https://doi.org/10.33698/NRF0202 Manpreet Kaur, Bhupinder Kaur
Abstract : The period of intrauterine growth and development is one of the most vulnerable period in the human lifecycle. Maternal weight gain during pregnancy can offer a good means of assessing the wellbeing of the pregnant mother and her baby. This study was undertaken with the objective to assess the effect of gestational weight gain on labor and fetal outcomes. The research design was non experimental descriptive design and was conducted from Dec 2014 to Jan 2015 in obstetrics and gynecology unit of G.G.S.Medical Hospital, Faridkot. Through convenience sampling technique 100 subjects were recruited. The demographic data was collected by interview. The labor and fetal outcome was assessed by observation at the time of labor and delivery. Duration of labor was calculated from onset of labor pains till expulsion of placenta. Weight of the newborn is checked by using calibrated baby weighing scale. APGAR score of the baby was assessed by researcher. The results revealed that most of the study subjects had low gestational weight gain. The gestational weight gain is significantly associated (p <.05) with mode of delivery, duration of labor, birth weight of newborn, gestational age and BMI of women at the time of booking. The low weight gain study subjects had higher odds of prolonged labor, other modes of delivery (caesarian delivery, induced and instrumental vaginal delivery) and had lower odds of normal birth weight babies as compared to the normal weight gain antenatal women. The low weight gain as well as normal weight gain subjects had the similar odds of gestational age, APGAR score, fetal complications and labor complications. Hence it can be concluded that the gestational weight gain is significantly associated with labor and fetal outcome. Nurses should be in forefront to prevent the complications by educating antenatal women related to adequate gestational weight gain and its effects on pregnancy, labor and fetal outcome.
Keywords
Gestational weight gain, labor outcome, fetal outcome
Correspondence at
Ms. Manpreet Kaur
Lecturer, College of Nursing,
Baba Banda Bahadur College of Nursing, Baba Farid University of Health Sciences, Faridkot– 151203, Punjab
Introduction
The period of intrauterine growth and development is one of the most vulnerable period in the human lifecycle. Giving life is vital; therefore, the mother prepares her body to become a suitable environment for the baby to grow while staying happy and healthy emotionally and mentally as well. The weight of the infant at birth is a powerful predictor of infant growth and survival, and is dependent on maternal health and nutrition during pregnancy.1 Maternal weight gain on labor outcome among during pregnancy can offer a good means of assessing the wellbeing of the pregnant mother and, by inference of her baby. Inadequate prenatal weight gain is a significant risk factor for intrauterine growth restriction, preterm delivery, and low birth weight among infants. Obesity and excessive weight gain on the other hand can lead to adverse maternal and fetal outcomes. These have led to suggestions for optimal weight gain to ensure the best outcomes.2 Ideally the weight gain should depend on the pre-pregnancy body mass index levels. Weight gain for a woman with normal BMI (20-26) is 11 to 16 kg. An obese woman (BMI> 29) should notgain more than 7kg whereas an underweight woman (BMI<19) may be allowed to gain upto18kg.
3 In India, poor fetal growth has been attributed to widespread maternal under- nutrition. Evidence suggests that inadequate gestational weight gain is a risk factor for low birth weight, intrauterine growth restriction, preterm birth, and perinatal mortality.4 Studies showed that pregnancy weight gain as per the Institute of Medicine’s (IOM) recommended ranges is associated with the best outcome for both mothers and infants. 5 During the maternity posting, the investigator was caring for intra-natal mothers. At that time, investigator witnessed that inadequate or increased weight gain led to poor labor and fetal outcome. Investigator noticed that the studies conducted so far were from the West and there is paucity of data from developing countries and this study will help to get information regarding the gestational weight gain of Indian mothers.
Objectives of the study
- To determine the effect of gestational antenatal women.
