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December26DigitalCRXCoverD1

Maternal Obesity and Excessive Weight Gain: 
Fetal Safety and Liability Risks

Case One
TOUCH
Case One: Lack of Training and Expertise and Failure to Obtain Informed Consent
Case One: Lack of Training and Expertise and Failure to Obtain Informed ConsentRead More
Case Two
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Case Two: Failure to Explain or Document Deviation from Injection Best Practices
Case Two: Failure to Explain or Document Deviation from Injection Best PracticesRead More
Conclusion
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Conclusion
ConclusionRead More

MaryLynnRyan

 

About the Author

Mary-Lynn Ryan, JD, CPHRM,
Senior Risk Management Consultant

Mary-Lynn Ryan is a Senior Risk Management Consultant. She began her professional career in medical liability defense litigation and later became a staff attorney at the California Medical Association. In addition to providing risk reduction services at ProAssurance, she teaches at the University of Minnesota School of Dentistry. Mary-Lynn obtained her JD from Pepperdine University School of Law, and she is licensed to practice law in California and Minnesota. She has a Graduate Certificate in Health Ethics.

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Introduction

Thirty-seven percent of women aged 20-39 are obese,1 and about three in four women with obesity who become pregnant will not fall within the Institute of Medicine’s (IOM) recommended gestational weight gain (GWG) targets.2 Both pre-pregnancy obesity and excessive GWG can complicate multiple aspects of pregnancy, labor, delivery, and neonatal well-being.3,4 It appears that the higher the maternal patient’s body mass index (BMI), the more likely complications are to occur.5,6

OBESITY RISKS DURING THE PRENATAL PERIOD

Pre-pregnancy obesity and excessive GWG have been identified as the most important and significant risk factor in the development and progression of type 2 diabetes mellitus (DM) during pregnancy. Maternal DM increases the risk of fetal structural anomalies, especially cardiac defects, neural tube defects, sacral agenesis, anal atresia, and limb reduction abnormalities.7,8 Pre-pregnancy obesity or excessive GWG (in either obese or normal-weight women) is also associated with increased rates of hypertensive disorders of pregnancy, which increase the risk for neurodevelopmental, psychiatric, and neurologic sequelae, including potential seizure disorder.9 High BMI is also linked to stillbirth.10

As a related issue, excess body fat can make it difficult to identify fetal anomalies by ultrasound.11

Looking at the fetal anomaly and ultrasound issues from a liability risk management perspective, if someone on the prenatal team does not explain these phenomena, parents may not realize their child’s congenital disability is unrelated to prenatal care, labor, or delivery. They similarly may not realize that maternal obesity negatively impacted the care team’s ability to identify defects on sonogram.

OBESITY RISKS AND COMPLICATIONS DURING LABOR AND DELIVERY

The size of the maternal patient and the size of the fetus can complicate labor and delivery. Maternal DM increases the risk of fetal macrosomia, which can increase the risk of shoulder dystocia, clavicle fracture, brachial plexus injury, and other adverse outcomes.12 Although predicting shoulder dystocia is difficult, the chances of obtaining an early resolution of a shoulder dystocia claim are increased when an OB has appropriately prepared for obesity and excessive GWG-related delivery complications. Inadequate documentation of the use of preparatory strategies is a common criticism in shoulder dystocia claims. Further, the difficulties obesity may pose in estimating fetal size should be documented and discussed with the patient to set appropriate labor and delivery expectations.

Electronic fetal monitoring (EFM) frequently plays a significant role in birth injury cases, with plaintiffs arguing nonreassuring fetal status on the fetal heart monitor should have prompted a timelier delivery. However, the depth of maternal adipose tissue can make fetal monitoring using external transducers technically difficult and ineffective.10,13 Consequently, a non-reassuring fetal status may not be recognized. A subsequent delay in delivery may result in poor outcomes that prompt lawsuits.

