I am 37 weeks pregnant with my third child. I was diagnosed with GD at 18 weeks; I had it with baby #2, which is why I was screened early.

I began my pregnancy with normal BMI and have gained 32 pounds to date. I take 22u of NPH insulin at night to control my morning blood sugars (target below 95). I have successfully controlled daytime blood sugars with diet. Baby has been monitored twice weekly since 32 weeks (NST on Mondays, biophysicals on Thursdays) and has passed each test with flying colors.

Last week, my OB told me she wanted to induce at 39 weeks. She indicated that this was "the standard of care" recommended by ACOG for women with insulin-dependent GD. I protested, saying that I carried my second child to term. (He weighed 8 lb 14 oz - I delivered him without pain meds and with minimal pushing - his blood sugar did crash following the birth, but I labored at home and had not been instructed about how to monitor my glucose levels during labor.)

At today's biophysical, baby measured 7 lb 4 oz. I'm aware of the high margin of error, but I'm worried this measurement is only going to fuel my OB's fire.

Can you please provide me with some studies and/or statistics I can share with my OB, to support my desire to start labor naturally? I don't like the idea of laboring with Pitosin (which would likely equal pain meds), nor am I interested in forcing baby out before she's ready.

Thank you!

As far as I know, the only reason to induce a woman with well-controlled diabetes is to reduce the likelihood of having a big baby and the problems that can go along with having a big baby, in particular, need for cesarean surgery or shoulder dystocia (the head is born but the shoulders hang up behind the pubic bone). The babies of women whose diabetes is under control are not at increased risk for other harms unless the mother experiences the serious complications affecting her health that can accompany long-term diabetes, a situation that doesn't describe you. You can see logically why the latter should be so: if your sugar levels are normalized by treatment, and you don't have any other medical complications, then you do not differ from a healthy pregnant woman who doesn't have diabetes. Here, then, is a systematic review of the medical research that addresses the "big baby" issue:

Obstet Gynecol. 2002 Nov;100(5 Pt 1):997-1002.  <script language=JavaScript1.2> </script> <script language=JavaScript1.2> </script> Links

Expectant management versus labor induction for suspected fetal macrosomia: a systematic review.

·         Sanchez-Ramos L,

·         Bernstein S,

·         Kaunitz AM.

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, laceType w:st="on">UniversitylaceType> of laceName w:st="on">FloridalaceName>, Jacksonville, Florida ostalCode w:st="on">32209ostalCode>, USA. luis.sanchez@jax.ufl.edu

OBJECTIVE: To systematically review and summarize the medical literature regarding the effects of expectant management and labor induction on mode of delivery and perinatal outcomes in patients with suspected fetal macrosomia. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify studies assessing management of patients with suspected fetal macrosomia. METHODS OF STUDY SELECTION: We evaluated, abstracted data, and performed quantitative analyses in studies assessing the outcome of patients with suspected fetal macrosomia. Observational studies and randomized trials were included in this systematic review. TABULATION, INTEGRATION, AND RESULTS: Twenty-nine studies were identified, 11 of which met our criteria for systematic review and meta-analysis. These 11 studies included 3751 subjects. Of these, 2700 were managed expectantly, and 1051 underwent labor induction. We calculated an estimate of the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes, using random- and fixed-effects models for outcomes. Summary statistics for the nine observational studies showed that, compared with those whose labor was induced, women who experienced spontaneous onset of labor had a lower incidence of cesarean delivery (OR 0.39, 95% CI 0.30, 0.50) and higher rates of spontaneous vaginal delivery (OR 2.07, 95% CI 1.34, 3,19); however, significant differences in these outcomes were not noted when the two randomized trials were assessed. No differences were noted in rates of operative vaginal deliveries, incidence of shoulder dystocia, or abnormal Apgar scores in the analyses of the observational or randomized studies. CONCLUSION: Based on data from observational studies, labor induction for suspected fetal macrosomia results in an increased cesarean delivery rate without improving perinatal outcomes. Although their statistical power is limited, randomized clinical trials have not confirmed these findings.