- To determine the effect of gestational weight gain on fetal outcome among antenatal
Materials and methods A Quantitative research approach with non experimental descriptive design was employed to assess the effect of gestational weight gain on labor and fetal outcomes. The study assumes that gestational weight gain will affect the labor and fetal outcome. The study was conducted in Guru Gobind Singh (GGS) Medical Hospital, Faridkot, Punjab. It is one of the tertiary care Government health and teaching institute in the state with bed strength of 750. Obstetrics and gynecology unit of this hospital has the bed strength of 60 and it undertakes about 100-120 deliveries in a month. The target population of the study was antenatal women admitted for delivery in G.G.S.Medical Hospital, Faridkot, Punjab. Convenience sampling technique was used for sample selection of total 100 antenatal women admitted for delivery meeting the inclusion criteria i.e. who were willing to participate in the study, were registered and present during the time of data collection were included as study subjects. Antenatal women who had pregnancy associated complications were excluded from the study. Variables under study were gestational weight gain, labor outcome, fetal outcome, age, gravida, parity, occupation, education, family income, dietary habits, BMI at the time of booking, gestational age at the time of delivery etc. Tool was developed by keeping in mind the objectives of the study, reviewing literature, previous studies, discussion with guide and co- guide. The tool consisted of 3 sections
Section A – It was an interview schedule designed to collect patient’s socio demographic profile and obstetrical history.
Section B – This section included base line performa for antenatal women about labor outcome [duration of labor, mode of delivery and any other related complications (premature rupture of membranes, post- partum hemorrhage and perineal tear)].
Section C – This section included base line performa for newborn such as sex of the newborn and fetal outcome [birth weight, APGAR score gestational age of the newborn, still birth, and any other related complications (meconium aspiration, birth trauma and seizures)].
The study had been approved by the ethical committee of University College of Nursing and Baba Farid University of Health Sciences, Faridkot, Punjab. Considering the rights of the subjects, only those who were willingly participated, included in the study. Besides, written informed consent was taken from each participant to participate in the study after explaining and giving written information to them. A written permission for conducting study from Medical Superintendent and Head of Obstetrics and Gynecology Department of G.G.S. Medical Hospital, Faridkot, Punjab was taken prior to conduct the study. The data was collected from 11 Dec 2014- 15 Jan 2015.The socio demographic data was collected by interview. Then labor and fetal outcome were assessed by observation during labor and delivery. Duration of labor was calculated from onset of labor pains till expulsion of placenta. Weight of the newborn is checked by using calibrated baby weighing scale(“r” =0.7). APGAR score of the baby was assessed by researcher. The mother and baby’s health status were assessed by researcher to detect complications. Inter-rater reliability of tool was confirmed by computing Pearson’s coefficient of correlation and “r” was 0.87. Data was coded and analysed by using descriptive and inferential statistics such as chi square test, odds ratio.
Results:
Table 1 depicts the recommended gestational weight gain according to Institute of Medicine’s(IOM) guidelines 2009. In the table, recommended gestational weight gain (GWG)) limits are; for underweight women (BMI <18.5) 12.5 –18 kg, for normal weight women (BMI category 18.5 – 24.9) 11.5– 16 kg, over – weight women (BMI category 25.0 – 29.9) 7 – 11.5 kg, and for obese women (BMI category ≥30.0)5–9 kg.
Table 1: Recommended gestational weight gain according to IOM guidelines (2009)
| Body Mass Index | <18.5
(Underweight) |
18.5-24.9
(normal weight) |
25.0-29.9
(over-weight) |
≥30.0
(obese) |
| GWG in kg | 12.5 – 18 | 11.5 – 16 | 7 – 11.5 | 5 – 9 |
Gestational weight gain among antenatal mothers who were in labor
The mean gestational weight gain was 9.565 kg and standard deviation 2.760. Two third (64%) of the antenatal women had low weight gain and 36% had normal weight gain, at the same time no one had high weight gain when gestational weight gain of antenatal women compared with the Institute of Medine’s recommendations for gestational weight gain
Distribution of antenatal women
Figure 1: Gestational weight gain among antenatal mothers according to IOM guidelines
A) Association of gestational weight gain of antenatal women with labor outcome
Table 2 shows that more than half of low weight gain antenatal women (51.6 %) had caesarean section, followed by 26.6 % had spontaneous vaginal delivery, followed by 21.8% had induced vaginal delivery. In normal weight gain group, 50 % antenatal women had spontaneous normal vaginal delivery, followed by 25 % had induced normal vaginal delivery and 25 % had caesarean section. In low weight gain group, 51.6 % had <18 hours and 48.4 % had ≥ 18 labor duration. On the other hand, in normal weight gain group, majority of antenatal women 80.6 % had <18 hours and 19.5 % had ≥ 18 labor duration. Majority of study sample in low weight gain group (92.2%) as well as normal weight gain group ( 91.7%) had no complications. Only 7.8% low weight gain group and 8.3% normal weight gain group women had complication of labor such as premature rupture of membranes, post partum hemorrhage, perineal tear.