PATIENT EDUCATION AS RISK MANAGEMENT

Although discussions about obesity with patients can be challenging, physicians and other members of the OB team can reduce their liability risk by ensuring their pregnant patients understand how obesity can affect fetal well-being. Patients may know about obesity risk in general, but they may not believe they are at personal risk.14 It is apparent that pregnant women with obesity underestimate their BMI, overestimate their recommended GWG, do not understand the fetal health risks associated with excessive GWG and maternal obesity, and misunderstand the safety and benefits of exercise and diet relative to GWG.14,15 Patient education may not have the desired effect of reducing maternal weight gain. Nevertheless, appropriate GWG counseling is arguably required by the standard of care.16,17

Patient education about meeting GWG recommendations is not only a fetal safety issue but also a liability risk management issue. As with informed consent and refusal, a patient who is aware of the risks and benefits of compliance or noncompliance is more likely to understand when those risks become reality. This awareness can reduce the likelihood of their filing a lawsuit. If a matter proceeds to litigation, a lack of counseling and follow-up can cast the OB team in a poor light and complicate their defense. Specifically documenting counseling efforts, maternal responses to those efforts, and further education about maternal failure to follow GWG recommendations can be used as evidence to bolster the defense. Regardless of whether a suit is filed, education about the risks can generally increase patient engagement and autonomy.18

While obesity and excessive GWG can increase maternal health risks, the cases discussed and the risk mitigation strategies provided in this issue focus on alleged fetal injuries.

OBESITY-ASSOCIATED BIRTH INJURY “CALLS TO ACTION” ON PLAINTIFFS’ ATTORNEYS’ WEBSITES

A quick Google™ search confirms that plaintiffs’ attorneys are advertising for what they consider obesity associated birth injuries on their websites. For example, relative to maternal obesity, these websites frequently mention the following “medical errors” as indicators of medical negligence:

  • Insufficient maternal weight gain monitoring and counseling
  • Ineffective ultrasound screening
  • Delayed diagnosis and treatment of gestational diabetes (GD) or hypertension
  • Improper fetal growth monitoring
  • Failure to perform a C-section in a timely manner
  • Inappropriate operative birth

The website examples of negligence tend to track closely with typical allegations in obesity-complicated birth injury lawsuits.
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magglassCASE ONE:
Sonographic Image Quality

Excess adipose tissue can make it difficult to identify fetal defects on ultrasound due to degraded acoustic windows, resulting in suboptimal visualization of fetal structures.8 This degradation becomes particularly problematic for obese patients with GD.20 GD, like MD, is associated with a significantly increased risk for congenital malformations including cardiac defects, neural tube defects, sacral agenesis, anal atresia, and limb reduction abnormalities.7,8 Several strategies can help improve sonographic imaging quality, including repeating exams, reducing the distance between the transducer and the fetus, selecting the proper probe, and using advanced ultrasound technologies for post-processing.8 In addition to using technical strategies, prenatal team members should explain the limitations of sonography caused by excess adipose tissue.17 

 

Consider the different strategies the OB could have employed to visualize the four chambers of the fetus’s heart adequately how could the OB have communicated the limitations of the office sonography to the patient? Should this patient have been referred?

A patient with obesity and GD had an otherwise unremarkable prenatal course. At 29 weeks gestation, her OB performed an ultrasound for potential fetal macrosomia. The fetus was of average size, but “shadowing” due to the mother’s obesity precluded visualization of the four chambers of the fetal heart. No further ultrasounds were done during the pregnancy. The infant, who was born with hypoplastic heart syndrome, died two weeks after birth. The maternal patient sued the OB for failure to diagnose hypoplastic heart syndrome, alleging diagnosis would have provided an opportunity to deliver the infant at a facility equipped to handle high-risk newborns, facilitating timely treatment and increasing the chance of the child’s survival.

DISCUSSION

scalesupdate

Various issues complicated the defense of this case, including the OB’s lack of persistence in attempting to visualize fetal anatomy and failure to refer the patient to a more skilled ultrasound operator with more advanced equipment. The OB advised the defense team that repeating the ultrasound to attempt to get a higher quality view of the fetal heart would have made no difference because of the patient’s obesity. The plaintiff argued that an inability to visualize the four chambers of the fetal heart in an obese patient should have resulted in various further actions. For example, the OB could have recalled the patient for an ultrasound when the fetus would likely have been in a different position, making the heart potentially more visible. Had the OB used alternative strategies but still missed the diagnosis, it would have been easier to argue that they made a reasonable attempt at an anatomical survey.

