Scales and Sutures: One Doctor’s Fight For Safer Pregnancies in Obese Women

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// Yale Daily News

On a chilly evening in early March, I stepped through the doors of the Yale-New Haven Hospital. Wide-eyed and exhilarated, I was on my way to observe Dr. Katherine Campbell deliver a baby.

I was soon to learn that this delivery was unlike ordinary ones, the deliveries often marked by the predictable but remarkable anticipation of a newborn. This delivery would shift everything I knew about medicine.

“Today, I and a team of surgeons will deliver a baby for a woman who is obese,” Campbell explains as we head toward the patient’s hospital room. The physician-nurse team considers this patient high-risk because her obesity is a threat to not only her own life, but also that of her baby.

After wrestling into an over-sized set of sea-green scrubs, I continue on with Campbell into the maternal-fetal medicine ward of the hospital. An energetic married mother of twins, Campbell is an obstetrician-gynecologist who treats New Haven women with high-risk pregnancies.

She knocks on the door of the patient’s hospital room and enters. The patient is a young Latina woman, who lies listlessly across the hospital bed, clearly in pain. Her family surrounds her with worried expressions. I would soon see this woman stripped, anesthetized and limp on a delivery table with bright lights, physicians and technicians taking the place of her family members.

Campbell, the other surgeons and I would soon be witnesses to the battle between obesity and this woman and her child’s life.

* * *

The only part of the patient I see is her pale belly bulging out of the opening of blue surgical drape sheets. Campbell and the other surgeons use scalpels to peel away her skin, muscle and fat to perform the cesarean section. Blood oozes over their gowns, settling into the mass of towels that are strewn on the bottom of the operating table.

Campbell is intensely focused. As she later puts it, delivery for an obese patient can be strenuous for both doctor and mother. There is more skin and muscle tissue to cut through, and more strength is required from the surgeons to heave through in order to reach the baby.

“We get tired,” she says.

Obese women are also at a greater risk for blood clots during delivery, along with diabetes and hypertension, according to Campbell. Because these illnesses can produce severe complications before, during and after childbirth (hemorrhage, stroke, anesthesia problems, surgical wound infections), Campbell and her team are on their toes, waiting for warning signs such as a drop in the baby’s or mother’s heart rate.

After a flurry of activity, a newborn baby finally emerges. The surgeons hand over the infant to the technicians to be cleaned and taken to the neonatal care unit. Because Campbell has to attend to another patient, she leaves the other surgeons in charge to suture up the incision and whisks me away. My adrenaline high dies down.

For Campbell, this kind of surgery has become routine. As a physician, she’s made it her personal mission to combat the risks involved in obese pregnancies. But the intense, and often emotional, complexities of the problem extend far beyond the operating rooms of Yale-New Haven.

America’s fat problem is hardly new news: Each year, obesity costs the U.S. $150 billion a year and causes 300,000 premature deaths. But obesity takes on an entirely new set of dangers for pregnant women — and with one-fifth of pregnant women in the U.S. currently obese, Campbell’s work is more urgent than ever.

* * *

Campbell and I meet again on a cool morning in early October at Yale-New Haven’s Primary Care Center. Once inside, she eagerly introduces me to “the team” of the day: Elizabeth Miller, Dr. Lydia Shook, Dr. Lisa Zuckerwise and Dr. Stephanie Bakaysa, a group of women aglow with enthusiasm.

Today, there are 20 patient visits scheduled for ultrasounds and non-stress tests, a measure for heart disease in the patient. These meetings serve to keep the team members up-to-date on what diseases the women have had, what diseases they now have, and what they need to have for a healthy pregnancy.

Dr. Bakaysa scans a patient list while placing a hot, steaming spoonful of oatmeal into her mouth. She begins to speak with a thick Boston accent, running off a series of medical conditions of the first patient of the day. “Obesity, congenital heart disease, anxiety, depression, suicide attempt, GERD …” she says, waiting for her audience to ask questions about the patient’s current and past treatment.

“This baby is going to be very sick when it’s born,” Campbell declares abruptly. Questions and comments erupt from the other physicians and the nurse, bouncing from one person to the next. It becomes clear that Campbell is the leader of the group.