In order to determine the association of gestational weight gain of antenatal Women with labor outcome chi square was computed. Gestational weight gain of antenatal women with mode of delivery and duration of labor found to be statistically significant at p value <0.05 level.
Table 2: Association between gestational weight gain and labor outcomes
N=100
| S.N. | Labor outcome | Low Weight Gain n (%) | Normal Weight Gain n (%) | Chi Square, df, p value |
| 1 | Mode of delivery | |||
| Normal vaginal delivery | ||||
| i. Spontaneous | 17 (26.6) | 18(50.0) | 10.329 | |
| ii. Induced | 14 (21.8) | 9 (25.0) | 3 | |
| Instrumental vaginal delivery | 0(0.00) | 1 ( 2.8) | 0.016 | |
| Caesarean delivery | 33 (51.6) | 8(22.2) | ||
| 2 | Duration of labour (in hours) | 8.220 | ||
| <18
≥18 |
33(51.6)
31(48.4) |
29(80.6)
7(19.7) |
1
0.005 |
|
| 3 | Any other related complications | 0.008 | ||
| Yes | 5(7.8) | 3(8.3) | 1 | |
| No | 59(92.2) | 33(91.7) | 0.927 |
*Others= premature rupture of membranes, post partum haemorrhage, perineal tear
- a) Odds Ratio of gestational weight gain of antenatal women with labor outcome:
Table 3 indicates that as per the mode of delivery, the low weight gain women were 2.7 times more likely to had other modes of delivery (caesarian section, induced vaginal delivery and instrumental vaginal delivery) as compared to the normal weight gain women. As regard to duration of labor, the odds of prolonged labor (OR= 3.892, 95% CI=1.490-10.164, p value =0.006) were more among the low weight gain. Women having lower weight gain during pregnancy are likely to have 3.8 times more chances of prolonged labour (>18 hours) as compared to woman to normal weight gain. The results depicted that the odds ratio of any labor complications (post partum hemorrhage, perineal tear, premature rupture of membranes) was 1.351 (95% CI= 0.327- 5.582, p value =0.678) that was similar among the both groups.
Hence, it can be concluded that odds of other modes of delivery and prolonged labor were more among the low weight gain women and odds of any labor complications were similar among both groups.
Table 3: Odds Ratio of gestational weight gain of antenatal women with labor outcome
N=100
| Labor outcome | Normal weight gain | Low weight gain | Odds ratio, Confidence
interval, p value |
| 1. Mode of delivery
a) Spontaneous vaginal delivery b) Other modes (induced vaginal delivery, instrumental delivery, caesarian delivery) |
18 18 |
17 47 |
2.765 1.173-6.514 0.020 |
| 2. Duration of labor | 3.892 | ||
| a) < 18 | 29 | 33 | 1.490-10.164 |
| b) ≥18 | 7 | 31 | 0.006 |
| 3. Any labor complications | 1.351 | ||
| a) Yes | 3 | 7 | 0.327-5.582 |
| b) No | 33 | 57 | 0.678 |
- a) Association of gestational weight gain of antenatal women with fetal outcome:
Table 4 indicates that the gestational weight gain (GWG)of antenatal women has statistically significant association with birth weight of newborn (in kg), gestational age of newborn. Most of women with normal GWG (80.5%) had babies with normal birth weight i.e. 2.5 Kg to 3.5 Kg. Only one third (37. 5%) women with low GWG had children with normal birth weight. Premature deliveries were in higher percentage among women with normal GWG (38.9%) as compared to the women with low GWG (15.6%). There was statistically no significant association of gestational weight gain with complications of labor, sex of newborn, APGAR score, fetal complications.
