Ep 186: Obesity And Pregnancy – Updated!

Dr. Nicole (00:00): In this episode, you are going to learn how carying extra weight affects pregnancy. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified ob gyn, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident and empowered to have a beautiful pregnancy in birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

(00:51): Hello there. Welcome to another episode of the podcast. This is episode number 186. I am so glad that you're spending some time with me today. So in today's episode of the podcast, I am addressing again how carrying extra weight can affect pregnancy. I originally did this episode back in 2019, so three years ago, but I feel like I missed the mark with it. I was a bit too negative focusing on some of the issues that can occur. And I also think, to be honest, I have some weight bias things or issues that I have been working on. So I want to come back to the episode today to address how carrying extra weight can affect pregnancy. Now, I know that weight in general can be a really sensitive topic, but it is something that we need to discuss because it is important and the reality is that it does affect pregnancy and affects quite a few women during pregnancy.

(01:57): Now, as far as topics during the episode or as terms during that episode, rather, I'm going to use the term obesity because that is what is used in the literature. And just for consistency's sake, I'm gonna use the term obesity. So please understand that I'm not trying to be or offend anyone or anything like that. I just wanna be consistent with what I use in the episode. I also want to acknowledge that weight is not the only indicator of health. It is an important indicator of health, but it's not the only one. Also, your activity level is important. Blood pressure is important, cholesterol is important. So please understand that. I recognize that weight is not the only indicator of health, but it is important one. So we need to talk about it. And the final thing I wanna talk about before we hop into the episode is I also wanna acknowledge the importance of body positivity and recognizing that bodies can come in all shapes in all sizes.

(02:53): And I know like Lizzo has been a big proponent of that, but we also need to address the realities that carrying extra weight can be detrimental to health. So yes, I fully acknowledge and support body positivity, but I don't want to ignore the implications of weight either. So in this episode, you are going to learn what obesity is, the definition, how common it is, how obesity affects pregnancy, how it affects babies, and then how pregnancy care changes if you are considered obese. I know this may seem like a lot overwhelming but again, this is just about understanding the facts, the data, giving you the information that you need so that you can take the best care of yourself and have your best pregnancy in birth. Now, I wanna mention a couple of other episodes that would be great to listen to go along with this, episode 79 with Jen McClellan.

(03:52): She's from plus size pregnancy, plus size birth, and we bust myths regarding being plus size during pregnancy. That's a great episode. So that's episode 79, and I'll link that in the show notes. Also episode 141 about prenatal nutrition. Prenatal nutrition with registered dietitian, Stephanie Lori, that's a great episode. That's actually becoming one of the more popular episodes of the podcast. And then episode 175 is with Dr. Katie Brown. She's an endocrinologist and an obesity medicine specialist, and she gives some great information in that episode as well. So we'll link all three of those in the show notes. All right, last thing before we get into the episode, if you have not checked out or if you don't have childbirth education, then do check out the Birth Preparation Course. The Birth Preparation Course is my signature online childbirth education class that will get you calm, confident, and empowered to have the most beautiful birth.

(04:46): It is created by me, a board certified ob gyn. Y'all know I've been in practice for a long time, well over 15 years, have had the privilege of helping over a thousand babies into this world, and I've taken my hearts soul passion and all of that knowledge and put it into a very well organized, informative course for you to help you have the best hospital birth. So do check it out, over 1500 mamas have gone through the course at this point. Actually, it's probably a lot more than that. I haven't checked in a while actually. And I would love to have you go through it too. So let's check out all the details of the Birth Preparation Course at drnicolerankins.com/enroll. Okay, let's get into the episode. So first thing I want to talk about is what is the definition of obesity? So definition, the definition of obesity is a body mass index greater than 30 kilograms per meter squared.