The OB in this case also failed to recognize and address their own limitations in providing ultrasound services for this patient. They admitted that the office’s ultrasound machine was outdated. As they had done in this case, the OB used it primarily to estimate fetal size. A more skilled ultrasound operator using more advanced technology and visualization techniques suitable for obese patients may have discovered the hypoplastic heart syndrome, which could have resulted in fetal health risk mitigation.

Improvements in ultrasound technology have produced higher-quality images of fetal structures farther from the transducer. Unfortunately, maternal obesity can still cause suboptimal visualization of various aspects of fetal anatomy.7 This OB may have been correct in assuming it was impossible to visualize the four chambers of the heart. However, they could have reduced their liability risk exposure by appropriately educating the patient about the limitations of ultrasonography in obese patients, ensuring her understanding of those limitations, documenting her understanding, and offering a referral to a facility with more advanced equipment and skilled technicians.

 
RISK REDUCTION STRATEGIES
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RISK MITIGATION STRATEGIES

Helping parents understand the relationship between diabetes and congenital disabilities—in addition to the limitations of sonography in obese patients—could challenge their assumptions that negligence was the cause of a failure to identify a fetal defect. Consider the following strategies:7

  • Document patient obesity in the medical record, including height, weight, and BMI.
    • Educate obese patients who are pregnant or planning on becoming pregnant about how obesity may cause a reduction in the detection rate of congenital anomalies due to acoustic impairment. Include the inverse relationship between BMI and the ability to visualize fetal anomalies by ultrasound.
  • When the patient has DM, help her understand the relationship between DM and congenital malformations.
  • Document education and resources provided.
  • When scheduling obese patients for fetal abnormality ultrasound examinations, provide flexibility for recalls or referrals due to poor visualization.
  • Document efforts to visualize the essential elements of a standard fetal anatomy examination, list elements that could not be visualized, and document the suspected reason for visualization issues.
    • If any elements of the standard examination of fetal anatomy cannot be visualized, inform the patient and include the suspected reason.
  • Set forth plans to reassess elements that were not visualized, which may necessitate referral elsewhere. Explain this rationale to the patient.
    • If a patient declines the needed referral, proceed with the informed refusal process.
  • Maintain ultrasound skills through practical experience, continuing education, medical literature review, and proctoring.
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magglass

CASE TWO:
Placental Insufficiency and Shoulder Dystocia

The following case involves two different obesity-related delivery complications: placental insufficiency and shoulder dystocia. The parents in this case alleged that their child’s brain injury was avoidable because the shoulder dystocia was avoidable. However, defense experts believed that the infant’s developmental delays were caused by the environment in which the fetus developed, which was significantly impacted by the mother’s GD and obesity. Although the OB’s management of the shoulder dystocia was not criticized by expert reviewers, many aspects of the mother’s prenatal course were determined to be below the standard of care and to have contributed to the adverse outcome.

Think of how the obesity-related risks to the fetus could have been communicated to the patient during the different stages of her pregnancy.

At 22 weeks gestation, a patient presented to an OB. The OB estimated an August 6 due date. Her pregravid BMI was 37 (weight 189, height 5 feet). Her current weight was 197. At 28.2 weeks gestation, the patient weighed 216 pounds. Her fundal height was 37 cm. At this appointment she was diagnosed with GD. The OB prescribed insulin and referred her to a GD management (GDM) program.

At 31 weeks gestation, the patient’s fundal height was 38 cm, and her weight was 223. The OB requested her glucose monitoring logs, which she delivered two weeks later. Although they were scanned into her file, there was no indication that the OB reviewed them. No further patient glucose monitoring logs were entered into the OB’s records.

At 34 weeks gestation, the OB noted that the patient’s serum glucose was not well controlled. There was no documentation that this was discussed with the patient, or that this prompted any further interventions on the part of the OB team.

At 38 weeks gestation, suspecting macrosomia (although failing to document the suspicion), the OB recommended an ultrasound. That day, the patient presented to an imaging center for an ultrasound. The radiologist there estimated fetal weight at 4,800 g.

