Pregnant, Obese and In Danger

ONE recent night on my delivery shift, eight out of 10 of my laboring patients were too heavy, with two weighing over 300 pounds.

Over two-thirds of adults and about one-third of children in America now are overweight or obese. An obese pregnant woman is more likely to have a very large baby, weighing roughly nine pounds or more. And babies of obese mothers are more likely to grow up to become overweight or obese themselves.

Maternal obesity causes more immediate problems as well. Obese pregnant patients are more likely to have elevated blood pressure, gestational diabetes and babies with birth complications. They are more likely to need cesareans. And they are more likely to have serious complications from the surgery, such as infections, hernias or life-threatening bleeding.

Early that night on the ward, we had a patient with a “shoulder dystocia” — a scary situation in which the baby’s head delivers, but the shoulders are too big to pass through the birth canal. Shoulder dystocia is strongly associated with obesity and excess maternal weight gain during pregnancy, and can lead to permanent fetal injury, neurological disorders and even death.

But the biggest emergency unfolded in the early morning. A 24-year-old, 300-pound diabetic woman, who was pregnant with her first child, had developed pre-eclampsia. Pre-eclampsia is a complication of pregnancy marked by elevated blood pressure, swelling and mild to severe organ dysfunction. If untreated, it can lead to the mother’s having seizures, stroke and liver rupture, and is a leading cause of maternal death. Although pre-eclampsia can occur in any pregnancy, it is three times more likely in obese patients. New research suggests that babies born to women with pre-eclampsia may have a significantly higher chance of autism or developmental delay. The only treatment for it is to deliver the baby, so this patient had been given drugs to induce her labor.

At 5 a.m. I was urgently called to her bedside. She was having seizures from the swelling and elevated blood pressures. Her baby’s heart rate dropped from 100 beats per minute to 70 to 40, and then the signal was lost — the monitor had come off.

As we worked to treat her seizure, we moved her to the operating room. We needed to sedate her, but struggled to find a vein. We needed to intubate her, but her airway was obstructed from the obesity and the swelling. Just moving her onto the operating table required an additional team: the table was too narrow and the straps too small.

Once she was safely secured to the table and intubated, I checked for the baby’s heartbeat. There was nothing on the monitors. Nor could I see the heart with the ultrasound, as the mother’s abdominal wall was too thick and swollen. There was nothing I could do but deliver the baby surgically and hope that it would survive. Quickly, I cut straight through her swollen abdomen and uterus. I reached through her placenta, wrapped my hand around the baby’s head and pulled it firmly out of the incision. As I gently extracted his body and untangled his legs from his pulsating cord, he clenched his fists and gasped.

Later that morning, when I left to go home, I was deeply grateful that all my patients and their babies were safe. There were many close calls.

Obesity is a sensitive subject, even for doctors. In a JAMA study from 2011, only 45 percent of patients with a body mass index of 25 or greater (defined as overweight) and 66 percent of patients with a B.M.I. of 30 or greater (defined as obese) reported having been told by a doctor that they were overweight. Notably, those who were told were more likely to have tried to lose weight.

There are many reasons doctors don’t speak up, including short office visits and a lack of training. But one growing problem is the role of “patient satisfaction scores,” which can be tied to doctors’ compensation and job security. If you offend a patient, you may never see her again.

But these conversations are crucial, especially for women who are, or want to become, pregnant. Obesity in mothers is strongly linked to their own compromised health, and to that of their unborn babies and our nation at large.

For doctors, the issue has become an everyday challenge. In the last year alone, three of the doctors I work with have been significantly injured while treating severely obese women. One even dislocated his shoulder while performing a cesarean on a 400-pound patient. We recently had two patients with B.M.I.’s of 53 and 60 in labor at the same time. B.M.I.’s above 50 are now classified in a new category: “super-obese.” It is frightening to think that this might become normal.

Policy makers need to pay attention. We should consider creating special labor and delivery centers for severely obese patients that are equipped with automatic lifts, specially designed monitors and appropriately trained teams.

We also need better prenatal programs that assist women in achieving appropriate weight goals during pregnancy, through better exercise and nutrition. The adage of “eating for two” is damaging. Thankfully, under the Affordable Care Act, more women and children have access to nutrition and health services than ever before. But we should be managing obesity even more aggressively, as we do elevated blood pressure and diabetes.

Above all, we need to end the taboo against talking frankly about obesity. Doctors need to be sensitive and nonjudgmental, and patients should not take offense, especially when their health, and their children’s health, is at stake.

Claire A. Putnam is an obstetrician and gynecologist at a Kaiser Permanente hospital.

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A version of this article appears in print on March 28, 2015, on Page SR10 of the New York edition with the headline: Pregnant, Obese…and in Danger.

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