(05:38): And it basically, it's a formula that we use. BMI is not the best indicator of weight because if you have a lot of muscle, your BMI is gonna be higher artificially, but it's one that we use pretty commonly. So obesity is a BMI greater than or equal to 30, and then that's further stratified. Class one is a BMI of 30 to 34.9. Class two is a BMI of 35 to 39.9, and then class three is a BMI greater than or equal to 40. For some real world examples, if you are five foot three inches tall and you weigh 170 pound 175 pounds rather, you would be considered obese based on your bmi. If you're five foot three inches tall and you weigh 225 pounds or more, then you would be considered in the highest obesity class. And if you're five foot five inches tall and you're 185 pounds, you would be considered obese.

(06:41): If you're five foot five inches tall and you're 240 pounds or more, you would be considered in the highest class of obesity. Sometimes that highest class of obesity greater than or equal to 40 is also referred to as morbidly obese. I think that's a really terrible term. So I try not to use it, but you may see it if you fall into that highest BMI category. Now, there are problems with using BMI for pregnant people. It doesn't actually adapt very well to the pregnant population because when you're pregnant, your weight is going to increase over a relatively short period of time. And much of that weight gain is related to things like the weight of the baby, amniotic fluid, the increased blood volume. But there aren't any really great standard definitions during pregnancy. So often what we typically do is define obesity or not being obese based on the pre pregnancy BMI and not the weight that you gained during pregnancy. Typically, we based it on your pre pregnancy bmi, what you weighed just before you got pregnant.

(07:51): Now, how prevalent is obesity? It's actually pretty prevalent in reproductive age and pregnant women. It varies depending on the definition, but when we look at data from the CDC from around 2019, 2020 ish, about 34% of all women age 20 to 39 are obese and it's higher for non-Hispanic black women, that number is 57%. It's lowest among Asian women, it's 17%. Among non-Hispanic white women is 30, sorry, 40% in among Hispanic women is 43%. So again, the prevalence of obesity is pretty high in our society. And when looking at live births in particular, one database indicated that about 26% of women were obese pre-pregnancy and another 26% were considered overweight. So again, it's a pretty common phenomenon in our society. We do know that based on the data, obese, pregnant women are at an increased risk for some maternal and perinatal complications. And I'm going to go through those in just a bit.

(09:01): And we know that those risks are amplified with increasing degrees of carrying extra weight. So the more weight you carry, the higher your risk are. It's been estimated that a full 25% of pregnancy complications like gestational hypertension, preeclampsia, gestational diabetes, preterm birth are attributable specifically to being overweight or obese. So a full 25% of pregnancy complications are attributable to being obese. We also know that babies born to moms who are obese are at an increased risk of childhood and adult obesity. And I'm gonna talk about that as well. So why is it an issue or why does carrying extra weight cause problems? Why do we think that's the case? Well, fat tissue, the medical term for it, it's adipose tissue. It's actually an active organ. It's an active endocrine organ. It secretes hormones directly into the blood. So when you have extra adipose tissue, it can have negative or dys regulatory effects on metabolism.

(10:10): It can also have negative effects on inflammatory pathways, and that can be amplified during pregnancy. So things that we may see are like insulin resistance. We may see inflammatory pathways, and I'm not gonna go into all of the technical names of the hormones, but that can affect placental growth and placental function. It can affect the development of preeclampsia. So again, it's that fat tissue actually secretes active hormones that can have negative impacts on not just health and pregnancy, but health outside of pregnancy as well. And that's supported by the fact that we know that with increasing degrees of carrying extra weight, then there are increased risk of problems. And we think that extra weight or maternal obesity can affect babies because of what are called epigenetic changes. So small changes in the genetic structure of the baby because they're exposed to potentially increased levels of sugar, insulin, fats, and inflammatory, what's called cytokines. And there's some concern or theories that these in utero effects can cause long term changes in the way babies' metabolism works both in childhood and even into adulthood.