Two days after the ultrasound, the patient had an appointment with her OB. They recorded her weight at 240 pounds. Her blood pressure was 140/100 and she had 2+ protein in her urine. The OB sent her to the hospital for a preeclampsia evaluation. Anticipating an induction, the patient’s prenatal record was forwarded to the hospital. It did not include the 38-week sonogram report, which had not yet been received. Significantly, the OB’s office, GDM program, ultrasound center, and hospital used EHR systems that did not interface with each other.

The OB team decided to move forward with an induction. After receiving oxytocin, the patient’s labor progressed without complication. When she was at +1 station and 8 cm dilated, the hospital called the OB, who arrived at 3:00 AM when the baby was crowning.

The OB estimated the baby’s weight to be less than 4,000 g using Leopold maneuvers. Twenty minutes later, the fetal heart tones became non-reassuring. Concerned for the infant’s well-being and knowing that a C-section was not an option (the hospital did not have in-house anesthesia or a surgical crew during off hours), the OB applied a vacuum device to hasten delivery. The head was delivered, but then a shoulder dystocia was encountered. McRoberts’ maneuver, suprapubic pressure, and Woods’ screw maneuver were performed. A 5,018 g infant was delivered. The infant’s right arm was noted to be flaccid. Erb’s paralysis was documented.

Apgar scores of 3, 6, and 8 were recorded at 1, 5, and 10 minutes. Cord gases were obtained. Lab results indicated “severe metabolic acidosis.” Placental pathology showed acute chorioamnionitis. In addition to permanent paralysis of the right upper extremity, the infant was diagnosed with severe neurological impairment.

The parents filed a lawsuit against multiple individuals who had been involved in the patient’s prenatal care, labor, and delivery. The parents alleged that their child’s developmental delays were caused by oxygen deprivation during the birth process. They further alleged the OB should have planned for a potentially difficult delivery because the mother was obese, exceeded GWG guidelines, and had GDM; and fetal macrosomia was suspected.

DISCUSSION

scalesupdate

There were various points during this patient’s pregnancy, labor, and delivery where the risk of fetal injury or risk of liability could have been mitigated.

Experts were critical of the OB’s GDM management. There was no indication that they had reviewed the patient’s glucose monitoring logs, acted on them, or encouraged the patient to continue keeping them. Further, the OB never modified the insulin dose, despite poor glucose control. Finally, there was no documentation that the patient understood the importance of weight management during pregnancy, and when asked in deposition, she denied it.

The patient consistently exceeded GWG limits throughout her pregnancy. She gained over 50 pounds, which exceeded the IOM recommendation of a 20-pound maximum. The patient’s records from the GDM management program indicated that she received only one dietary counseling session (related to GDM, not weight gain). There was no evidence of ongoing exercise or nutritional interventions related to weight gain. During her deposition, the patient denied being advised that she had gained too much weight or that fetal macrosomia increased the risk of shoulder dystocia, operative birth, and C-section. She did not recall ever being counseled about her weight, diet, or physical activity. She testified she was not aware that her obesity or excessive GWG exposed her fetus to increased risk.

The 38-week ultrasound report, which estimated fetal macrosomia, was not received by the OB or the hospital, although it was available. There was finger-pointing among the defendants relative to this issue. The other defendants argued that it was incumbent on the OB to follow up. If the OB had, they would not have had to rely solely on Leopold’s maneuvers to estimate fetal weight, the accuracy of which is decreased by maternal obesity.20

Because there was an increased risk that a C-section would be necessary due to the patient’s obesity and excessive GWG, experts believed the OB should have been prepared for a C-section. Lack of anesthesia and surgical staff onsite when delivery became imminent provided no option for C-section.

