diagnostic tests and stuff in pregnancy and how to kind of navigate those. So and we've also got another podcast episode on induction of labour as well. So go do go back and have a listen to those as well, if you want to kind of more detail and all of the sort of many topics that we're dipping our toe in? 

Alice Keely  

Yeah. I think it's important when when it's acknowledged that we aren't, you know, we haven't gotten all the answers. And we think this might be this might this might this is recommended. But this is why it's just a lots of uncertainty. And I think that's what this whole problem around high risk boils down to, because what we all really want on the pregnant is just for someone to to be like to wave their magic wand and say, just do this next thing. Me Absolutely. Alright, I can promise you that everything is going to be alright. And cause no one can do that for you. And although your chances of complications, whatever size you are, are really small. Your mind just goes to that worst possible scenario, because you're human, you're anxious, and the stakes are really high. Right? You're pregnant. 

Megan Rossiter  

So so the language around it isn't it is because it is called high risk, which implies that the risk is high. Yeah. And you're like, well, actually, no, the risk is low, but they're potentially higher than somebody else. And that is, as soon as you've got a label on yourself, and you're thinking of your pregnancy as a high risk pregnancy, it's absolutely terrifying. Like whatever it is that's making that risk appear. And I think what is what you've just shared very eloquently, but what is often lacking in the way that this information is communicated with women is I don't think they they realise that actually, the evidence isn't very good. Or actually we don't know, the best amount of folic acid to take it is presented as this is used to you do this. And it's it's that nuances, I think what gets lost in the not having enough time and appointments, that information potentially not reaching every midwife that's having those conversations. And so, we often take we take things so black and white, it's like, well, this is what I have to do, because I tick this box, rather than and I think hopefully just hearing what you've been saying there. And actually showing people that actually, it's just very, the whole lot is very grey, it really I think creates a bit more space to find hopefully that confidence in going okay, so that's great. We don't necessarily know, maybe this is going to be helpful. What is important to me, and how do I maybe bring those two things together, when we realise that it's not quite so black and white, hopefully that creates a little bit more space, in your own mind and your own choices of like, actually, what you want is also a very important factor in deciding what to do.

Alice Keely  

Yeah, absolutely. You know, there are lots of lots of people out there's lots of women out there that don't understand don't, you know, don't realise what the stats are or that you know, that actually, if you get told you're high risk, it doesn't mean it's likely to happen. But people think it's likely to happen. And that's just absolutely not true for women of any any weight. But actually, I'm not sure if this is what you're getting at, but also lots of healthcare practitioners don't realise that either. Or they don't really remember, because I teach senior students, or whenever I speak with health professionals, I do a like a little quiz about, you know, what's the, what I mean? It is kind of broad, it's just kind of using using percentages. So if I if I use that example of 80 to 90% of plus size, women will not get gestational diabetes. So I say I'll do like a little a little quiz. What proportion of plus size women will get gestational diabetes. And I've got I'll do like a multiple choice and they always worry though that I was way over estimate it unless if you know been joined my group or if they've just just been like studying, studying, advising about it, because they just they just forget and that's that's what the high risk and low risk is all about that they just, they forget and also Our healthcare is divided into is organised in a way that will quite high risk labour wards and lowest birth centres. And, you know, we talk we talk about personalised care and individualised care and continuity of care. And we have been doing that for a long time. But we have these great big industrial labour wards that are absolutely nowhere conducive to that sort of that delivery of that sort of care. Yeah, and that's before I even get started on staffing crisis. 

Megan Rossiter  

Yeah.

