The aim of this study was to explore practitioners’ experiences of providing intrapartum care to obese pregnant women. Our findings described the experiences of health professionals, when caring for obese women during labour, including the medicalisation of obese birth, the promotion of normality for obese women and the complexities of health professionals’ behaviour surrounding obese women in labour.

Promotion of normal birth

In the UK, successive policy documents have explicitly promoted normal birth for healthy women and their babies for over two decades [36, 37]. Our earlier survey found the promotion of normal birth is not included in the majority of clinical guidelines for the care of obese pregnant women. However, despite this, midwives and obstetricians who participated in this study described the promotion of normality and normal birth as an integral part of their role when caring for obese women during labour. Antenatal education for obese women was viewed by midwives as an essential aspect in this, in order to allow women to have realistic expectations of labour and birth and promote normal birth. This is supported by Schott & Priest who suggest that if you prepare women for the physical and emotional realities of labour and birth, they will be confident that what they are actually experiencing is normal and are more equipped and able to cope [38]. The national guidance on obesity recommends that women should be informed of the risks associated with obesity during pregnancy and advised on how to minimise them. It states that women should be made aware of the potential difficulties with caesarean section, but offers no guidance on how to minimise the need for caesarean section [29]. This is not just specific to obese women, as currently there is no guidance available on minimising the risk of caesarean section, regardless of Body Mass Index, however, all pregnant women are offered the opportunity to attend antenatal education in order to prepare for labour and birth.

The promotion of mobility during labour was viewed as an essential aspect of their care, in order to minimise the associated risks of prolonged labour and operative birth and midwives felt that if women were advised during the antenatal period of the importance of mobility during labour, they would be more likely to mobilise from the outset. Mobilisation during labour is widely acknowledged as a way of optimising the likelihood of normal birth [39, 40] and this is reflected in the practices and attitudes described by the midwives, who viewed it as an integral part of their care, despite the challenges faced with this population. Interestingly, Singleton & Furber found that although midwives advocated the need for mobilisation, they felt obese women were not able to remain mobile during labour because of the associated risks of obesity during labour, which restricted their options [32].

In order to support and encourage mobilisation during labour and the promotion of normal birth, techniques used to promote normal birth were described. Techniques such as the use of an FSE to allow women to be fully mobile during labour, whilst continuously monitoring the fetal heart rate are commonly utilised with obese women, with many seeing their usage as a positive intervention and a potential catalyst for normal birth. However there was conflicting views of this practice, with some practitioners viewing the use of an FSE as a medical intervention, with the potential to inhibit mobility and normality. The wide spread use of FSE in obese women reflects the national guidance that suggests that fetal scalp electrodes should be utilised if adequate fetal heart monitoring proves challenging [29]. Many midwives adopted this guidance into their practice and whilst acknowledging the use of an FSE to be an intervention, they utilised this method of fetal monitoring to prevent women becoming immobile in order to adequately monitor the fetal heart.

Conflicting attitudes

The apparent lack of consensus surrounding the clinical management of labour and birth for obese women, particularly caesarean section, is interesting. Some obstetricians reported a much lower threshold for making a decision to proceed to caesarean section than they would with a non-obese woman, whilst other obstetricians reported actively trying to avoid a caesarean section because of the increased associated risks of operative birth in this population.

It could be argued that the increased risk of caesarean section in obese women [18–20], should be a used to encourage the facilitation of normal labour and birth. The most common reason for caesarean section is delay during the first stage of labour, even after augmentation with oxytocin [17–19] and therefore, the facilitation of mobility during labour and the use of mobility aids may prevent delay during labour and therefore the need for caesarean section. Some obstetricians reported trying to avoid a performing a caesarean section on an obese woman, unless absolutely necessary and would often allow more time for labour to progress before making a decision that operative delivery was necessary. The facilitation of mobility during labour, would minimise the risk of delay and therefore the need for caesarean section [41].

At the same time it was evident that negative attitudes towards obese women were directly influencing clinical decision making processes with obese women commonly viewed as problematic and decisions to proceed to caesarean section were made a lot earlier compared to non-obese women, in order to attempt to minimise additional intrapartum or postnatal complications. In this situation, it could be argued that the increased risk of caesarean section encouraged obstetricians to proceed to caesarean section sooner than they would with a non-obese woman, preventing women from optimising their chance of normal birth. Interestingly the negative attitudes towards caring for obese women was attributed to colleagues. None of the participants admitted to displaying negative attitudes themselves.

Medicalisation of birth

The medicalisation concept has been variously theorised in medical sociology in general [42, 43] and in relation to childbirth in particular [44, 45]. Whilst early medicalisation of childbirth literature was almost exclusively critical, by the mid-1980’s there was increasing recognition of how these processes are co-constituted by clinicians’ and women themselves. Over the last two decades there has been a dearth of medicalisation theorising in relation to childbirth [46]. The present study highlights the need to revisit the medicalisation concept in relation to different groups of women’s contemporary experiences of childbirth. This study challenges the old medicalisation of childbirth dichotomy between medical and natural (midwifery) models of childbirth for all women. Our findings demonstrate the complex and contradictory use of technology to promote normal birth by midwives and obstetricians, specifically for obese women.

The medicalisation of obese women during labour and the challenges to providing care was discussed. Some participants expressed the view that obese women should be viewed as ‘high-risk’ and the care should be medicalised, reflecting the UK national guidance. However, some midwives expressed an opposing view and viewed the promotion of normality to be an integral part of the care they provide to obese women, challenging the medicalisation of care advised in the national guidance. It was widely acknowledged that continuous monitoring of the fetal heart was one of the biggest challenges and led to the medicalisation of labour and birth. Many practitioners challenged this practice and were unable to confidently recall the evidence on which this practice is based. The national guidance on the management of obesity during pregnancy (page 12) is quite ambiguous, suggesting that fetal heart rate monitoring in obese women can be challenging and ‘close surveillance is required with recourse to fetal scalp electrode or ultrasound assessment of the fetal heart if necessary.’ [29], however, it does not explicitly state that continuous monitoring is necessary. The accepted practice of continuous monitoring could be questioned and challenged as it has a significant impact on the management of labour and may lead to unnecessary intervention and medicalistion of birth.

The discouragement of water birth for obese women was viewed as a contributing factor to the medicalisation of care for obese women. The reasons for obese women being discouraged from using hydrotherapy were stated to be related to manual handling risks, but the multiple benefits were also acknowledged, including the increased ability to stay mobile during labour. Swann & Davies suggest that the advantages of using water in labour are equally, if not more applicable to obese women and include the use of water as a mobility and positon aid, increasing the pelvic outlet and reducing the potential for delay during labour [47]. Difficulties monitoring the fetal heart rate are commonly cited as reasons for discouraging water birth in obese women, Swann & Davies suggest that the use of waterproof telemetry could overcome this difficulty and with the increasing availability of wireless telemetry, this could also be utilised to facilitate the use of hydrotherapy for women who require continuous electronic fetal heart monitoring [47]. However, as discussed earlier, the common practice of continuous fetal heart monitoring for obese could be challenged, as it could be argued that the evidence on which this practice is currently based is ambiguous.

The need to promote normal birth for obese women, including antenatal education, the promotion of mobility and the need to minimise the risk of caesarean section and the challenges to providing care to obese women, including the practice of continuous monitoring and the discouragement of water birth was widely discussed and reported. However, Singleton & Furber suggest that instead of practitioners striving to encourage normal birth, it may be more appropriate to advocate ‘optimal care’, as this aims to achieve the best possible birth for the women, whilst acknowledging the associated risks [32].