PMID: 12423867 [PubMed - indexed for MEDLINE]

The best way to avert harm from shoulder dystocia to either baby or mother is the Gaskin maneuver, which is getting onto all fours either when a big baby is anticipated and the care provider believes shoulder dystocia is likely or in response to it. It can be done even if the woman has had an epidural if she has a little assistance, but my personal recommendation would be to avoid an epidural when the odds are good, as they are in your case, that the baby is going to be on the large side. You will be able to push more effectively and in a greater variety of positions. Here is the study on the Gaskin maneuver. The abstract doesn't tell you this, but the study compares outcomes with other studies using other techniques, and the Gaskin maneuver wins hands down in terms of safely getting the baby born.

Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43.

OBJECTIVE: To report on a large amount of clinical experience with shoulder dystocia managed primarily with the all-fours maneuver. STUDY DESIGN: The all-fours maneuver consists of moving the laboring patient to her hands and knees. Eighty-two consecutive cases of shoulder dystocia managed with this technique were reported to a registry through January 1996. RESULTS: The incidence of shoulder dystocia was 1.8%, and half of the newborns weighed > or = 4,000 g. Sixty-eight women (83%) delivered without the need for any additional maneuvers. The mean diagnosis-to-delivery interval was 2.3 +/- 1.0 (SD) minutes (range, 1-6). No maternal or perinatal mortality occurred. Morbidity was noted in only four deliveries: a single case of postpartum hemorrhage that did not require transfusion (maternal morbidity, 1.2%), one infant with a fractured humerus and three with low Apgar scores (neonatal morbidity, 4.9%). All morbidity occurred in cases with a birth weight > 4,500 g (P = .0009). CONCLUSION: The all-fours maneuver appears to be a rapid, safe and effective technique for reducing shoulder dystocia in laboring women.

In order to make an informed decision, you are entitled to information on the benefits vs. harms of all your options, including doing nothing. The fact that ACOG recommends a practice does not tell you anything about these. You may well wish to find out on what grounds ACOG recommends induction at 39 weeks. Don't allow yourself to be rushed into a decision. As a friend of mine says, "Deciding to induce labor is never an emergency." Finally, if, after considering the pros and cons of inducing labor vs. awaiting spontaneous labor, you decide to await labor, you should know that you have a right to informed refusal as well as informed consent.

One more thing to be aware of:  the tests of fetal well-being all have high false-positive rates, that is, the test says the baby has a problem when it doesn't. If a test comes up "iffy," repeating the test or doing a different test will reduce the odds of a false positive. Also, make sure you are not dehydrated before having amniotic fluid volume measured.

-- Henci

Thank you so much for this reply.

I told my OB that I do not want to be induced.

However ... literally as she was on her way out the door from our appointment yesterday, she said, "So let's plan to strip your membranes next week" (at 38 weeks). Is that necessary or a good idea??

At this point I would be tempted to say to her, "And part of not wanting to be induced didn't you understand?" but that would be rude and counterproductive. The research says that according to the random assignment trials, stripping/sweeping membranes does tend to shorten the duration of pregnancy, but it doesn't reduce the cesarean rate or improve newborn outcomes compared with not stripping membranes, so it has no clinical benefits. And, of course, like all medical interventions, it is not harmless. It opens the possibility of accidently rupturing membranes or introducing infection. Also, in your case, with her plan to do it at 38 wks, you might end up with a baby who isn't ready to be born yet along with the complications that can entail: breathing problems, problems breastfeeding, underweight. The best way to tell when a baby is ready to be born is by awaiting labor. It is, after all, the baby who initiates the cascade of events that results in labor. Well, actually, stripping membranes does have one so-called benefit: it reduces the need for induction, but that could equally well be accomplished simply by saying "no" to the induction.