Megan Rossiter  

Ad - I remember choosing a pram for my first baby almost eight years ago and honestly it required as much research as giving birth. Is it going to fit on my beat when it converts would double one day? Will it last and past 18 months old? Can I attach a car seat? Will it roll in mud? Can I put it down with one hand? And eventually I found the answer to all my questions. For me it was the iCandy peach which by the way, fits into the back of a Fiat 500 car which sounds unbelievable for pushchair that sturdy but seriously it does. We knew then that we hope to have more than one baby. So choosing something that was going to stand the test of time and not end up in landfill in a year was really important. iCandy pushchairs come with a five year warranty. And believe me we've put it through its paces. It's been up mountains and wailed, it's been on and off the escalators and the tubes of London Underground. It's been in and out of my car boot every day on the school run. It's flown all over Europe. And yet still seven years on aside from being completely filthy, it's going strong. If you're looking for a push out or travel system that's really going to see you through the early years with this baby and maybe any future babies, nieces nephews, best friends children that might join your family. For me iCandy has been an investment worth making. Follow the link in the show notes to find the perfect pram or travel system for you. 

Megan Rossiter  

You're leading me on quite nicely to starting to think about the kind of the birth care. So we've looked very surface level that some of the kinds of things that you might experience will be offered in pregnancy. But there are whether there's a guideline based or culture base, there are frequently things that women are told about their birth that they must do that they can't do. And occasionally that they're recommended, but it's often lacking that bit of language shift. So things that I certainly know women might be told would be that they have to give birth on a labour ward that they have to have continuous foetal heart rate monitoring. But that probably needs to be with this sort of electrode thing that goes on to babies under baby's scalp, that they have to have active management of the placenta that they cannot use a birth pool. You know, what are we? What is this reflected in what you're seeing women told and how much of this is actually helpful for them. And how much of this is we started to touch upon the culture of care and the discrimination that someone might experience in care and how that can potentially lead to complexities? You know, there's a whole lot to explore here, isn't that?

