It is extremely unusual for a young, low-weight woman to have such extremely high sugar values. I think she must be one of the "needles in the haystack," the woman who has true, undiagnosed diabetes. I have also said that the screening would be a good thing if all it did was identify those rare "needles" and alert women with what would be be termed "carbohydrate intolerance of pregnancy" that they need to be especially careful to eat a healthy diet and engage in regular moderate exercise. The problem is that typical management and care provider attitude that the pregnancy and birth are a disaster waiting to happen is likely to do more harm than the sugar intolerance. 

I'm glad your daughter was identified and is getting appropriate care.  

-- Henci

Just wanted to add that my daughter is 21 years old. Healthy from day one. Weighed 90 lbs prior to pregnancy and had no risk factors at all. She failed the one hour glucose (277) and went immediately to endo who put her on insulin. In a million years I would not have believed there was even a possibility she'd fail that test.  Don't just assume that it doesn't happen to active, healthy women.

Posted By on 12 Oct 2009 02:59 PM

Henci,

I want to comment on one argument that you have made in several replies with regard to labor induction for GD patients at 39 weeks. Your argument is that if the patient has good blood sugar control, then she does not differ from other normal pregnant women. It follows that her treatment should not differ from others as well. This argument is not necessarily water-tight. A GD patient with good sugar control may appear to be the same as normal pregnant women in terms of blood sugar level, but she has the underlying etiology, which can produce problems even when sugar level is under control. Stillbirth, for example, is not limited to women whose sugar level is too high; it does happen with greater probability in GD patients with good glycogin control. Similarly, a woman with good sugar control can show other symptoms of GD (e.g., I am 39-weeks with diet-controlled GD, but I have polyhydroamnio - too much fluid, a symptom of GD). Unless one assumes that sugar level is the only damage to a pregnancy, and denies other possible effects caused by the underlying etiology, one simply cannot treat GD women the same way as other normal pregnancies. Ultimately it is the science that will resolve these questions. Taking an extremely strong stance on this may lead to dangerous recommendations to your GD patients.

-Vanessa

The only strong stance I take is that women should make informed choices based on accurate, unbiased information on the potential benefits and harms of all their options, including doing nothing. This, unfortunately, is hard to come by with conventional medical management.

-- Henci    

Posted By on 10 Oct 2009 09:44 AM

Hi! I am 35 weeks pregnant with Gestational Diabetes. I am controlling with diet but my fasting blood sugar (Overnight) is sometimes just a little high, maybe by one or two points. My midwife told me if I cant control it at night she wants to put me on insulin at night. I really hesitate bc I am taking three different meds right now. I have my prenatal, an oral antibiotic (I will explain), and albuteral.  First my asthma has never been bad but in the last few weeks with the baby pushing on my diaphram on top of having a mild case of asthma, has made it worse. I have to take at least 3-4 puffs every 4-5 hours to keep it under control. (under advisement of the ER doc I saw)  The oral antibiotic is a preventative measure, as at the end of my first trimester I had a UTI, kidney infection, and kidney stone (all at the same time!).  I am also GroupB Strep positive. As you can see this pregnancy, my first, has not been the easiest.  I have lost 3 pounds since the begining of my pregnancy and the baby is measuring right on target.  My first question is it really necessary to take insulin if my blood sugars are relatively under control? And second my midwife has mentioned that she may want to induce me at around 39 weeks.  I wanted to go natrually, but when I asked about going over my due date she said that would never happen, they dont allow GD patients to go overdue.  I am not willing to induce before November 12, and I am due November 15, if the baby is not that big anyway.  I dont want to make a big fuss, but I have been scared and pulled to my wits end.  I am getting a little angry that I am not being listened to about my body and my baby. Am I being hypersensitive?  Thank you so much for your time and input.

Patti Reposa

No, you are not being hypersensitive. You have the right to make informed decisions about what happens to you and that includes informed refusal as well as informed consent. In order to do that, you need to know the benefits and harms of all your options, not what you will be "allowed" to do or not.

Clearly, your pregnancy is more complicated than simply having blood sugars that are on the high side after eating. If I were you, I would want to get all the specialists involved in my care (asthma, diabetes, pregnancy) in one room (or one conference call) and come up with a plan based on evaluating those benefits and harms according to my individual case. I would also want to discuss how that plan might change under various scenarios. In addition, I would also want to know if there were any interactions among my medications that might be affecting my blood sugars, asthma control, and vulnerability to infection, and whether adjusting them might be helpful. I hope you are under the care of specialists because neither your midwife, her back up obstetrician, nor an ER physician have the specialized training and knowledge to best advise you on the treatment of diabetes or asthma, not to mention the nuances of dealing with asthma in pregnancy. The reason I recommend getting them all together is that specialists are usually limited to their own bodies of knowledge and may miss or not take into account something not in their field.

