 So now we are going to introduce our speaker, I'm really very honored to present Cecilia Chebis. She is the midwifery director and a tenure associate professor at the University of British Columbia, Faculty of Medicine. From 2013 to 2018, she directed Yale School of Nursing's Midwifery and Women's Health Nurse Practitioner Master's Degree programs. She has done capacity building, teaching and curriculum consultation in Switzerland, Laos, China and Ghana. Cecilia studied midwifery at Emory University. Her 1993 doctorate in Applied Medical Anthropology is from the University of South Florida. She establishes an academic division of midwifery with the University of South Florida College of Medicine while jointly appointed to the College of Nursing and Public Health. Cecilia is an elected fellow of the American College of Nurse-Midwives and has served of the ACNM Board of Directors representing Region 3, the U.S. South, and on the Fellow of Shift Board of Directors. Cecilia was the Florida Nurses Association's great 100 nurse in 2009. The 2010 reviewer of the year for the Journal of Midwifery and Women's Health, the University of South Florida Department of Anthropology distinguished alumni in 2012 and in 2014 connected with Nightingale Excellence in Nursing Award winner. Cecilia has completed research and published on Fuspartum Stressors and Depression. And Cecilia currently is called her shift focus on Paynital Way, Gain Optimization and Obesity Prevention during the Paynital and lactation periods with additional goals of reducing weight, stigma, and the atrohandic harm caused by over-yellows risk management for those with obesity. Her teaching materials and writings about advanced counseling are available without charge at advancewithwifery.org. Welcome, Cecilia. And whenever you are ready, we are so aimed to listen to your presentation. Thank you all for listening tonight. I'm sorry for those of you who thought you would be hearing about long-acting contraceptives in Ethiopia. I'm going to try to give you information that's as useful to your practice. We're going to talk about very briefly the perinatal risks associated with high BMIs and then really look at who is most at risk and how that affects our care. I'm going to blast through some of these slides. They were actually written for a little bit different target audience. I want to make sure we're all on the same page when we're talking about obesity. Medically, obesity is defined as a body mass index greater than or equal to 30. It's a research measurement that's been used in the medical literature. It's not a perfect measure, but we do know that as BMIs increase as weight increases, outcomes in pregnancy and birth have more complications for some people. Many electronic medical records recalculate a BMI at each visit. The research about risk in pregnancy is tied to pre-pregnancy BMI or BMI in the first trimester. A woman could actually start in an overweight category and gain enough weight in pregnancy to be within an obese category, but that doesn't mean the risk has increased. There is an effect of excessive weight gain in pregnancy that increases risks for poor outcomes independent of BMI. Sorry, it's allergy season here. Obesity is more than a high BMI and there are many contributors to it. This is a complicated diagram. I'm not going to go through it all. Except to say that obesity is not overeating. It's not lack of physical exercise. It's a response to environments that are filled with unhealthy foods, stressors like chronic racism, poor sleep and what happens in pregnancy with maternal nutrition and exposure to endocrine disrupting chemicals affects not only the fetus during the pregnancy. If it's a female fetus, the ova that that female fetus carries for the rest of her life are affected. So excessive weight gain, obesity in the mother flip epigenetic switches that individuals don't have good control over. We've really looked at high weights, obesity. I'm going to use that term obesity because I most often speak to medical audiences, but there are individuals who prefer to be called fat. They might prefer to be called plus size mothers. Whatever language individuals want to use is what we should be using clinically. So there are relationships, not only between what we eat, but between our intestinal microbiomes and the chemicals we're exposed to in the environment and the foods we eat. They all react with our HPA axis so that simply saying we're going to cut back on our eating doesn't work for very many individuals. This is a brief slide of the complications that can be caused by high BMIs in pregnancy. These have been so well publicized over the last 20 years. I don't want to dwell on them except the largest ones, the ones that occur most often. So gestational diabetes, hypertensive disorders of pregnancy, and then increased cesarean births are all linked with high BMIs, particularly those 35 and greater. Most individuals with high BMIs will have uncomplicated perinatal courses. And boy, here's flashing lights. This is the message I really want you to take home today. Yes, there are increase in risks, particularly when BMIs are 40 or greater. But as humans, we focus on risks, we focus on bad outcomes, it's self-protective. We also remember problems, risk, bad outcome that sticks with us emotionally more than data. So I want to use the data a little bit differently than it's been used in the medical literature and talk about what some people call metabolically healthy obesity. One way of looking at obesity is to use the Edmonton Obesity Staging System. Maria Sharma from the University of Alberta is one of the researchers who worked on the Edmonton Staging System. Coincidentally, his daughter is a midwife here in Vancouver. The Edmonton Obesity Staging System looks at individuals with BMIs greater than 30, but sorts them into those with no apparent risk, normal blood glucose, no high blood pressure, no other diseases. A Stage 1 Edmonton Obesity Stage has maybe transient hyperglycemia, maybe borderline high blood