Alice Keely  

Yeah, absolutely. And those are absolutely the things that I get asked about all the time. And I know that that's what that is what women are kind of hearing. And that's the way they're sort of experiences are being shaped and controlled. And also, I would add to that a lot of them for various broad reasons that are offered or recommended to have it are pressurised to an induction as well. And so we can just we can take, we can have a look at all of those sort of in the order that you listed them. But what I think what broadly what all of those things come down to, and that kind of none of them should be recommended to you before the fact. So, you know, your risk. Risk is a very problematic term, but your risk your chances of complications, it's a very dynamic thing. So most women can expect to have no problems and pregnancy. And actually, one thing that I think as midwives, we kind of forget to point this out to people, we kind of it just kind of sinks into our, our approach. But we forget to tell people, if you have if you have a problem for a pregnancy, that's a really good reassuring indication that you can have a problem free birth. It sounds obvious, but I don't know if people kind of there's such a lot of fear around birth, it was a really, really good indication that you're not going to have any problems during a birth, because birth is a part of pregnancy is all part of the same thing. It's not kind of like a separate thing that happens at the end, you know. So that is what should be guiding these sorts of decisions around. You know, where you give birth, how your progress and your well being and your baby's well being is monitored. That should be guided by is your pregnancy and birth complicated or not, and how you know by what I'm watching, what should what's the appropriate response to that. If as for the majority of women, the answer is no young guy and complications then you should have all of the options open to you that anybody would have any weight. And the really key thing to do here is to put is to prepare for that. Because the guidelines might be and by the way, the guidelines are that if you are plus size but uncomplicated in in labour with it and with no complications, continuous monitoring of foetal heart rate isn't recommended. So that's not in the guidelines. And obviously, if you know that, you can just refuse that even if somebody isn't it, that's kind of he wasn't aware of it, or they're keen to continuously monitor you. But you don't, you know, you don't want to be in a battle with people do that you want to be, like I was saying before, you want to be in this sort of respectful space, you know, with this, this care, you don't want to be refusing stuff or setting yourself up for a battle, when you thinking you're going to need to battle when you get to the hospital, or wherever it is, you're going to have your baby. So that's not to have confidence and preparations and plans in place. So I would say in terms of those common issues, like wanting to use a birth pool, wanting to use a birth centre, rather than go to a labour ward, or to have the option for that, right? Because there's lots of people that actually on the day that give birth, like, you know, what an epidural, actually, you know, good you can change your mind. But you what you want is the options. Yeah, open to the thing to do is to kind of get at that gatekeeper, your trust has got a gatekeeper. Right. So if your midwife is saying to you in the clinic, oh, well, you know, if you've got a BMI of 30, or more, when you can't go to the birth centre, you can say, right, so who can I speak to about this, because I'm, you know, I want to have a discussion with somebody else, I know that I can have a conversation about what's term birth outside of the guidelines. So that's going to be either a consultant midwife, or a head of mid Midwifery, there is somebody who will be doing a clinic every week or so, to talk to women who are mostly those women that are considered too big or too old, to do things that they want to do it considered high risk, to have a conversation about your wishes. And to get a piece of paper that you sign, and a conversation that's in your notes that says, I've had this, I had this conversation with a representative of the trust. And this is what has been agreed, so that when you then turn up at 2am, in your in labour, no one can then say, Oh, that's not in the guidelines, and you got to then have a discussion about it exactly the wrong time. That's been happening. When you want all you feel happy hormones flowing. And that also gives you that confidence that you've you've got everything in place. So in terms of place of birth, and using water and options beforehand, you know, that's the thing to do the things that kind of the trust or representative of the trust can be in control of a can block you, in effect, you know, can kind of get keep those things. So put things in place beforehand and get access as early as you know, as early as you want, you know, because sometimes the the wheels grind slowly, can go into the stress website can find contact, often there is the muzzle devices partnership can help you with that. So the MVP, there'll be a link to that on the Trust website, or there's certainly should be, there might even be the contact details for the head of midwifery. So if you can't, if anything else is failing, just get in touch with the head of midwifery who can either meet you are signpost you. So putting plans in place is one really important thing. And then also knowing the arguments for and against the reasons why things like continuous monitoring or active management might be recommended? Because both of those things have a place. But both of those places aren't because your BMI is higher. So yeah, the simple answer is continuous monitoring is not recommended, simply on the basis of your BMI and putting it a clip, or what is so a foetal scalp electrode is like a sharp pin that's that clips to the baby's scalp, that's only recommended if there's a need to monitor the baby's heartbeat closely, continuously. And it's not possible doing that externally through a woman's abdomen. And again, it's something that you know, you can is that's up to you, whether you want to do that, and it should be discussed in the moment is not something that should ever be told to you that you will need because whether or not somebody can have their baby's heart rate monitor through their abdomen is dependent on loads of different factors. So um, one of those might be how big a tummy is, but it might not. So it's just something that isn't isn't going to be known until the fact is something that's that might be used in in a complicated labour. Yeah. And that's not that shouldn't be anticipated just because of your BMI in terms of active management, so that's when you're recommended to have an injection of hormone oxytocin just at the point that your baby's born, that is recommended to all women So that's kind of a controversial recommendation. And it's believed to reduce the chances of excessive bleeding. And again, this is something that is in the RTG guidelines that plus size, women might be at increased risk of excessive bleeding when they give birth or just just after they give birth, so you shouldn't be having any bleeding during labour. But everybody has a blood loss after they've had their baby. And it's totally brings to light, this idea that your cash should be moment to moment should be individualised because it might be something that's a good idea for you to have. But it depends on a number of different factors. So it is something for you again, it's another one that could feel a podcast, it's something for you to kind of find out about it is, you know, it's an intervention is something that is a really huge dose of oxytocin, this hormone that your body produces in order to make your uterus to a really big contraction after the baby's been born, in order to close off those blood vessels so that you're bleeding starts to slow down immediately, Sukhoi, your placenta is bleeding, and it's come away, there's going to be bleeding because there are open blood vessels there we wave placenta developed and was attached inside your uterus, your body's you know, is capable of doing that by itself unless there's some some issue or some problem. And, you know, health professional midwives and doctors are highly trained, frequently updated, absolutely brilliant dealing with these problems, when they occur, really, really rarely causes any problems, particularly in someone that's kind of uncomplicated or hasn't got problems, that might indicate that they're at high risk of bleeding beforehand. So it's another conversation to have if you know if it really if it's a really important one for you. Lots of women think, you know, I'm not planning to have any drugs or intervention during my, during my labour. So why would I want to have one straight afterwards to help with this birth at the centre? I don't need anything any other help. So other people aren't, aren't so bothered, I couldn't honestly tell you. I've had three babies, I couldn't honestly tell you. I know that I had a had active management for at least one but maybe two, I can't even remember. So at the time, it didn't really matter an awful lot to me. But it's just something that you can you could insert the information is out there to read about it, if it matters to you, but don't just take it as that's what happens. That's what's recommended. So it's another intervention that's proposed, recommended. But there's a there's a lot, you know, there's a lot around it. That is there's a choice choices for you to make.