Experts believed the OB’s management of the shoulder dystocia met the standard of care. The defense team also believed the case could be defended on lack of causation. Defense experts believed that the Apgar scores and the infant’s later developmental delays were consistent with abnormal intrauterine development secondary to inadequate perfusion of the fetus in the womb because of the less-than-ideal environment. They opined that no action or inaction on the part of the labor and delivery team caused or contributed to the developmental delays. Despite the causation support, competing expert standard-of-care opinions, factual disputes, finger-pointing among defendants, sympathetic plaintiffs, and a plaintiff-friendly jurisdiction presented an excess verdict risk. Therefore, this case was settled

 
RISK MITIGATION STRATEGIES
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Prevention of excessive GWG is imperative, but not always achievable. Even when GWG goals are met, obese patients require delivery plans that consider obesity-related labor complications, including fetal distress, shoulder dystocia, failed operative delivery, technical difficulties, and emergency C-section. Documentation of prenatal, labor, and delivery interventions associated with a patient’s obesity and excessive GWG provides the best evidence of compliance with the standard of care. In this case, the OB’s documentation of the management of the shoulder dystocia reduced damages associated with that aspect of this lawsuit during settlement negotiations. 

GWG AND GD COUNSELING

Consider the following strategies:21,22,23

  • Access resources to develop expertise in discussing weight with pregnant patients. For example: Talking with Your Patients about Weight;21 Begin the Conversation About Weight and Pregnancy;22 and Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy: US Preventive Services Task Force Recommendation Statement.24
  • Respectfully and realistically discuss how the patient’s obesity or excessive GWG may affect her pregnancy, labor, delivery, and postpartum experience, and how obesity or excessive GWG may affect fetal health.
    • When a patient is exceeding GWG recommendations, reeducate the patient about the risks to the fetus.
    • Adequately document discussions and indications of patient understanding.
  • Give the patient a GWG treatment plan that includes nutrition and exercise interventions.
    • Set weight goals for set intervals, following up at each visit, and adjusting accordingly.
    • When appropriate, refer to nutrition and exercise specialists.
    • Use the recommendations in the American College of Obstetricians and Gynecologists’ Physical Activity and Exercise During Pregnancy and the Postpartum Period.23
  • Appropriately manage patient GD using clinical guidelines when appropriate, such as the American Diabetes Association’s “Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2026.”16
  • Document the patient’s understanding of the importance of GD treatment compliance and its role in weight gain during pregnancy. If the patient refuses treatment recommendations, engage her in an informed refusal discussion.

INFORMED CONSENT

Consider the following strategies:

  • Initiate the labor and delivery informed consent process during prenatal care visits.
    • Specifically discuss obesity and excessive GWG risks as they affect labor and delivery.
    • Explain and discuss the risks and benefits of vaginal delivery versus C-section in obese patients.
    • Particularly when the patient has diabetes, ensure she is aware of her potential risk factors for shoulder dystocia.
  • Inform the patient about the effect of maternal obesity on fetal monitoring.
  • Document discussions, patient questions, the patient’s choice, and informed refusal if the patient does not agree to the recommended labor and delivery plan.

DELIVERY PREPARATION

Consider the following strategies:

  • Ensure the latest imaging and test results are available to the labor and delivery team.
  • If labor and delivery risks and options were discussed during the prenatal period, revisit and update informed consent at the time of labor and delivery to include any new risks and alternatives that have developed since those discussions.
  • Prepare for the possibility of a C-section, including ensuring appropriate access to anesthesiologists, surgeons, pediatricians, and others, as appropriate.
    • Plan ahead if these resources are not generally available at the planned delivery location.

SHOULDER DYSTOCIA DOCUMENTATION

Consider the following strategies:12, 25

  • Adequately document the prenatal course of patients who are at risk for developing shoulder dystocia, including:
    • Shoulder dystocia risk factors
    • Clinical and sonographic estimation of fetal weight during the prenatal course, including the effect of obesity on estimates
    • The delivery plan (e.g., trial of labor) and justification for the plan
    • Patient education about potential risk factors for shoulder dystocia, other complications associated with obesity and excessive GWG, and the risks and benefits of vaginal delivery versus C-section
    • Patient questions, the patient’s choice, and informed refusal if the patient does not agree to a recommended labor and delivery plan
    • Adequately document the labor and delivery process, including:
    • Estimated fetal weight on admission to labor and delivery, including whether the estimated fetal weight is consistent with the prenatal fundal height measurements, and whether patient obesity impacts fetal size estimates
    • Observations about labor slowing
    • When and how the shoulder dystocia was diagnosed
    • The shoulder dystocia management plan
    • Updates to the patient’s informed consent or refusal if the delivery plan has changed
    • Notation of clinical staff called to assist (e.g., pediatrician, neonatologist, anesthesiologist)
    • Interventions and clinical events, with a focus on presenting the step-by-step approach used to relieve the impacted shoulder and resuscitate the newborn, including:
      • Maneuvers used, the order in which they were performed, their degree of difficulty or success, and the clinical rationale for using them
      • A thoughtful indication of the necessary amount of traction applied
      • A close approximation of the time interval between delivery of fetal head and body
      • A realistic description of the level of impaction
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Conclusion