pressure. These are individuals who look healthy on physical exam. It's not until an individual has an obesity-related chronic disease, particularly hypertension, diabetes, osteoarthritis, or sleep apnea, where we start expecting other complications to health. Edmonton systems 3 and 4 midwives rarely take care of. These are individuals who've had hypertensive strokes, who have heart failure. They're outside of our scope of practice. But here's another way of looking at this. So all of the individuals in this diagram have BMIs greater than 30, but those in Edmonton Stage 0 and 1 are healthy on physical exam. That is actually where most individuals are during pregnancy. Aria and his other co-researchers took NHANES data from the United States, a huge data set, and divided those in different weight categories by the Edmonton staging system. And their findings were that in Class 1 obesity, these two groups of individuals had no apparent disease. Even when you look at Class 3 obesity, which are individuals with a BMI of 40 or greater, 19% of those individuals have no disease of any kind. Their lipids are normal, their blood glucose is normal. These are individuals we could expect to have healthy pregnancies. There are some contributors to complications in addition to obesity and pregnancy. You'll see these are the people on this slide who already have coexisting disease and individuals who are having pregnancies at age 35 or greater. Some of my captions here aren't showing up. This is a study from the University of Alberta again where a group of obstetricians applied the Edmonton staging system to individuals who were having inductions of labor. And they found that those without other risk factors had the lowest rates of cesarean birth. They could use the EOSS to help predict outcomes. You will have these slides if you go back into the website. You'll be able to see these captions that aren't showing up. This is the same study as the prior study, but what I want to show you is individuals with no comorbid conditions in a normal BMI range had a 70% chance of a vaginal birth. Those in Edmonton staging system one had a 70% chance. And it wasn't until people were in stage two that their vaginal birth rate started to drop. Here are the individuals with terrible chronic disease like end-organ disease. They only had about a 10% chance of a vaginal birth. This is a large Ontario cohort that looked at all individuals with obesity. All of those individuals had almost a 60% chance of a pregnancy with no complications. The individuals from that same study in Ontario who had the most pregnancy complications were the ones with BMI's of 35 or greater. In the United States, all individuals with a BMI of 30 or greater are considered at the same risk. In the United Kingdom, the guidelines start thinking about special care at a BMI of 35 or greater. And our Canadian guidelines are staged to look at individuals holistically. Well, I don't know what that slide was going to be. I am not going to go through every one of these slides. I'm going to give you my website too and you will see lists of references. These are all midwifery studies showing that individuals with high BMI's who had midwifery care had great outcomes. This is a study I did for the American Association of Birth Centers. And I show you this one to show you that individuals with high BMI's do not necessarily have to give birth in a hospital. That's kind of a U.S. assumption. In this study, Primiporas who started labor at a birth center had a 30% transfer rate. Most of that was for pain management. They had an 89% vaginal birth rate. Those individuals had great supportive care. They continued to receive care from midwives in the hospitals and they had great outcomes. If we approach clients, we can help them lower their own risk and have healthier outcomes regardless of their BMI. So, first of all, we want to make sure that our offices, our practices are welcoming. We need to get past our own biases against weight. That's why I showed you those initial slides that we've treated this as a problem of the individual. Actually, obesity is an environmental problem and it's related to broken food systems. That's the World Health Organization definition. So, we want to make sure everybody in the practice is welcoming and non-judgmental. We want to make sure that chairs and exam tables are comfortable. We want to make sure that our scales are in private areas and that they weigh up to 500 pounds. You can order a scale that weighs up to 500 pounds for less than $25 on the Amazon and have it delivered to your office. We should make sure that large blood pressure cuffs are in every room so that we aren't scrambling to look for them when a woman needs them. It's kind of insulting to have to look for something bigger. And we can show our clients how to weigh themselves and self-report their weight. So, what I'm suggesting is a holistic assessment of the individual. So, on the first prenatal visit, all individuals should have their height and their weight measured, assuming they want that. We need to offer women choices. If the BMI is 30 or greater, the next step for us is to think, is there comorbid disease? Is there not? If everything else looks healthy, then we should be helping women with nutrition choices, planning their weight gain, thinking about activity during pregnancy, and later in prenatal care, discussing an appropriate place of birth. If there's comorbid disease at the first visit or any time later in the pregnancy, then we need to offer the client additional help. This is somebody who will need an obstetrical consultation or maybe referral to an obstetrician depending on individual assessment. We need to avoid stereotypical thinking about intake and activity. When many clinicians start talking about weight gain, they say things like, so you're going to need to cut out sodas during pregnancy. No more desserts for you until this baby's born, or you are going to need to get out there and be walking 30 minutes a day every day. We need to assess what