Megan Rossiter  

Yeah, and I think what this whole conversation has, hopefully, sort of affirmed to people is that at every single step of the way, there are choices for you to make and approaching those from a place of curiosity rather than defensiveness. And then taking that information and you know, doing with it, whatever you want, taking into account your kind of whole holistic picture, not just this one box that has been ticked on a bit of paper will hopefully help you find a way of staying centred in that, in that pregnancy and that birth experience. The final thing I just wanted to go loop all the way background to something we sort of started to touch on at the beginning, was just this sort of like the stigma that is attached to ticking this high BMI box, or the sort of the way that it can really, really impact your emotional experience of pregnancy at a time where we want to be celebrating what an incredible thing or bodies are capable of doing where we really want to actually be building trust in our bodies and building a connection with this baby, when that is kind of consistently undermined the whole way through pregnancy by having what might be something that we feel quite vulnerable about that being that that nerve kind of being poked the whole way through pregnancy. Or it might be something that we actually felt totally confident with. And then suddenly somebody keeps bringing it up as though it's supposed to be a big issue. Do you have any tips on like what people can do to make that experience as positive and like, enjoy that pregnancy experience?

Alice Keely  

Yeah, definitely. And I think, you know, it's kind of like trained years ago as a hypnobirthing instructor in Australia and more recently, I've been thinking about and I recommend for anyone that's in my Facebook group will have seen me recommending this idea about you having your birth partner and you know, the role of the birth partner and Hypno birthing, etc. But you know, if you are plus sized and pregnant, or you know, trying to conceive the whole journey of fertility, conception pregnancy, you need a partner sort of through that you need a pregnancy partner, you need support. thought, because all of the all the principles that we think about in terms of being calm, centred in control for birth, those rings true for pregnancy as well. So every so much, I think ticket is typically for me, women that I help, they have that those levels of anxiety going into kind of almost all of their appointments scans, you know, we haven't talked about ScanSnap scans is a really big one, in terms of feeling the stigma of feeling anxious, you know, wondering how you'll be treated. So what I try and coach people to do is is to just pick themselves up, get themselves ready, completely anticipate that everything will be will be great, and they will be treated really well. And respectfully. So anticipate expect that, but be ready in case that isn't what you get. And part of that is taking your pregnancy partner along with you who was fully on board on your side. That is, you know, you've written your questions down, they know what you're going to ask their lesson, as well, as you listen to take notes for you, it's someone to kind of sitting around to do you know, you're not sitting there on your own, I'm getting more and more anxious, going and taking you home or going home with you, you know that that that sort of person that might not actually be your parent, but life partly because maybe they're at work or you know, you might need a bit of a team of people, or certain other trusted person. So, you know, feeling feeling good all the way through pregnancy, it's not just it that it needs to be prepped for and switched on kind of for the birth. That's really, really important. And I think if you've hit the nail on the head, they're making about being undermined all the way through. That's what you needed to resist. It's like, you know, I've used as an analogy before, and it's probably familiar one to you, if you you know, for anyone that knows what Hypno birthing, it's like, if you if you were as most people make a baby, most people make a baby through having sex. If someone was kind of poking and prodding you like before, the moment when you were going to be getting together with the love of your life, this this this life partner, and saying, you know, well, the first time that you go to bed together, maybe they'll just think that you're a bit rubbish, and you're not going to please them. And it's just going to be, you know, it's going to be a bit hopeless, maybe you'll just never see each other again afterwards. And if you are consistently undermined in that way, that's a little bit of an allergy, towards what this high risk does. It's making you feel scared, worried, all the way through pregnancy, about your ability. And I'm a massive fan of evidence and and really, you know, the way that scientific evidence is presented, quantitative evidence is, you know, it's taken our careful with leaps and bounds. But, you know, it's very limited in what it does look at, and I'm always interested to hear about the stats around plus size, women are more likely to have a prolonged pregnancy. And, you know, I sort of I've seen that I'm thinking, Yeah, I wonder if there could be a link between that and people type telling them over and over again, you're more likely to need an induction, you're, you know, you're not likely to have as efficient a labour, your body's not going to do its job properly. When you do go into labour, if you do, you might need help, all of those undermining messages that we get, it's about that mind body duality, isn't it, it must, it must have an effect. It's just that that's not the kind of thing that we that we look into in research. So absolutely, just treating this as a you know, treating this as this pregnancy as a as a really important project is kind of a bit of a work related word. But you know, this isn't this is a mission for you yet, it's absolutely your priority. So not just preparing for the birth, but actually really working on and thinking about all of your, all of your appointments and making those work for you, making sure that you don't just assume that everybody knows what they're talking about. And they and they're going to tell you what to do. While gives you the best recommendations. Three, everything is the conversation and an opportunity to ask questions and get your priorities addressed.