Table 4: Association between gestational weight gain and fetal outcomes
N=100
| S.No. | Fetal Outcome | Low Weight Gain n(%) | Normal Weight Gain n(%) | Chi-square df, p value |
| 1 | Sex of newborn | 1.759 | ||
| Male | 25(39.1) | 19(52.7) | df=1 | |
| Female | 39(60.9) | 17(47.3) | 0.185 | |
| 2. | Gestational age of the | |||
| newborn (in weeks) | ||||
| Preterm (<37) | 10(15.6) | 14(38.9) | 9.465 | |
| Term (37-40) | 43(67.2) | 21(58.3) | df=2 | |
| Post term (>40) | 11(17.2) | 1(2.8) | 0.009 | |
| 3. | Birth weight of baby (in kg) | |||
| <2.5 | 40(62.5) | 5(13.9) | 23.713 | |
| 2.5 – 3.5 | 24(37.5) | 29(80.5) | df=2 | |
| > 3.5 | 0(0) | 2(5.6) | <0.01 | |
| 4. | Apgar score | 0.174 | ||
| 6-10 | 63(98.4) | 35(97.2) | df=1 | |
| 0- 5 | 1(1.6) | 1(2.8) | 0.677 | |
| 5. | Any other related complications | 0.154 | ||
| Yes | 4(7.2) | 3(8.4) | df=1 | |
| No | 60(93.8) | 33(91.6) | 0.695 |
*Other = meconium aspiration, birth trauma and seizures
- Odds ratio of gestational weight gain of antenatal women with fetal outcome:
Table 5 depicts that the low weight gain antenatal women had lower odds of normal birth weight babies than normal weight gain antenatal women. As per the birth weight, the normal weight gain women were 5.4 times likely to deliver normal birth weight babies as compared to low weight gain
woman. The low weight gain as well as normal weight gain had the similar odds of gestational age, APGAR score, fetal complications. With regard to the gestational age of newborn, the low weight gain women had similar odds of term deliveries as compared to normal weight gain group (OR= 0.684 , 95% CI= 0.294-
1.589, p value =0.377 ).
Table 5 : Odds ratio of gestational weight gain of antenatal women with fetal outcome
N=100
| Fetal Outcome | Gestational weight gain | Odds Ratio, Confidence
Interval p-value |
||
| Normal
Weight Gain |
Low
Weight Gain |
|||
| 1. | Gestational age of newborn (in weeks) a. Term(37-40)
b. Preterm, post-term (< 37,> 40) |
21 15 |
43 21 |
0.684 0.294-1.589 0.377 |
| 2. | Birth weight (in Kg)
a. 2.5 – 3.5 b. < 2.5, >3.5 |
28 8 |
25 39 |
5. 460
2.149-13.873 0.001 |
| 3. | APGAR score
a) 7 -10 b) 4-6, 0-3 |
35 1 |
63 1 |
0.556
0.034- 9.158 0.681 |
| 4. | Any other related fetal complications.
a) No b) Yes |
33 3 |
60 4 |
0.733 0.155- 3.476 0.696 |
- Association of gestational weight gain of antenatal women with socio demographic variables:
Table 6 indicates that there was statistically significant association of gestational weight gain with BMI of women at the time of booking, gestational age at the time of delivery (in weeks). Gestational weight gain was not related to age, gravida, parity, educational status, family income, occupation and dietary habits of women.
Discussion
Maternal weight gain during pregnancy can offer a good means of assessing the well being of the pregnant mother and, by inference of her baby.2 The present study was conducted to assess the gestational weight gain among antenatal women and to find association of gestational weight gain with labor and fetal outcome. The main aim of the study was to assess the gestational weight gain among antenatal women and its effect on labor and
Table 6: Association of gestational weight gain of antenatal women with socio
demographic variables N=100
| S.