(11:37): So what are some of the issues that can happen in pregnancy? Okay, so let's talk about the overall risk of severe morbidity or mortality for those who are obese in pregnancy, or rather, let's talk about it stratified by weight in general. Okay, so one study that looked at over 740,000 women found that the overall risk of severe morbidity and mortality in those who have a normal BMI was 143 per 10,000 women had severe morbidity or mortality. When you're overweight, that number went up to 160, over 160 out of 10,000 women, class one obesity, BMI 30 to 34, that number went up to 168 out of 10,000 women. Class two obesity, BMI 35 to forty nine, a hundred and seventy eight out of 10,000 women. And then class three, obesity. BMI 40 or greater. It's 203 out of a hun, 10,000 women. So, oh, I'm sorry, I'm getting a little tongue tied with the numbers, but again, normal bmi, 143 out of 10,000 women had some severe maternal morbidity or mortality event.

(12:59): As the BMI increases, that number goes up and gets up to 203 of 10,000 women when you have the most severe obesity, BMI 40 or above. Now, what are some of those events that are occurring for morbidity? That can include hemorrhag requiring transfusion, serious cardiac, respiratory, brain events, blood clots in the legs with the lungs, sepsis, which is an infection of the blood, kidney failure, liver failure, anesthesia related complications in uterine rupture. So those were the things that they were looking for. And those events, again, steadily increase the more weight that you carry. And the study also noted that women with the BMI of greater than 50 have a very high risk of adverse maternal and perinatal outcomes. Okay, so let's further break down some of the things that can happen based on the antipartum period, intrapartum. So during labor and then postpartum. Okay, so obesity does slightly increase the risk of early pregnancy loss compared to women with the normal bmi.

(14:15): What's something called the odds ratio of having early pregnancy loss if you're obese is 1.75. So that's a little bit increased but not terribly increased. And one of the things that's interesting in general, we see that miscarriages related to chromosome abnormalities in pregnancy, but in women who are obese, it's often seen that the chromosomes are normal, but we think that it's an unfavorable hormone environment that makes it so that the lining of the uterus is not receptive to pregnancy. And also the inflammatory changes make it difficult for the pregnancy to stick. So we think the reasons for miscarriage may be different in women who are obese.

(15:09): Now, when we look at pregnancy complications that can occur, some are a lot more than others, some are not that significant. I'm just gonna go through some of the numbers and tell you what they are. So for gestational hypertension and one study, this was a study of over 15,000 women for gestational hypertension, the percentage who developed gestational hypertension in normal weight folks was 4.8%. If you're obese, it was 10.2%. So double the risk, but still not likely, but double the risk and morbidly obese bmi. And in this study it was defined as greater than or equal to 35, then it was 12.3%. So definitely much more increased for preeclampsia. It was 2% in normal weight, 3% in obese women, so just a tiny bit higher. And then 6.3% in morbidly obese women. Gestational diabetes, 2.3% in normal weight, women, 6.3% in obese women, so almost three times as much, and then 9.5% in morbidly obese women.

(16:26): Some other factors water breaking early was actually about the same. 1.7, 2.1, 2.2. Preterm delivery, just a tiny bit elevated, 3.3 4.0, 5.5%. Growth restriction was actually about the same in this particular big cohort, 1.1%, 1%, 0.8%. Birth weight greater than 4,000 grams, which is a pretty big baby. 4,000 grams is about eight and a half pounds. That was 8%. And then 13.3% in obese women, 14.6% in morbidly obese women. So definitely a big increase there. Birth weight greater than 4,500 grams 1%, 2%, 2.6%. Placenta previa was about the same. Placenta abruption was about the same. Actually operative vaginal delivery was higher in normal weight women than obese women, 10.5% versus 8.5%. So when you look at the overall numbers, the biggest risk are for gestational hypertension. So developing blood pressure issues during pregnancy. Also, gestational diabetes are the biggest risk. And having a birth weight greater than 4,000 grams, which is probably related to gestational diabetes. But then again, the overall numbers were favorable in the sense that there's a very strong chance that you won't develop these problems. You don't have to necessarily have problems just because you carry extra weight. Yes, you are at an increased risk, but that doesn't mean that you automatically are going to have issues. As a matter of fact, this data shows that most likely not, okay, most likely you're not.