Megan Rossiter  

And I always say it's fine. If you ask somebody for the evidence, whatever, it's fine if they don't know it, but you just need for them to say actually, I don't know, I will go and find out for you. And then suddenly that reveals that actually, there is actually maybe more information.

Alice Keely  

Yeah. Yeah, someone said that someone said to me this week, or you know, my GP was googling this stuff. When I was in the office. I didn't know Googling, I think they'll hopefully I hope they were looking in their trusted guidelines. But there was you know, they were just doing that they were not in front of me in the in the surgery is like all good. Because apart from the really kind of common things that GPUs deal with all the time. I don't expect them to keep it in their mind, and I definitely expect them to check. Yeah, because also guidelines change all the time. You want someone who's confident to say, Look, I'm just going to check this out for you. I don't know exactly off the top of my head, but and also it might have changed. I'll check for you. I'll get back to you. Yeah, that's fine. And also just make you say, Oh, can you just repeat that or can you just explain that a bit better because You know, I know that I know from years of being a midwife, a doctor comes into a room when you're on labour ward, and they talk about something for a while the torch, talk to this woman. And they'll be like, Okay, so we'll do this, and you do that, and then they'll, and either when they're not just there, or maybe when they've gone, I'll go. Do you understand what happened? You stand on that note? Yeah. Oh, and then they start to ask questions. It's difficult, you know, but just kind of give yourself some affirmations beforehand, before your appointment. Or even just sometimes a bit of a cheat that I do is, when you do understand something, just ask anyway, just just to kind of start to build your confidence about asking for them to repeat or explain things. Because it's fine to you know, and it's, it's absolutely run of the mill that people just don't remember or understand what was said to them. And, you know, for as far as possible, just don't Don't, don't let that be you. Fake your confidence until you get the confidence because ask it's this is all about you. So ask questions, take notes.

Megan Rossiter  

Yeah. Write down your questions before you get there. If you've got, if you know that you want to ask something I was thinking, you feel so vulnerable, asking a question, don't you and sometimes reading it off a bit of paper makes it just a touch easier. 

