BMI, High-Risk, VBAC?

[Meleroo]

I'm in Ontario and I see a mid-wife.  My 20 week U/S found a small mass on my ovary and I was referred to an Obstetrician to ensure that it would not interfere with the birth and what the appropriate course of action should be.  I saw the OB this week and he spent 30 seconds telling me to wait until baby was born, repeat the U/S and if necessary have the mass removed and 30 minutes telling me why I should not be planning to VBAC.  I have all kinds of questions about his ethics on this one.

First C-Section was for mild pre-eclampsia and a failed induction at 37 weeks.  Obviously if the pre-eclampsia returns then we will reconsider our plans to VBAC but so far I am not showing any symptoms and I have a 70% chance that it will not recur.  

1)  He told me repeatedly that the SOGC recommends that someone of my BMI (currently 35 at 32 weeks) is now a high risk pregnancy and therefore should not attempt to VBAC.  I realize that different docs have different opinions but NOWHERE in the SOGC guidelines does it say that.  He told me the reason is because I am at higher risk for diabetes, high blood pressure and macrosmonia.  I said, yes, but I currently don't have any indication of any of those.  Oddly enough none of those complications are contraindications to a VBAC according to the SOGC.  I have a huge problem with him using his professional organization to lend credibility when he is not telling me what they recommend!

2)  After we didn't seem to be buying the high BMI thing (particularly because he used my pregnancy and not pre-pregnancy weight) we proceeded to tell me the baby was breech.  Baby could be breech or not at this point but I believe there is time for it to turn.  I told him it was good to know and we would confirm before delivery.

I started counting part way through the number of times he told me that my BMI of 35 makes me morbidly obese and got to 8 times by the end of the appointment.

I guess I just feel discouraged.  Being told repeatedly that you are too fat to have a baby is painful.  Particularly because I lost 45 pounds before getting pregnant to help avoid pre-eclampsia again.  Our midwife would like us to have a hospital birth but will support a homebirth if things continue to go well but the more I encounter lying medical professionals like this one the more I want to stay away from the hospital.  We are in a small community so if my care does need to be transferred to a doctor it will be back to my family doc and not to this guy.  But now I need to meet with my family doc to find out what he makes of this guy's advice back to him just in case I do get transferred.  

Part of me wants to go on a low GI diet to make sure I don't gain any more weight.  It seems a little crazy but I feel out of control on this one and want to be doing something!  I have to have one more meeting with the local surgeon in case of an emergency repeat c-section who will recommend forgetting about the VBAC and just scheduling a C-Section.  I have been big my whole life and I work hard to stay healthy and fit even when I can't hit the BMI targets.  My confidence is so shaken right now.  Any support or positive stories would be appreciated or any research around BMI and VBAC would be great.  

Thanks!

[Lynann]

I have no idea what my bmi is, but I'm 5ft2in and was 189lb at the start of my latest pregnancy. I had home birth vbac 5 weeks ago. Weight does not make you unsuitable for a vbac.

[LisaSedai]

http://www.mcsig.com/documents/BODY_MASS_INDEX_CHART_doc.pdf
Although the BMI is an universally accepted measure, it has some limitations. BMI is not a good indicator for excess fat for heavily muscled
individuals (athletes), frail adults, pregnant women and children. These individuals could have high BMI scores but not be overweight, in the case
of athletes and pregnant women.

IMHO that doctor isn't practicing fact based medicine nor following the guidelines of SCOG so I would take whatever he says with a *huge* grain of salt.

My BMI when I VBAC'ed was 40. I am a type II diabetic and my baby was 9lbs 14oz. Oh, and I was 42 years old.

HTH

[hildare]

i've been doing mega research about vbac and risks.  i found this literature review to be pretty helpful

http://emedicine.medscape.com/article/275854-overview 

which is an examination of risk factors in rupture over much of the published scientific research.  it DOESN'T EVEN MENTION BMI as a factor. 

personally, and i am being extremely cautious in looking at my own risk factors with a vbac, i would discount anything that physician says about BMI.  i think that some of the factors associated with having a high number could influence you physically and contribute to conditions that themselves ARE actual risk factors, which you know and mentioned, such as the pre-e or gest. diabetes (and not that condition itself but the macrosomia has been indicated in some studies to increase risk - which is my reason for researching all this to begin with).  but in and of itself and in the absence of anything OTHER than a high BMI, i would ignore all of that bad professional advice. 

what i would do, though, if it is possible, is to find another obstetrician if you need one to back up your midwife or for the cyst removal.  i am sure you could find someone who knows what they are talking about. 

[AlexisT]

I have a BMI >35, chronic hypertension and a history of severe preeclampsia (with #1 I didn't even get the induction, the PE put dd into distress and I needed an emergency CS before I labored). My OB this time was cautious about a VBAC, but she did not mention my weight--her concern was that my blood pressure would rise before I went into labor, based on my history. IMnon-professionalO, that was a reasonable fear and I was okay with that; she didn't want to promise what she couldn't deliver. If my blood pressure behaved, and I didn't spill, she was fine with a TOL (again, she wasn't being fear-mongering with that term--hypertension can spike in labor and we had no way to know how well I'd tolerate it).

I wound up choosing a 39 week RCS, but I was never pressured to do so. I'm not going to lie and say my OB wasn't relieved with that choice, but I felt throughout that her feelings were based on real concerns about my blood pressure and not hysteria about weight. This, FWIW, was at a university based practice that I would describe as "conservatively evidence based"--they weren't crazy like some places I've heard about, and always had reasons for what they did, but definitely not crunchy or touchy-feely or low-intervention. I got weighed every visit (okay by me with my PE history) but not once did they ever discuss the numbers or berate me about my weight, which I was a little worried about because I gained 45 lbs.

Plus, surgery on high BMI patients is no cakewalk, either. I now have 2 scars. My OB this time had to make a new incision, because my first was buried and I had so much trouble with it at the time that she didn't want to reuse the incision.

[Viola]

Honestly, it sounds like this doctor is not in favor of vbac in general, and is using various factors to try and talk you out of it.  I found a study on the success of vbac and BMI, but it doesn't talk about the risks, just the percentage of women of certain BMIs having vbacs: http://www.ncbi.nlm.nih.gov/pubmed/15467571

This was at Well Rounded Mama about vbacs in general:

 http://wellroundedmama.blogspot.com/2009/03/history-of-vbacs-and-cesareans-in-usa.html  There are birth stories from plus-sized mothers who have had vbacs, but I don't know if you would find those helpful. There might be things there to help you.

[roadfamily6now]

I'm  pretty sure I have been well over 35BMI for ALL My deliveries and 5 were successful VBACs.

Fat-phobic OB's really annoy me.

[Devaskyla]

My BMI is over 40. I've had 2 UBAC's & I'm planning a 3rd.

Sounds like the OB is both anti VBAC & fat-phobic. BMI is a tool designed for populations, not individuals. On an individual basis, BMI can't predict anything.

I suggest checking out plus-size-pregnancy.org & the Well Rounded Mama blog someone else mentioned above