(18:12): Interestingly, there's also an increased instead incidence of fraternal twins in obese women. And the other thing that can impact pregnancy is that obese women often have an increased chances of having obstructive sleep apnea, which can get worse during pregnancy and may increase the risk for gestational diabetes and potentially blood pressure issues in pregnancy. Okay, now during labor, one of the really, really important things to note is that labor can be slower. Like signif take significantly longer to get to from four to 10 centimeters. It can take as much as two hours longer to get from four to 10 centimeters. So you really wanna be careful if you carry extra weight, whether they're overweight or obese, that we're giving enough time for your labor to progress. Because studies definitely show that labor is longer to get from four centimeters to 10 centimeters. So that active part of labor takes longer.

(19:18): However, the duration of what's called the second stage of labor, and by the way, you can learn all the stages of labor in the Birth Preparation Course. But the second stage of labor is when you're pushing that does not actually appear to be affected by bmi. So it's really the part getting from four centimeters to 10 centimeters, that is longer in people who are obese. The pushing phase actually is not longer. Obese women are at an increased risk of labor induction, and that's directly related to the increased risk of pregnancy issues, particularly like gestational diabetes or sometimes issues with concerns of the baby being big. Another key point is that we have to be patient with the induction process because it can be longer. One study showed that for women having their first baby with increments and increase in weight, it added another 0.3 hours for the induction experience. So we definitely have to be patient with the induction process and get things enough time to unfold.

(20:26): Obesity is also a risk factor for cesarean birth, both elective cesarean birth and emergency cesarean birth. And that risk increases with increasing maternal weight. There's also an increased risk of during the cesarean difficulties with anesthesia, it can be more challenging to place an epidural or a spinal. And I'm gonna be honest with you, it's because of it's very difficult to feel. It can be difficult to feel the anatomical landmarks. So when an anesthesiologist places an epidural, epidural is a catheter that stays in during labor. A spinal is just a one shot dose of medicine with either one of those. They feel along the bones to find the right place. And if you carry extra weight, it's difficult. It can be very difficult actually to feel those landmarks. And so it can be challenging to place. So be prepared that if you do carry extra weight, it may take quite a bit longer to get an epidural placed or a spinal place just because it can be challenging to feel the right landmarks.

(21:36): There's also an increased risk of endometritis, which is infection of the uterus after cesarean birth, blood clots developing, as well as wound infection. In order for a caesarian incision to heal well, you want it to be exposed to air, you don't want it to be covered up. And if you have extra weight around your belly, especially where the incision is kind of tucked underneath a fold of fat, it can have issues with healing cuz it's just in a moist, dark environment that allows bacteria to proliferate. So you have to be careful about really keeping the wound clean and dry. We have to do that anyway, but there's an increased risk of wound infection if you're obese. And honestly, I also wanna be honest that it's actually technically a more difficult procedure technically to do a cesarean birth when someone carries extra weight. Sometimes we have to tape up the belly in order to get the tissue out of the way so we can get to where we need to get.

(22:42): We have to use instruments sometimes that are deeper because we have to go through more fat tissue. It is often more physically demanding on the part of the surgeon to navigate that extra tissue. And I'm not trying to be disparaging, I wanna be very careful about that. I'm just trying to give you the honest realities of how challenging it can be when someone carries a lot of extra weight and doing those procedures. Even with the vaginal birth, it can be challenging because if you're trying to hold the legs up get people in a position where they can push, all of those things can be physically demanding to hold and carry that extra weight.

(23:26): And just in general, in the postpartum period, people who carry extra weight, obese folks are at an increased risk regardless of the method of birth for blood clots to form in the legs and travel to the lungs. For those who are normal weight compared to those who are obese, the number is as high as 4.6 times the chances of developing a blood clot. There's also an increased risk of infection regardless of the mode of delivery for vaginal birth. There could be an increased risk of infection at any tears that happen in the vagina that needed to be repaired. And then there's also an increased risk of postpartum depression with obesity as well.