No. |
Content | Low Weight Gain n(%) | Normal Weight Gain n(%) | Chi-square df p value |
| 1. | Age of the women (in years) | |||
| 18-23 | 27( 42.2) | 13(36.1) | 4.122 | |
| 24-29 | 35( 54.7) | 18(50) | df=2 | |
| 30-35 & above | 2 (3.1) | 5(13.9) | 0.127 | |
| 2. | Gravida | 0.900 | ||
| Primigravida | 40 (62.5) | 19 (52.8) | df=1 | |
| Multigravida | 24 (37.5) | 17 (47.2) | 0.343 | |
| 3. | Parity | 0.900 | ||
| Primipara | 40 (62.5) | 19 (52.8) | df=1 | |
| Multipara | 24 (37.5) | 17 (47.2) | 0.343 | |
| 4. | Educational status | |||
| No formal education | 1(1.6) | 2(5.6) | ||
| Primary or middle | 26(40.6) | 10(27.8) | 4.963 | |
| Secondary | 18(28.1) | 9(25.0) | df=4 | |
| Senior secondary | 14(21.9) | 8(22.2) | 0.291 | |
| Graduation and above | 5(7.8) | 7(19.4) | ||
| 5. | Occupation of the women | 2.952 | ||
| Employed | 5(7.8) | 7(19.4) | df=1 | |
| Unemployed | 59(92.2) | 29(80.6) | 0.086 | |
| 6. | Monthly income of the family (in rupees) | |||
| ≤5000 | 13(20.3) | 7(19.5) | 4.53 | |
| 5001-10000 | 30(46.9) | 13(36.1) | df=4 | |
| 10001-15000 | 12(18.7) | 9(25.0) | 0.339 | |
| 15001-20000 | 5(7.8) | 1(2.8) | ||
| >20000 | 4(6.2) | 6(16.6) | ||
| 7. | Dietary habits | 0.080 | ||
| Vegetarian | 53(82.8) | 29(80.6) | df=1 | |
| Non-vegetarian | 11(17.2) | 7(19.4) | 0.778 | |
| 8. | BMI of mother at the time of booking | |||
| Underweight | 40(62.5) | 11(30.6) | 9.411 | |
| Normal weight | 21(32.8) | 22(61.1) | df=3 | |
| Over weight | 29(3.1) | 2(5.5) | 0.024 | |
| Obese | 1(1.6) | 1(2.8) | ||
| 9. | Gestational age of the mother (in weeks) | |||
| <37 | 10(15.6) | 14(38.9) | 9.465 | |
| 37 – 40 | 43(67.2) | 21(58.4) | df=2 | |
| > 40 | 11(17.2) | 1(2.7) | 0.009 |
fetal outcome. The present study findings revealed that the higher percentage (64%) of the antenatal women had low weight gain and 36% had normal weight gain, at the same time no one had high weight gain. These findings were consistent with the study conducted by Sarika A. (2013)6 concluded that 60% belonged to low weight gain category and 40% belonged to normal weight gain category.
The present study findings showed that the low weight gain women were 2.7 times (OR= 2.765, 95% CI= 1.173-6.514, value =0.020) more likely to had other modes of delivery (caesarian section, induced and instrumental vaginal delivery) as compared to the normal weight gain women. The results revealed the statistically significant association of gestational weight gain with mode of delivery (chi square= 10.329, p value=.016). These findings were opposite to Z Yekta (2006)7 which reported that abnormal weight gain during pregnancy was not related to an increased risk of cesarean delivery. The difference can be due to the different settings and small sample size.
In the present study, findings showed the odds of prolonged labor (OR= 3.892, 95% CI=1.490-10.164, p value =0.006) were 3.8 times among the low weight gain antenatal women. There was statistically significant association of gestational weight gain of antenatal women with duration of labor (chi square= 8.220, p-value=.004). Findings were consistent with study done by.The present study findings showed that the normal weight gain women were more likely to deliver normal birth weight babies (OR= 5. 460, 95% CI= 2.149-13.873, p value = < 0.001). It can also be interpreted as the women with low weight gain had the lower odds of normal birth weight babies. There was statistically significant association between gestational weight gain and birth weight of newborn (chi square=20.106, p value= <0.01). These findings were compared with other studies such as Henriksson P et al (2014)9 which revealed that women with weight gain below the recommendations had infants that were shorter. Inadequate GWG was associated with shorter infants, while excessive GWG was associated with greater infant fetal mass for women who were of normal weight before pregnancy. Also supported by Simas TA et al (2012)10 that inadequate GWG was associated with increased odds of SGA (Small for gestational age) and decreased odds of LGA (large for gestational age).