The OB team should be aware of obesity-related pregnancy, labor, and delivery complications, making sure that patients know about these risks so they can make informed decisions. Pregnant women should be counseled by their OB practitioners about appropriate GWG, health risks associated with excessive GWG and maternal obesity, and the safety and benefits of exercise and diet relative to GWG. In addition to patient education, all OB practitioners should consider and prepare for the additional accommodations that may be necessary for obese patients during their labor and delivery. Finally, because injuries associated with shoulder dystocia so frequently lead to liability claims, OB practitioners should carefully consider and document shoulder dystocia risks. They should appropriately follow up when such risks are present, educate patients as to risks and interventions, and be prepared to appropriately handle a shoulder dystocia. Further, the OB practitioner should carefully document the delivery process when a shoulder dystocia is encountered. 

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Endnotes

1. Samuel D. Emmerich et.al, “Obesity and Severe Obesity Prevalence in Adults: United States, August 2021–August 2023,” National Center or Health Statistics, accessed September 2, 2026, https:// www.cdc.gov/nchs/products/databriefs/db508.htm#table3.

2. Anna Maria Siega-Riz et al, “The Current Understanding of Gestational Weight Gain Among Women with Obesity and the Need for Future Research,” National Academy of Medicine, accessed September 2, 2026, https://nam.edu/perspectives/the-current-understanding-of-gestational-weightgain-among-women-with-obesity-and-the-need-for-future-research/.

3. Maria Grazia Dalfrà, Silvia Burlina, and Annunziata Lapolla, “Weight Gain During Pregnancy: A Narrative Review on the Recent Evidences” Diabetes Research and Clinical Practice 188 (2022), https://doi.org/10.1016/j.diabres.2022.109913.

4. Kathrin Brunner et al, “The Impact of Overweight and Obesity on Pregnancy: A Narrative Review of Physiological Consequences, Risks and Challenges in Prenatal Care and Early Intervention Strategies,” Current Diabetes Reports 25, no. 30 (2025), https://link.springer.com/article/10.1007/s11892-025-01585-3.

5. A. Dhanya Mackeen et al, “The Impact of Pre pregnancy Body Mass Index on Pregnancy and Neonatal Outcomes,” Journal of Osteopathic Medicine 124, no. 10 (2024): 447-453, https://doi.org/10.1515/jom-2024-0025.

6. Chunawala Prachi Jatin et al, “Managing Obstetric and Gynecologic Complications in Obese Women: Evidence-Based Strategies for Optimizing Outcomes and Reducing Risks,” Annals of Medicine and Surgery 87, no. 6 (2025): 3586–3595, https://doi.org/10.1097/MS9.0000000000003300.

7. Kathleen Chung and Christina S. Han, “Obstetric Ultrasound Imaging in the Patient with Obesity,” The Global Library of Women’s Medicine, GLOWM (2023), https://doi.org/10.3843/GLOWM.419113.

8. Mitra Moazzami et al, “Gestational Diabetes Mellitus: The Impact of Body Mass Index on Clinical Outcomes” Metabolic Syndrome and Related Disorders 23, no. 8 (2025), https://doi.org/10.1177/15578518251366372.

9. Baojian Xue et al, “Gestational Hypertension Increases Risk of Seizures in Children and Mice,” The Journal of Clinical Investigation 135, no. 12 (2025), https://doi.org/10.1172/JCI183393.