Here is an page from the Childbirth Connection website on informed consent/refusal. I would add that you are looking for information: How often does that happen? What might that lead to? What action would we take if it did happen? Can you show me the sources that support that? Red flags would be scare tactics--anecdotes intended to frighten you into doing something--threats, or assurance that there are no adverse effects to medical interventions such as induction. Every medical intervention has potential harms as well as benefits.

As a general principle, unless there is a good reason to do otherwise, your best option for a safe, healthy birth is to let the process unfold in its own time with supportive rather than interventive care. The issue here is whether there is a good reason to do otherwise, and that is a question that cannot be answered simplistically.

-- Henci

Henci,

I want to comment on one argument that you have made in several replies with regard to labor induction for GD patients at 39 weeks. Your argument is that if the patient has good blood sugar control, then she does not differ from other normal pregnant women. It follows that her treatment should not differ from others as well. This argument is not necessarily water-tight. A GD patient with good sugar control may appear to be the same as normal pregnant women in terms of blood sugar level, but she has the underlying etiology, which can produce problems even when sugar level is under control. Stillbirth, for example, is not limited to women whose sugar level is too high; it does happen with greater probability in GD patients with good glycogin control. Similarly, a woman with good sugar control can show other symptoms of GD (e.g., I am 39-weeks with diet-controlled GD, but I have polyhydroamnio - too much fluid, a symptom of GD). Unless one assumes that sugar level is the only damage to a pregnancy, and denies other possible effects caused by the underlying etiology, one simply cannot treat GD women the same way as other normal pregnancies. Ultimately it is the science that will resolve these questions. Taking an extremely strong stance on this may lead to dangerous recommendations to your GD patients.

-Vanessa

Hi! I am 35 weeks pregnant with Gestational Diabetes. I am controlling with diet but my fasting blood sugar (Overnight) is sometimes just a little high, maybe by one or two points. My midwife told me if I cant control it at night she wants to put me on insulin at night. I really hesitate bc I am taking three different meds right now. I have my prenatal, an oral antibiotic (I will explain), and albuteral.  First my asthma has never been bad but in the last few weeks with the baby pushing on my diaphram on top of having a mild case of asthma, has made it worse. I have to take at least 3-4 puffs every 4-5 hours to keep it under control. (under advisement of the ER doc I saw)  The oral antibiotic is a preventative measure, as at the end of my first trimester I had a UTI, kidney infection, and kidney stone (all at the same time!).  I am also GroupB Strep positive. As you can see this pregnancy, my first, has not been the easiest.  I have lost 3 pounds since the begining of my pregnancy and the baby is measuring right on target.  My first question is it really necessary to take insulin if my blood sugars are relatively under control? And second my midwife has mentioned that she may want to induce me at around 39 weeks.  I wanted to go natrually, but when I asked about going over my due date she said that would never happen, they dont allow GD patients to go overdue.  I am not willing to induce before November 12, and I am due November 15, if the baby is not that big anyway.  I dont want to make a big fuss, but I have been scared and pulled to my wits end.  I am getting a little angry that I am not being listened to about my body and my baby. Am I being hypersensitive?  Thank you so much for your time and input.

Patti Reposa

In addition to Henci's excellent list above, here is resource from Lamaze and InJoy that you can use if you determine that induction is your best bet. Tips for keeping your birth as healthy and safe as possible when induction is necessary.

Posted By on 17 Aug 2009 02:41 PM

thank you so much for your reply. i did read the rest of the thread before i posted - i think i just wasn't sure about how much the "big baby" aspect affects this. now they want me to do an elective c-section because the growth scan showed him to be "estimated" at about 11 lbs, or 5,000 grams. His head was estimated to be 35 cm and his belly 41 cm. i am 37 1/2 weeks. now i'm not even concerned about induction any more - my issue is whether to have a c-section or whether to try to get him out vaginally first. i'm really torn about it. any thoughts you have would be great, although i apologize if there is another thread on this topic that i have missed. either way, i really appreciate your time! my doula speaks very highly of you. :)