Alice Keely  

Lots of doctors have still come from the private school system. And the private school system teaches them an air of confidence, right that they carry about with them. And that can be quite intimidating for people. So that's why it's quite right and proper for you to need that. That kind of background work just yet. As I say, Just treat it as a little project. Take notes, and prepare yourself rehearse what you're going to say, actually rehearse write down, I'm going to a scab, right. And I feel really subconscious about the size of my tummy, I'm worried about how it's going to go and if you'll be able to see everything, and I'm worried what they'll write in the notes afterwards. So those are three things that you can say, when you walk in before you even start pulling your tarp up. I'm really worried today because I am plus size or whatever word you'd rather use, and worried about having the scan done? Can you talk me through it, I'm worried that you're not gonna be able to see anything? And can you tell me? Can you talk me through the scan as we're doing it? And tell me if there is anything that you can't see or anything at all that I should know about? And can you tell me what you're going to write in the notes afterwards? And then write that down, and then just practice saying it and practising it on the way there and then just say it when you get there? And expect that there'll be that because you're inviting them then to be on your side? And to make it clear? All right, well, yeah, this what you need great are this, this is fine, I'll talk you through it. scans of scan, ultrasound waves are really, really powerful, we're, you know, we're not going to have a problem seeing the baby due to being precise, you'll probably see something you notice about it because that all BMI above 30 scans say that. But if you do see that in the notes, that's just something that we're obliged to put, because it's part of defensive the defensiveness in practice, you'll get a really good conversation going on that you have led. And that starts to build your confidence for your care.

Megan Rossiter  

I absolutely love that. That is it's, it's the connecting with somebody on a human level, not their service provider, your client or a patient or whatever it is, but it's like, actually, we're two people, and we can have a human conversation and then suddenly you see each other differently, don't you?

Alice Keely  

Yeah, exactly. Because a lot of practitioners, you know, there's a, there's a smart men, that minority that are horrible, and then a lot of them are just great, and that there might not be brilliant communication, and they might not want to offend you. And they might do things wrong. Because of that. They might think that not saying anything is the best way, which I mostly disagree with. So if you go in there and make it clear, what you want to ask is going to help them to do things better for you as well. And help them to sort of educate them to in law, it feels good, because that's open. That's an open discussion. You know, most of them are great, but you got some of them, you got to bring out the best in. 

Megan Rossiter  

Yeah, thank you so much. So Alice, people might be listening to this and they might be thinking like, Oh, this is really helpful, like I need I need more where am I gonna get like more information and more support from from you and More information about this kind of pregnancy. So where can people find you if they would like to find some more? 

Alice Keely  

Definitely, yeah, so I am the heavyweight midwife, and I am on Tik Tok, and I am on Instagram. And you can also join my Facebook group, it's just the headway made my Facebook group. And if you want to get a bit more intensive support, direct support from me, you can sign up to my essential service, which is really, really affordable. It's just a pay monthly leave when you want no contract service. So there are all of those options. I would say. The best first port of call is just join up to the heavyweight mid level Facebook group. It's a really brilliant community that's it's growing really, really fast if you've got about one and a half 1000 members now so it's still it's still kind of little the vibe in there. It's just really, really, it's a lovely community lovely supportive community. So if you're trying to conceive or pregnant, just just come come along and join.

Megan Rossiter  

Amazing. And I'll put links to everything that you've mentioned in the show notes. So if you want to access that, you can go and click there. Thank you so much for joining me. We have really jumped around and covered all sorts of things, but hopefully lots of kind of take away and a new way of thinking and hopefully plenty of reassurance.

Alice Keely  

And it's been a pleasure. Thanks for having me on.

Megan Rossiter  

Thank you so much for listening to today's episode of the Birth-ed podcast. It's my actual life mission to get these conversations in front of as many expensive families as possible and you can be a part of this mission. Don't worry, I'm not recruiting you into my cult. But if you leave a five star rating and review of the podcast then we creep up the charts getting more ears, change more births, change more lives and come on, you know you want to be a part of that change.