(24:14): But I wanna reiterate that increased risk is not the same as it's going to happen, okay? We have to be aware of the possibilities that may come up, address them as they come up. But the most likely thing is that things are gonna be fine. We just have to be patient with the labor process, do all of the things that we know how to do to prevent issues and complications from occurring. But we do need to be mindful that there are increased risk of things that may occur. All right. So what are possible complications that can occur in babies born to moms who are obese? So obese women are at an increased risk for having babies with congenital anomalies, including neural tube defects, cardiac problems, oral and facial defects like cleft lip cleft palate, and also issues with the limbs. The risk again, increases with increasing degrees of weight.

(25:11): We're not exactly sure what causes these, but we think it's again, related to the altered status that the baby is in. In terms of the nutritional environment, it can be tricky to detect problems with prenatal ultrasound. The way ultrasound works is that it sends sound waves through tissue and the sound waves bounce back and produce images depending on how they hit the baby's the structures inside of the body. And when there's extra fat to go through for those sound waves to travel, it can be difficult to sometimes get the images that we need to get. So that can be a challenge as well, detecting any issues that occur during pregnancy too. Some other things that are also increased slightly. There's an increased risk of stillbirth. There's an increased risk of perinatal death that's within the first 28 days after death. There's an increased risk of neonatal death and infant death.

(26:14): So basically within the first year of life, there's an increased risk of death for babies that are born to obese mothers. We're not entirely sure why that happens, but that concern is there. And then as I mentioned, there's also an increased risk for baby being larger at birth. The chances of a baby being greater than 4,000 grams is higher. There are two potential things that we get concerned about. Shoulder dystocia, which is where the shoulder gets stuck underneath the pubic bone. That can be a difficult complication of pregnancy. It's not very common, but it does happen. And then it also increases the risk of obesity for the child later in life if they are born on the larger side. In fact, childhood obesity in general is increased. If you have one obese parent that increases the risk of obesity by two to threefold for the child.

(27:10): If you have two obese parents, that increases the risk of obesity actually up to 15 fold. And we think that particular for mom being obese potentially creates an in utero environment that can permanently change the way the baby metabolizes or the baby's metabolize metabolism, I should say, which can lead to an increased risk of obesity developing later in life. There's also some concern that maternal obesity may contribute to changes in the fetal brain. There's increasing evidence that maternal obesity can lead to an increased risk of autism, adhd, anxiety, depression, and eating disorders. Not terribly higher risk, but a potentially increased risk.

(28:06): So what can we do about this? Really the most important thing that we should do is try to optimize weight before pregnancy. Doctors really should be discussing with women who have extra weight, their reproductive planning well before conception so you know what the potential issues are. Because the ideal situation is to lose weight before pregnancy. And the key is that you don't have to get down to a normal weight. Even a 10% reduction in pre-pregnancy BMI can reduce the risk of preeclampsia, gestational diabetes, pre-term delivery, big baby stillbirth, 10% reduction in pre-pregnancy BMI can reduce those things by 10%. And if you reduce it even more, it even reduces the risk further. So ideally, you want people to even lose a few pounds before they get pregnant. Those are gonna be the best options in order to prevent issues from occurring during pregnancy.

(29:18): It's also important to look at weight between pregnancies. One study showed that women who reduce their BMI by even one or two units reduce their risk in a next pregnancy of having a large baby. They increases increase the chances of having a vaginal birth, reduce the risk of having gestational diabetes. So even small amounts can make a big difference in terms of pregnancy outcomes. Some women may even consider undergoing bariatric surgery that we're finding is one of the most effective ways in order to lose weight. That will definitely decrease the risk of reclaimed the gestational diabetes, but you need some time to recover from that procedure and get yourself optimized in terms of your nutrition before you get pregnant. So that's an option as well. Now, as far as pregnancy management, there's actually not that much that is terribly different in terms of pregnancy management.