• Hire an experienced doula whose references you have checked. (Looks like you've already got that one covered.) She can give you ideas on how to help labor progress, encourage you when others would discourage you, and help you talk through your options so that you make decisions based on reason rather than fear.
• Starting labor on your own is your best option for a complication-free experience.
• If you have no medical problems, stay home until you are in active labor, that is, contractions for at least a couple of hours that are no more than 5 min apart (count from the beginning of one contraction to the beginning of the next), a minute long, and strong enough that you cannot walk or talk during one.
• Do not allow yourself to be admitted to the hospital until you are at least 3-4 cm dilated. If it is during the day, get checked at your care provider's office. At night, explain that you want to know what is happening, but you will go home if you are still in early labor. You may wish to hang out for an hour or two and get checked again if you think things are going hot and heavy. 
• Ask for the nurse who is most comfortable working with couples who want natural childbirth.
• Tell nursing staff that you are hoping for an unmedicated birth. Please do not suggest an epidural, but you welcome any ideas they have for making your comfortable. If you change your mind, they will be the first to know.
• Unless there is an emergency--and you will know when that is the case--if medical intervention is suggested, ask questions and then ask for time alone to consider whether you will agree.
• Refuse any intervention based on exceeding an arbitrary time limit for making progress. 
• Stay mobile in labor. Insist on intermittent listening rather than continuous electronic fetal monitoring, refuse an IV, and avoid, or at least delay, an epidural.
•  Avoiding an epidural means you will need other ways of coping with labor pain. A good set of childbirth education classes and your doula should prove useful there. 
• Develop a system so that your spouse and doula can distinguish between "I don't think I can do this" from "I want an epidural."
  • code word: some word that you would not ordinarily use. Until you use it, you can bitch, moan, complain, curse or do whatever you need to say or do to cope.
  • preset time period: If you say you want an epidural, your team has some prearranged period of time (say, 30 min or 5 contractions) to try to make you more comfortable. If, at the end of that time, you haven't changed your mind, you get an epidural.
• Push in an upright position. Give birth on hands and knees as the safest and best means of avoiding or resolving shoulder dystocia.
• Nonconfrontational strategies for resolving conflict include:
  • Make statements no one can disagree with: "I know we all want what is best for this baby, which is why I want to do X. "
  •  If an intervention is suggested, don't respond. Look at the person and wait. Silence makes people uncomfortable and they will fill it by making a different suggestion. Wait for one you like and then agree. Then they think it was their idea. This was told to me by a doula who got it from her father who was in sales. She has seen it work.
  • Don't be drawn into an argument. Just politely repeat your position in slightly different words. "We have decided that we don't want to have membranes ruptured now." "I hear what you are saying, but we have decided to wait." 
• Spend time in the bathroom. It makes you unavailble. If you want to clear the room of medical people, start necking with your husband. Necking is good for the labor too.

Here is a set of videos jointly produced by Lamaze International and Injoy Videos that should prove helpful.

Please keep us posted on how things work out.

-- Henci

thank you so much for your reply. i did read the rest of the thread before i posted - i think i just wasn't sure about how much the "big baby" aspect affects this. now they want me to do an elective c-section because the growth scan showed him to be "estimated" at about 11 lbs, or 5,000 grams. His head was estimated to be 35 cm and his belly 41 cm. i am 37 1/2 weeks. now i'm not even concerned about induction any more - my issue is whether to have a c-section or whether to try to get him out vaginally first. i'm really torn about it. any thoughts you have would be great, although i apologize if there is another thread on this topic that i have missed. either way, i really appreciate your time! my doula speaks very highly of you. :)

Please read over the rest of this thread and follow the links to sources that are relevant to your situation. I think you will find that the thread  and links will respond to your concerns about gestational diabetes and help you stand your ground. However, if something isn't addressed to your satisfaction, please get back to me on it. 

-- Henci

I am 37 weeks today, with my first baby. I was just diagnosed GD a week and a half ago. I passed the three-hour GTT test with flying colors at 30 weeks, and then at 34 weeks had an ultrasound where they were estimating my baby to be approximately 7 lbs 3 oz already. So they wanted me to test my blood sugars 4 times a day for a week - fasting and then 1 hr after each meal. Some of these were high - nearly all of the fasting ones were high - so they went ahead and diagnosed me GD and gave me Glyburide to have at night, which has brought all of my fasting blood sugars back down. The rest of them I am handling well with diet and exercise, except for a few small spikes here and there. Baby has passed every non-stress test and biophysical they have given him (twice a week for the past three weeks). I have stopped gaining weight - in fact, I lost two pounds. Also, my amniotic fluid decreased from 22-23 cm to 15 cm, which they seem to like better as well. So far, so good, right? I'm not into intervention, but I buy keeping my blood sugars in line as better for baby and for me.