individuals are doing, hear from them what their activities are like. Many individuals with obesity have been doing healthy eating for years. We want to make sure that we're using the language that the client uses about themselves. And we want to make sure that we are using client-centered language. So clients with obesity, not the obese patient in room three. And we want to convey that we respect the individual's choices. When we disrespect a client's autonomy, it erodes their self-esteem and reduces self-efficacy. We can assist clients to target the Institute of Medicine weight gain targets. These have been in place since 2009. We can offer regular weighing during pregnancy. It was out of style for about 15 years in many countries. It is coming back in. And there are at least five studies, English speaking, where individuals are saying we want help with our weights in pregnancy. We want to be weighed. I'm going to talk a little bit more about epigenetic nourishment, adequate sleep, aspirin prophylaxis, and a place of birth. So here in Canada, our guidelines talk about monitoring gestational weight gain and encouraging us to do that at least once a trimester. Individuals with high BMIs do not need to gain as much in pregnancy as others. In most pregnancies, individuals gain two to four kilograms. That was meant to be adipose tissue, calories to be used during breastfeeding. Individuals with high BMIs have that reserve in place already so that you'll see they would only gain 11 to 20 pounds or about five to nine kilograms. Those are targets. We shouldn't think about them as limits. So here is something I didn't put the references on. They are easy to find. Regular physical activity reduces the risk for cesarean section. No matter what else you do, if you're doing 30 minutes of physical activity, five days a week, you reduce your risk of a surgical birth. I talk about taking the baby for a walk. It's a phrase a lot of people are used to once the baby's born, take them for a walk during pregnancy. 30 minutes a day, five days a week is ideal. That does not need to be a 30-minute hike. It can be two 15-minute intervals. It can be three 10-minute intervals. Women who don't feel safe outside their home walking can pace back and forth in front of TV or a podcast they're watching. Sleep is activity. It's not moving activity, but it's hugely important for weight optimization. Individuals need six to seven hours of sleep. For years, I asked my patients how many hours of sleep at night they got, and so many mothers are burning the candles at both ends, getting four to five hours of sleep at night. That actually makes them more insulin resistant. When individuals are tired, their brain wants more glucose, and their appetite stimulates them to eat so that sleep is as important as being up and moving around. I've watched aspirin prophylaxis come in and out of style for about 20 years now. It is now the current recommendation in Canada. One of the things that adipose tissue does is produce inflammatory cytokines, and that increases the risk for hypertensive disorders. It's also the major culprit in postpartum thrombosis. So aspirin prophylaxis helps ameliorate that risk. Folic acid, it's ideal pre-pregnancy, definitely for the first trimester to help prevent neural tube defects. Which individuals with high BMIs and diabetes are at higher risk for? I want to talk a minute about what's called epigenetic eating. Why epigenetic? This eating actually sets metabolic pathways in the fetus. It's simple to explain. It may not be quite as simple to do. The my plate diet from the U.S. is used for diabetes management. It's an epigenetic diet that's safe and beneficial in pregnancy. The my plate diet is a high fiber, low glycemic index diet. And if individuals follow this eating pattern during pregnancy, they actually reduce their risk for gestational diabetes. My plate is half of every meal or snack being fruits or vegetables. Guidelines internationally don't agree with each other perfectly. The guidelines from the American College of Obstetricians and Gynecologists assume that everybody's going to give birth in the hospital. And we'll have continuous electronic fetal monitoring. In Canada, the Society of Obstetricians and Gynecologists recommends that those with a body mass index of 30 or greater consider continuous electronic fetal monitoring. And if you're going to have electronic fetal monitoring, then you will be in a hospital unit. They do caution that decision to delivery time is increased in women with obesity. That's so important for us here in Canada. You have the same considerations in Australia with rural areas where if individuals are having a community birth or a birth in a level one hospital without 24 hour services. They may not be able to have a timely cesarean section. So in rural Canada, women with a BMI of particularly 40 or greater are encouraged to move south to a city in the last trimester so that they're at a center that has the best resources for them. The Royal College of Obstetricians and Gynecologists, which has great experience with midwifery led units, says that women who are multiparous and otherwise low risk can be offered a choice of setting for planning their birth. Women, even with high BMIs who've had one uncomplicated vaginal birth have very successful outcomes with subsequent births. So labor management, intermittent auscultation for all women that we can use that on, have women up and mobile, hydro therapy is great. Now we will need to assess for some with very high BMIs how comfortable they are in the tub and if they can move quickly if we need them out of the tub. We need to give individuals with high BMIs longer time for cervical ripening in inductions of labor and longer stages of labor. Leptin, which is an appetite regulating hormone is a growth hormone in pregnancy. Leptin levels are higher when BMIs are higher and Leptin is a tocolytic. It shuts uterine contractions down by counteracting oxytocin. That doesn't mean that all individuals with high BMIs will need oxytocin, but