“The practice of medicine has had to change so much to accommodate our obese patients,” Campbell later explains. She describes how, although vaginal deliveries are safer than cesarean sections, she often has to quickly decide to perform cesarean sections on obese women. Campbell and her team do these urgent cesarean sections oftentimes because of dystocia, “when the baby is unable to fit down and out the birth canal.” Obese women face a greater risk of dystocia because they have extra soft tissue in the birth canal.

Furthermore, she says, when an obese woman is scheduled to go into the operating room, the labor and delivery team (made up of nursing, anesthesia and surgical teams) must change its protocol for many factors. They must plan for the extra time needed to transfer her into the operating room, the time it takes to position and prepare her for surgery and the time required to administer anesthesia. Most importantly, they must prepare for the added strength and concentration needed to move from making skin incisions to delivering the fetus.

For Campbell and other doctors, when it comes to delivering the child of an obese woman, time is of the essence.

But time can also be their biggest enemy when a baby is under distress, experiencing inconsistent breathing levels and low heart rates. In such cases, the child needs to be delivered quickly, and a slower cesarean section is dangerous. Ultimately, any wasted time in the womb could be fatal for the child.

“We don’t want to be in a situation where we say ‘we need to deliver this baby right now,’” Campbell says.

She contrasts this with the practice for non-obese women whose babies are undergoing similar distress during delivery. She explains the episode of a thin, 160-pound patient who insisted on having a vaginal delivery rather than a cesarean section. When the patient went into labor, the baby’s heart rate began to decelerate abnormally. Campbell and the other surgeons waited for the protocol time of half an hour so that the baby’s heart rate would stabilize and the vaginal delivery could proceed.

It’s a luxury that doctors cannot afford for obese women.

“If this patient had been obese, I never would have waited,” Campbell says firmly.

* * *

It’s 11 a.m., Campbell’s typing information into the electronic system, and I step away for a moment to get a cup of tea. On my way into the break room, I run into Katie Sullivan, who coordinates the diabetes pregnancy program in the maternal-fetal medicine department. As a nurse practitioner, Sullivan works to control and treat diabetes in obese pregnant women.

I speak with Sullivan for a while, who tells me that when treating these obese pregnant women, “it’s all about education.” Sullivan believes, above all, that education and communication are the most effective ways to minimize risks in the pregnancy. Further, education and communication ensure that obese pregnant women not only understand their own condition, but also the dangers it poses for their future children.

To educate patients, Sullivan is upfront: “The way you eat is the problem.”

If this is true, what is Campbell doing to educate her patients about the risks they face? She introduces me to a patient whose case illustrates just how crucial education is in lowering the risks of obese pregnant women.

* * *

Don’i Caesar is the most glamorous pregnant woman I’ve ever seen. A pink bandana garnishes her head, green eye shadow glitters her eyelids and floral pants and animal print acrylics add a special touch to her ensemble. She is 34, single and 22 weeks pregnant. According to her chart, she’s also clinically obese.

On a Tuesday in mid-October, in a room in the back of the Tompkins clinic, I sit down with Caesar to talk.

A school bus driver in the neighboring town of Milford, Caesar had five children before this one, all boys. “My 6-year old and 3-year old were both born early,” she explains. “26 weeks for the 6-year-old, and 30 weeks for the 3-year-old. The one who came out at 26 weeks weighed two pounds.”

A full-term baby is born anywhere from 37 to 40 weeks into the pregnancy and weighs five to eight pounds. In many ways, the startlingly low birth weight of Caesar’s child was to be expected: preterm birth is one and a half times more common in obese women than it is for normal weight women.

Caesar tells me her children are all healthy today, but when the 26-week-old boy was born, “he couldn’t keep his body warmth.”

This is because Caesar had preeclampsia, which occurs when a pregnant woman develops high blood pressure. Sometimes it can cause the baby to grow slowly, and it can lead to more life-threatening outcomes. Obese women have six times the risk of developing preeclampsia compared to women of normal weight.

“They gave him a 10 percent chance to live,” she recalls. “They said that his lungs were underdeveloped. They thought he would be handicapped, but now, he doesn’t have any issues at all. The only thing is at nine months, he developed asthma.”

