Ms. Goer,

 

Thank you so much for your time. 

 

I am 38.5 weeks pregnant with my second child.  I was diagnosed with gestational diabetes my first pregnancy and had it closely managed.  This pregnancy, I saw a midwife and planned a homebirth.  I chose not to monitor my blood sugars, except very sporadically this pregnancy, and to eat a sensible diet.  I had my A1C checked at 29 weeks, and it was 6.1 (normal range is 4.2 to 6.0).  Last week I had increased sugar in my urine, and decided to look at my blood sugars.  After breakfast I was 220, and the next morning fasting was 130.  I transferred my care to an obstetrician, at my midwife's advice.  I am now on insulin.  My A1C is 6.8. 

 

My OB is very open minded and has made it clear that the decision-making is up to me.  She also pointed out that with standard obstetric management, I would be induced at 39 weeks to reduce the risk of cesaerian and shoulder dystocia.  (My last pregnancy was 42 weeks, 3 days long, and my baby weighed 9 pound, one ounce.  I had him vaginally.)  I've read all the research showing that induction actually increases cesaerian rates for suspected large babies.  I've read that induction has little or no effect on shoulder dystocia rates/birth injury rates. 

 

What I'm wondering is, do my specific circumstances change any of this?  Is there any research that I'm missing that would leave me to believe that inducing labor would be safer for my baby than letting nature decide?

 

Thank you so much for any information you could give me or expand upon!!!!

 

Sara Uselton

I'm glad to hear that your obstetrician is open minded because you are right about the research. Inducing labor for predicted big baby does not reduce the incidence of shoulder dystocia, birth injuries, or cesarean surgeries. That conclusion doesn't change when the mother has diabetes. Here is what I would recommend to minimize the chance of having problems at the birth:

• Avoid epidural analgesia: It will interfere with your ability to push effectively and to get into the most effective pushing positions. Early epidurals in particular increase the chance of having a persistent occiput posterior baby (facing your belly instead of your back), and malposition plays a stronger role in cesareans for lack of progress than the baby's size.
• Plan on getting on all fours for the birth or for turning onto hands-and-knees (the Gaskin maneuver) should the shoulders hang up: All fours is the most effective thing to do to get a baby safely born without injuring the baby or the mother. Here is a reference you and your ob might want to read:

  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.

Discuss this with your obstetrician ahead of time because she may never have had a patient give birth in this position, and you will want to plan for this possibility together.

• Put the baby to breast as soon after the birth as the baby is ready and willing: Your baby is more likely to have low blood sugar after the birth than the average baby.

The nice thing about these recommendations is that unlike medical interventions like induction, these have no potential harms, only potential benefits.

You are fortunate in that you already know you can birth a big baby. That knowledge will be a good thing to bolster your confidence as you go into labor with what is likely to be another big baby.

BTW, if your sugars are under control now, don't be too concerned that your A1C values haven't come down. The A1C actually gives a broad picture of what your blood sugars have been like over the previous weeks, not what they are currently. In other words, they lag behind where you are now.

-- Henci

Ms. Goer,

Thank you so much!  That info definitely boosts my confidence in my decision to not induce.  Thankfully, my midwife will be present at the birth.  She and my doctor know I want to deliver on all 4's. 

I ended up receiving an epidural and pitocin my last delivery because of a long labor.  I intend not to accept these interventions this time.  It does give me confidence to know that I pushed out a 9lb 1oz boy laying on my back numb from the waiste down.  If I can do that, I feel I can birth any size baby without the epidural and in an open pelvic position.'

Thank you again!

Sara

You're welcome! Let us know how things go.

-- Henci