they will need us to expect longer inductions of labor and longer particularly stage one. That same oxytocin inhibition from Leptin predisposes individuals to postpartum hemorrhage. So we encourage active management of the third stage and that's most importantly give a hemorrhage preventing drug like hemobate, oxytocin, get the baby immediately skin to skin and start breastfeeding within the first hour. That's the best way to get past the slower lactogenesis to that occurs in individuals with obesity. Once again, Leptin's a culprit in that slower milk production and a little bit poke your initial milk ejection reflex. But early breastfeeding and stimulation every two hours particularly for first time breastfeeders helps mothers over that hump. We have a number of places to intervene. We really can help break cycles of overweight and obesity. So we can help individuals by helping them optimize the nutrients that go through placental transfer. We can help individuals eat their best to optimize nutrients. Whatever is in the maternal circulation circulates to the fetus and to the over in a female fetus great capacity there to change health for three generations forward. Ideal nutrients by helping mothers do their best at breastfeeding and then many midwives are the people who give infant toddler feeding advice. So encouraging breastfeeding for a full year with appropriate food choices. And then for those of us midwives who are caring for women between pregnancies helping individuals with their best nutrition. So in summary, reducing the stigma around obesity being confident for women so that they can be confident for themselves. Recommending folic acid vitamin D and aspirin prophylaxis really supporting efforts to breastfeed and then encouraging the clients. They can take charge of their own health optimizing their weight gain healthy eating physical activity with sufficient sleep and breastfeeding the newborn appropriate risk assessment. Not thinking of every single individual being prone to the worst outcomes appropriate risk assessment with supportive care improves health for two to three generations forward. I am going to put since some of these slides didn't show up the best. I've put my website in the chat box. It is loaded with resources it started for educators. Now there's some clinician supports some handouts that you can use for your clients with obesity. I keep adding to that site and everything there is free of charge. I'm happy to take questions. You must feel like you've been whiplashed through care for high BMI is in pregnancy. I see my my facilitator says she's having some issues with her internet. So if you can type your questions in the chat box I can see them and I'm happy to answer them. Ah, ginger. Thanks. I actually am doing a presentation. I'm doing a workshop at the American College of Nurse Midwives meeting, which is coming up shortly and for all of the educational programs. I have a little flash drive loaded with resources that I'm going to give to the dome leader to pass out at the meeting. So ginger is asking. Yeah, so much about the physiology. I hate to promote my own readings. But if you if you Google me or look into PubMed, I've got a few publications that really go in depth about the physiology of obesity. When I talk about endocrine disrupting chemicals, those are things like fire retardants and pesticides and a huge culprit. Many of the plastics, all of those chemicals are in our environment. They're in our water supplies. We take them in and our body sees them as hormones. And some of the appetite stimuli stimulating and weight increasing hormones. We don't have personal control over that. Many individuals live in neighborhoods where it's not safe for them to go out walking in some cultures. Women shouldn't be out walking by themselves. That is seen as just trashy behavior. So we need to really think about what works for our individual patient, our individual patients and how we can give them the best support. I'll put a plug in for breastfeeding to since I'm not seeing other questions. Breastfeeding helps set infant appetite pathways. It actually sets some metabolic pathways. So individuals who are breastfed, even for one to three months have benefit from that breastfeeding. Boy, it's so important. One of the psychological complicators for individuals with obesity is that they often have lowered confidence and lowered self-esteem. And they come into pregnancy thinking, I can't do this. My body doesn't work for me. And we have to be careful that we don't reinforce that for them. If they've had a caesarean birth, they may feel like they've failed. Their body's not going to be able to breastfeed. And we need to pull out the stops and really help them with breastfeeding. I've always talked about it as medication. We can't take breastfeeding too seriously. I'm not sure I said that correctly. Breastfeeding, to me, is one of our most important measures. Ah, Jumi is saying that's how she felt after her caesarean. You know, another broad thing that we can do to help individuals is to work with our colleagues who worry about the risk if they don't do a caesarean section. And give them the confidence to wait a little while. I mean, this is a little bit off topic, but weight gain in pregnancy isn't my own interest. When the World Health Organization started talking about broken food systems, I got very interested in that topic. And we now have war in Eastern Europe. It's very close to my heart. I have cousins in Poland and some of my dear friends have family in the Ukraine. The Ukraine is one of the bread baskets of the world, as are the steps of Russia. And food production in those two countries will not be available to many parts of the world. So we need to think broadly as midwives. First of all, work for peace. And then think broadly about food systems. In another five years, we may not be worrying about individuals with too much to eat. We may be back as a world working on getting enough nutrients to pregnant women again. I think I'm going to end there.