I turn the focus of the conversation to Caesar herself. “Do you have any health problems?” I ask.

“I’ve had diabetes for eight years, and high blood pressure for three years,” she tells me. “I take care of the diabetes with insulin, but now that I’m high-risk and pregnant, I can’t take anything for the blood pressure.”

Caesar tells me the diabetes “goes up and down, but lately it’s been good.” She also says that her high blood pressure has been fine recently.

Although I don’t know Caesar well, I want to know her answer to a critical question. What is she afraid of with this pregnancy?

“Having another baby early,” she says quietly. “Some babies are born with a lot of complications.”

Caesar is well informed. She tells me Campbell has been teaching her “a lot” about her condition, and she frequently uses to internet to look up information. She also tells me that she has been following Campbell’s instructions and watching what she eats, avoiding starch and bread and trying to be active.

Caesar seems to have a thorough understanding of her situation, but does she consider herself as obese?

“I would probably say I’m overweight,” she says.

The clinical definitions of “obesity” and “overweight” are different. While overweight is defined as having a BMI as over 25, obesity is defined as having a BMI of over 30.

Campbell tries to dispel these misconceptions — the definitional difference between “obese” and “overweight” — from the moment she meets a new patient. She undergoes a thorough education session with each of her obese pregnant patients at the beginning of their pregnancies. In this session, she defines obesity; explains the patient’s increased risks for diabetes, preterm birth, stillborn birth, blood clotting and wound infection; talks about optimal weight gain during pregnancy; and explains the proper eating and exercise habits.

Despite all this education, obesity is still a tough issue to discuss.

“Sometimes it’s hard to talk about [obesity], or patients may not have the same language. For example, Don’i may not fully understand the word ‘obese’ and think that ‘obese’ and ‘overweight’ are interchangeable,” Campbell says.

Still Campbell says Caesar “had insight into her risks.” Most of her patients understand that their pregnancies are more complicated than other pregnancies, even though they may not like talking about it.

“Some women embrace the necessary changes during their pregnancy and do a great job, but some women are not as organized as that,” she says. “It’s very hard to change your diet, especially if you grow up in a household where you eat a certain way.”

But others are less successful, and many of these patients are faced with myriad economic and social factors that may limit their understanding or capacity for change, she adds. The frustration that comes from attempting to lose weight, while also naturally gaining weight from the pregnancy, leads many women to give up entirely. Furthermore, Campbell says that her obese patients often live and work around other obese people, clouding their understanding of where their weight falls on the spectrum.

Both nurse Katie Sullivan and Campbell agree that, while they can provide the education and support needed to make these changes, it’s up to the patients to follow through.

“Ultimately the patient makes their independent decision … whether they are going to buy the whole grain pasta or the cookies,” Campbell says. “It’s two-sided — we’re a team and they have to meet us in the middle.”

According to Campbell, such is what makes Caesar’s case particularly encouraging. Caesar’s efforts have proven, above all, that her methods for minimizing risks of obese pregnancies are “making a visible difference” in the lives of her patients.

* * *

A couple of months after my conversation with Caesar, Campbell informs me that she delivered a premature baby.

Under the lights of the operating table, Caesar was the portrait of a woman who heeded the advice of her doctor, taking every precautionary step to ensure the safe delivery of her baby. For Campbell, the preparation was as thorough as possible, with every preventative measure fulfilled. But even with all these bases covered, and then some, the severe risks of an obese pregnancy remained. This reality speaks to the larger cultural problem of obesity, one that Campbell and her team consistently must face during each day, each delivery.

The pregnant and obese women who file into these operating and consulting rooms are soldiers; they carry their fears on their backs like a rucksack, unpacking their loads in the hearts and minds of the physicians, nurses and receptionists who wait on them every step of the way. But as Caesar shows, many are open to learning about their risks, eager to change their habits to improve their own health and the health of their future children.

Campbell understands that for the most part, the roots of obesity are beyond her control.

“Every patient has the potential to change,” Campbell says. “And as a physician, it’s my job to unlock that potential for my patients and let them see that they are capable of making changes to improve their health.”

 

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