10. American College of Obstetricians & Gynecologists, “Obesity and Pregnancy,” accessed September 2, 2026, https://www.acog.org/womens-health/faqs/obesity-and-pregnancy.

11. Asher Ornoy et al, “Diabetes during Pregnancy: A Maternal Disease Complicating the Course of Pregnancy with Long-Term Deleterious Effects on the Offspring A Clinical Review,” International Journal of Molecular Sciences 22, no. 6 (2021): 2965, https://doi.org/10.3390/ijms22062965.

12. D. Ashley Hill, Jorge Lense, and Fay Roepcke, “Shoulder Dystocia: Managing an Obstetric Emergency,” American Family Physician 102, no. 2 (2020), https://pubmed.ncbi.nlm.nih.gov/32667171/.

13. Madeline Hawke et al, ““When It Works Well, It’s Great!”: Midwives Perspectives on the Beltless Non-Invasive Fetal Electrocardiogram for Women in Larger Bodies in Labour,” Women and Birth.39, no. 1 (2026), https://doi.org/10.1016/j.wombi.2025.102150.

14. Veronica Maria Pimentel et al, “Perception of the Impact of Maternal Weight on Pregnancy Outcomes in Overweight and Obese Women,” The Journal of Maternal-Fetal & Neonatal Medicine 35, no. 26 (2022): 10676-10684, https://doi.org/10.1080/14767058.2022.2155038.

15. Tamara Escañuela Sánchez et al, “Facilitators and Barriers Influencing Weight Management Behaviours During Pregnancy: A Meta-Synthesis of Qualitative Research,” BMC Pregnancy Childbirth 22, (2022): 682, https://doi.org/10.1186/s12884-022-04929-z.

16. American Diabetes Association Professional Practice Committee for Diabetes, “Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2026,” Diabetes Care 49, suppl 1 (2025): S321–S338, https://doi.org/10.2337/dc26-S015.

17. American College of Obstetricians & Gynecologists, “Obesity in Pregnancy: ACOG Practice Bulletin, no. 230,” Obstetrics & Gynecology 137, no. 6 (2021): e128–e144, https://doi.org/10.1097/AOG.0000000000004395.

18. Patient Safety Network, Agency for Healthcare Research and Quality, “Patient Engagement and Safety,” accessed September 2, 2026, https://psnet.ahrq.gov/primer/patient-engagement-and-safety.

19. Mohammad Yaqub et al, “The Effect of Maternal Body Mass Index on Fetal Ultrasound Image Quality,” American Journal of Obstetrics & Gynecology 225, no. 2 (2021): 200-202,. https://doi.org/10.1016/j.ajog.2021.04.248.

20. Amir Krencel et al, “Influence of Maternal Body Mass Index on the Accuracy of Clinical and Sonographic Fetal Weight Estimation,” International Journal of Gynecology & Obstetrics 175, no. 1 (2026): 1-10, https://doi.org/10.1002/ijgo.71012.

21. National Institute of Diabetes and Digestive and Kidney Diseases, “Talking with Your Patients About Weight,” reviewed August 2023, https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/weight-management/talking-with-your-patients-about-weight.

22. Eunice Kennedy Shriver National Institute of Child Health and Human Development, “Begin the Conversation About Weight and Pregnancy,” reviewed July 2, 2021, https://www.nichd.nih.gov/ncmhep/materials/begin-conversation-txtalt.

23. “Physical Activity and Exercise During Pregnancy and the Postpartum Period,” ACOG Committee Opinion, no. 804,” Obstetrics & Gynecology 135, no. 4 (2020, reaffirmed 2023): e178-e188, https://doi.org/10.1097/AOG.0000000000003772.

24. U.S. Preventive Services Task Force, “Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy: U.S. Preventive Services Task Force Recommendation Statement,” JAMA 325, no. 20 (2021): 2087-3, https://doi.org/10.1001/jama.2021.6949.

25. Michael L. Stitely, Robert B. Gherman, “Shoulder Dystocia: Management and Documentation,” Seminars in Perinatology 38, no 4 (2014): 194-200, https://www.sciencedirect.com/science/article/pii/S0146000514000226.