The present study findings showed that in low weight gain as well as in normal weight gain group, the 43 (67.2 %) and 21(32.8 %) antenatal women respectively were of term gestation and there was statistically significant association between gestational weight gain and gestational age of newborn (chi square=9.465, p value=009). The study findings were supported by Sharma AJ et al (2015)11 that low GWG in the first and second trimesters was not associated with preterm birth.
Robinson E. Mbu et al (2013)8 which The present study findings showed the showed that the odds of prolonged labor was about 4 times among abnormal weight gain women. statistically significant association between gestational weight gain and maternal pre- pregnancy body mass index (chi square=9.411, df= 3, p value=0.024). These findings were consistent with Pregnancy Health Weights Initiative Report (2007)12 which revealed that women of normal pre- pregnancy weight were less likely to had excessive weight gain (39.3%) compared with women who were overweight (60.4%) or obese (65.7%).
The findings of the study concluded that there was statistically significant association of gestational weight gain with labor and fetal outcome. On the basis of present findings it is recommended that a large sample should be studied at different community setting. However, further investigations can be carried out to find out the prevalence and contributing factors of inadequate gestational weight gain. Further studies can be carried out to assess the long term complications of neonates and postpartum complications of women with inadequate gestational weight gain. Nurses should be in forefront to prevent the complications by educating women on adequate gestational weight gain and its effects on pregnancy, labor and fetal outcome to the people. They need to identify the cases of inadequate gestational weight gain and provide necessary care throughout pregnancy. Nurses can motivate the antenatal women to gain the adequate weight during pregnancy and to maintain the pre-pregnancy weight.
References
- Muthayya Maternal nutrition and low birth weight – what is really important? Indian Journal of Medical Research.2009 Nov; 130:600-8.
- Addo VN. Body mass index, weight gain during pregnancy and obstetric outcomes. Ghana Medical 2010 Nov; 44(2):64-9.
- Dutta Textbook of obstetric. edition sixth. New central book agency (P) ltd. 2004.51.
- Rao Nutritional status of the Indian population. Journal of Biosciences. 2001 Nov; 26(4):481–9.
- Krishnamoorthy U, Schram CMH, Hill SR. Review article: Maternal obesity in pregnancy: is it time for meaningful research to inform preventive and management strategies? International Journal of Obstetrics & 2006;113(10):1134- 40.
- Sarika A. The effect of gestational weight gain on labor outcomes. The journal of obstetrics and 2010 Nov; 23(1):23-5.
- Yekta Z, Ayatollahi H, Porali R and Farzin A. The effect of pre-pregnancy body mass index and gestational weight gain on pregnancy outcomes in urban care settings in Urmia-Iran. BMC Pregnancy Childbirth. 2006; 6:
- Robinson Mbu et al. Effects of gestational weight gain on the outcome of labor at the Yaounde central hospital maternity, Cameroon .Open Journal of Obstetrics and Gynecology.2013;3: 648-52.
- Henriksson P, Eriksson B, Forsum E, Löf M. Gestational weight gain according to Institute of Medicine recommendations in relation to infant size and body Pediatric Obesity. 2014 Dec 1 7 . Available f r o m : http://www.ncbi.nlm.nih.gov/pubmed/25521831
- Simas TA et al. Prepregnancy weight, gestational weight gain, and risk of growth affected Journal of Womens Health. 2012 Apr; 21(4):410-7.Sharma AJ et Associations of Gestational Weight Gain with Preterm Birth among Underweight and Normal Weight Women. Maternal & Child Health Journal. 2015 Feb. Available from: www.ncbi.nlm.nih.gov/pubmed/25652068
- British Columbia Perinatal Database Registry. 2005/6 Pregnancy Health Weights Initiative Prepared December 11, 2007. British Columbia Perinatal Health Program. Unpublished report. A v a i l a b l e f r o m : www.perinatalservicesbc.ca/NR/…/0/MaternalWei ghtGainReport.pdf