-- Henci

I thought about deleting your post because you are attacking a poster to the Forum. I'm going to let it stand, however, because you illustrate the difficulties women face in trying to make informed decisions in the face of medical staff members such as yourself using misinformation and strongarm tactics to shame, terrify, threaten, or otherwise coerce them into going along with what their care provider wants to do to them or their babies. Even if what you are saying had some basis in fact, which it does not, emotionally abusing a patient is a violation of that patient's rights and of medical ethics. Unfortunately, there is no accountability in the system, and so persons such as yourself can continue to act with impunity. 

As for the substance of your attack, somehow you have failed to notice that conventional obstetric management is, by any standard, an abysmal failure. The research literature comparing obstetric management with care that supports, facilitates, and promotes the normal process and only intervenes medically when necessary is rock solid on this point. Few women subjected to conventional obstetric management escape exposure to at least one and usually several procedures, drugs, or restrictions that are unsafe and ineffective with routine or frequent use and sometimes with any use at all. As a result, U.S. maternal and infant morbidity rates are indefensibly, shockingly high, far higher than most developed countries and not a few developing ones. Just consider this: the cesarean surgery rate in low-risk first-time mothers was one in four several years ago. It's almost certainly higher now. If you knew a mechanic who recommended major repairs that, while occasionally needed, would permanently weaken the engine--yes, a uterine scar is permanent damage--on one in four cars brought in for routine maintenance, would you take your car to that mechanic? It's a safe bet that a fair percentage of the babies in your neonatal intensive care unit are victims of their mother's obstetrician's injudicious meddling, some of which she may have been persuaded to agree to against her better judgment by people like you. Shamefully, the American College of Obstetricians and Gynecologists has not shown the least interest in reining in their members.

We agree on one point, though: I, too, wonder why women knowingly stay with obstetricians (or midwives, for that matter) whose management practices (I cannot bring myself to call it care) jeopardize them and their babies and who treat them badly to boot. I emphasize “knowingly” because most women haven’t the least idea of the real state of obstetrics. But, then, women stay in abusive domestic relationships, so I am sure they have their reasons.

-- Henci 

I recommend rereading my other posts in this thread. Inducing you at 38 wks for gestational diabetes is not supported by the research. It offers no benefits, and among its harms, as a first-time mother, it substantially increases your risk of cesarean surgery, the incidence of abnormal fetal heart rate patterns in labor, and need for newborn resuscitation.

Goer H, Sagady Leslie M, Romano A. Step 6: Does Not Routinely Employ Practices, Procedures Unsupported by Scientific Evidence. J Perinat Educ 2007;16(1):32S-64S.

And if that weren't enough, inducing labor at 38 weeks increases your chances of having a baby who experiences respiratory difficulties because the baby wasn't ready to be born.

I am sorry to say this, but your doctor's practices are not in line with the research evidence, which means, unfortunately, that you cannot trust your doctor's judgment in other matters either. I would recommend looking for someone whose practices are evidence based, but it is hard--although not impossible--to find someone who will take a woman on in late pregnancy. If you go this route, here are two resources from the CIMS and Childbirth Connection websites: Having a Baby? Ten Questions to Ask and Choosing a Caregiver. At the very least, I strongly recommend getting full information before agreeing to any medical interventions so that you can make an informed choice and hiring a doula. Go to Informed Decision Making on the Childbirth Connection website to find out about the former and How to Hire a Doula on the DONA International website for more on the latter.

-- Henci

Not that I'm aware of but then I haven't systematically researched GD for several years. Still, if a woman's sugar levels are under control, and she was not a pregestational diabetic, how is she different from a pregnant woman who doesn't have GD? It is also important to remember that inducing labor is not harmless. Among other potential harms, it increases the likelihood of cesarean surgery, especially in first-time mothers. I would ask those who refer to "the studies" for copies so you can educate yourself on this issue. If they have some, I would be happy to review them and comment. 

-- Henci