(30:15): Some things that I think we don't do enough of, actually. I feel like we should refer everyone to a registered dietician during pregnancy, but I think insurance insurance tends to be the issue with that. Who's gonna pay for it? But I think if you have obesity, that's a reason to go to a dietician because it's going to help improve outcomes. So everyone should see a registered dietician during pregnancy, and especially if you're obese, you may need to see a high risk pregnancy doctor, maternal fetal medicine specialist in order to get special ultrasounds or counseling. Depending on your weight and your history, you may need to have a consultation with an anesthesiologist before you get to labor and delivery to make sure they can go over the options for anesthesia for you. So I would say those are the biggest things. They don't happen. I would say the anesthesiologist is not common that that needs to happen.

(31:11): But a fair number of people, if not most people, will see a maternal fetal medicine specialist, also known as a perinatologist. And I think everyone should see that. Registered dietician will do the same things that we do for everyone. Blood pressure, ultrasound examinations, look at medications. If you're obese, then it's appropriate to get a early diabetes screen in pregnancy. Sometimes women aren't seeing a doctor before they get pregnant, and this is the first opportunity to really screen for diabetes. So you will get early diabetes screening if you are obese to look for undetected diabetes. And then you will get screened again to look for diabetes at the typical time in pregnancy, which is 24 to 28 weeks. And if you've had bariatric surgery, I forgot to say, then it's really important for you to see a dietician so you can make sure that you are on a good diet to get all the nutrients that you need.

(32:02): Now, one thing that is definitely different is gestational weight gain. We recommend that people who are obese, we don't recommend that you lose weight during pregnancy, but the recommendation is that you gain no more than 20 pounds your entire pregnancy. Okay? So no more than 20 pounds, your entire pregnancy, limiting weight gain has been shown to reduce some of the risk of adverse pregnancy outcomes. So you don't wanna lose weight, but you don't wanna gain a lot of weight either. Another thing is NIPT tests or non-invasive prenatal tests, cell free DNA screening, the gender tests as it's often referred to in obese people, you have a higher chance of the test failing or getting an inaccurate result because there's a lower fraction of the DNA in your blood. Not sure exactly why that occurs, but you do have an increased chance of getting a test failure or in an accurate result.

(33:01): And then the final couple things about pregnancy care, we will almost always recommend that obese women are taking aspirin, low dose aspirin, starting at about 16 weeks in order to reduce the risk of preeclampsia. Aspirin is one of the things that has been shown for sure to decrease the risk of preeclampsia. And if you have obesity in one other factor, you should be on it, and almost everybody will have another factor like being African American being over 35. If you had a previous bad pregnancy outcome, almost everyone will have, they're a bunch of factors that will qualify you, but being obese, you should be on a baby aspirin to reduce the chances of having preeclamsia. And then the final thing is ultrasound. We often do ultrasounds to look at baby's weight. Some typically during prenatal care, we measure the fundal height, the height of the uterus to see how the pregnancy is growing.

(33:58): But that can be challenging if you carry extra weight. So sometimes we have to do serial ultrasounds, meaning every three to four weeks, typically four weeks in order to assess the baby's growth, just so we know that everything is going on with the pregnancy. Okay, and the last thing I wanna talk about is labor and delivery. So the hospital has to have the appropriate physical resources in order to care for folks who have extra weight. So we have to have larger gowns, we have to have appropriate beds, we have to have operating room tables that can carry extra weight. We have to have wheelchairs where people can be transported, all of those things in order to make sure we are taking the best care of folks. One of the other things I talked about this earlier is the anesthesia consultation because anesthesia can be more difficult or challenging.

(34:47): We really don't want to have to put people to sleep at all during pregnancy, but it can be definitely increase the risk of having to go to sleep or general anesthesia. For example, during a cesarean for someone who's obese, there's a increased chance of complications from that. So you likely will get an anesthesia consultation early. And remember, it may take a bit longer to do that epidural just because it's technically more challenging. And then the final thing is monitoring the baby. So the external monitor that monitors the baby's heart rate and the transducer that monitors contractions. The external monitor for the heart rate is similar to ultrasound in the sense that it sends sound waves through the tissue and then they bounce back to the transducer. And if you have more tissue, it's going to be potentially more difficult to hear the baby's heart rate.

(35:41): Sometimes we have to strap the monitors very, very tight in order to get them down closer so we can monitor the contractions, monitor the heart rate. Sometimes we have to do internal monitors, meaning monitors. One is on the baby scalp or one what's called an intrauterine pressure catheter that monitors contractions from the inside just because of the challenges of monitoring the baby and the contractions on an external monitor if mom is obese. Okay, and the last thing I'll say is that it remains controversial about when women who are obese should have their baby. Some recommend delivery by the due date in order to reduce the risk of stillbirth and complications from the baby continuing to grow and getting bigger. It's not scientifically proven, and that's the best, or I don't know the best option or the most the option that's going to automatically reduce the risk of things happening.

(36:43): But many times that approach is taken and it doesn't increase the cesarean birth rate in order to induce by the due date. But it really depends on the resources of the hospital, resources of the practice because it could be a longer induction. So it really is an individualized approach to delivery. One thing I will say is that definitely we should be going for a vaginal birth. We should not be saying, okay, you should just have a cesarean birth because of your weight. It is not associated with less problems in a planned vaginal birth, even if we have to do an emergency cesarean. So there should be no discussion of, oh, you should have a cesarean birth just based on your weight alone. That is not appropriate.

(37:34): Okay, so that's it. Just to wrap up, we know obesity in pregnancy is a pre-pregnancy BMI of greater than or equal to 30, and there's class one, two or three. Class three is bmi greater than equal to 40. That's where we see the most problems. Fat tissue or adipose tissue is actually an active endocrine organ. It can have dys regulatory effects on metabolism, inflammatory pathways that can lead to issues for moms and babies compared to people who have a BMI that is normal. Pregnancies among those with obesity are an increased risk for several outcomes, including early pregnancy loss, congenital anomalies, stillbirth, gestational hypertension, preterm birth, gestational diabetes, cesarean birth, birth of a large baby, not likely to happen, okay? Remember that? Not likely to happen, but there is an increased risk. Ideally, weight management before pregnancy is the most optimal outcome or most optimal strategy in order to reduce the risk of outcomes.

(38:43): Even losing a little bit of weight is going to be helpful to prevent some of those negative outcomes. But during pregnancy, the things that will change are screening for diabetes twice during the pregnancy, both early and later during the pregnancy. We wanna limit weight gain to 20 pounds or less, and then we'll do ultrasounds potentially to look at the baby's growth. Also, you definitely wanna be on the low dose aspirin because we know that that will help reduce the risk of preeclampsia and delivery. Timing should be may or may not be altered. We'll say that depending on what other factors you may have going on, definitely you should not be offered a C-section just because of your weight. We do have to be patient with the labor process because it's going to take longer for both overweight and obese people. All right. But the pushing phase should not be any longer.

(39:39): All right, so there you have it. I hope you found this episode useful. I would love to hear your feedback, good, bad or otherwise on your thoughts about the episode. Also, do me a solid. If you found this podcast helpful, share it with a friend. Sharing is caring and helps me to reach and serve more pregnant folks, so do share it with a friend. Also, subscribe to the podcast wherever you are listening to me right now, and be sure to leave an honest review. It helps other women to find the show, helps the show to grow. Do find me on Instagram. I am there posting videos, posting post to help you during your pregnancy. You can also shoot me a DM on Instagram to let me know what you think about the show. I'm on Instagram at Dr. Nicole Rankins. All right, so that's it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.