Now, of course, they want to induce me. They've tried everything - telling me that shoulder dystocia kills babies, telling me they won't "let" me go past 40 weeks, and probably not past 39, and even telling me that women with GD have a higher rate of "spontaneous fetal death" in the uterus. They're clearly trying to scare the crap out of me. But if baby has passed every test, and my blood sugars are all under control, I just don't see why we would want to induce. Why not just wait?

I have another growth scan on Monday, and I'm wondering how it will turn out. The reason why I am posting here is because people keep saying "besides the risk of a big baby," and I'm fairly certain I'm going to have a big baby. Even with as inaccurate as ultrasounds are, there's not much wiggle room for an approximately 7 lb 3 oz baby at 34 weeks to not be pretty big at 39 or 40. Sometimes I want to stand my ground, and sometimes I get tired and I just want to give in. I got a second and third opinion from other OBs - even one whose a good friend of my mom's - and they agree with inducing diabetics between 39-40 weeks. I feel stuck. I can say no, but I'd hate for him to have shoulder dystocia because I was stubborn.

Thank you for sharing your wisdom. Your students are lucky to have you as their teacher. I wish I could claim the "induction is never an emergency" line, but as I wrote in my post, it isn't mine., and I don't want to take credit where credit isn't due. I also wish I could remember who I heard it from. 

-- Henci 

Exactly. The key thing is to find a care provider with a philosophy aligned with your own, which you have done once you move, and then to make decisions collaboratively.

-- Henci

Posted By n/a on 11/05/2008 4:23 PM

Henci, thank you for being an advocate for mothers and babies, and for your clear reasoning on this subject.

You're welcome. I'm going to interweave my responses with your comments.

Based on my research and my belief in and understanding of my own body, I decided to refuse the glucose tolerance test.  Basically, I'm pretty sure that I don't have diabetes or problems with glucose, and I don't want to risk a false positive.  Plus I think the test itself is rather yucky.  I was a competitive athlete for 3 years before I got pregnant, and I still eat pretty well and exercise regularly (though not nearly as intensely!).  My mother & uncle are both diabetics, but they developed diabetes later in life when they were obese and not active, so I don't think their experience necessarily pertains to me.  My mom also did not have GD for either of her pregnancies, and I was born very healthy through natural childbirth, 7 1/2 lbs at 43 weeks(!).

I think your reasoning is sound.

At my last appointment with my OB, the subject of GTT came up, and I told her that I was going to decline the test.  She listened to my reasoning and of course disagreed with me, and said she felt that I should be screened.  She did say that it was my right to refuse, but she really argued her point very heavily.  One of her concerns was that I could be insulin dependent and not know it, and my baby could be born with blood sugar problems and need testing and all that (she even said that my baby could have seizures if left with untreated blood sugar problems, which made me think this woman is really laying the scare tactics on thick).  I feel that the chances of that happening are much smaller than the chances that a GD diagnosis will somehow harm me & the baby and get in the way of me having a normal, natural childbirth.  But I think she is trained to worry about the 1 in 1,000 chance that something might be wrong and not the 1 in 50 chance that all this testing & intervention could cause something to go wrong- it's just the way most doctors are.

Oh, my, where to start. You are right to be concerned about the effect of the GD label. I think the best thing to do is send you over to a post in another thread on GD with links to two articles of mine on the subject and a study showing that identifying women as gestational diabetics did not improve outcomes. Scroll down to the 4th post in the thread. As for your ob's specific arguments, I think your ob is talking about neonatal seizures from low blood sugar. But low blood sugar in newborns can come from any number of causes--a stressful birth, getting cold, being separated from their mothers--anything that stresses the baby and leads to drawing on its glucose reserves. Seizure is a late symptom, not an early one. Care providers are on the lookout for babies who might be having problems, and if low blood sugar is suspected,  the baby’s blood can be tested. Moreover, the best way to ensure the baby doesn't get into this kind of trouble is to keep the baby skin-to-skin, which keeps the baby calm and warm, and initiate breastfeeding within an hour after birth. Colostrum is high in sugar. As for scare tactics about the baby's size, high blood sugar is a much weaker predictive factor for big babies than mother's prepregnant weight. Plus-sized women tend to have plus-sized babies, and they are also more likely to have GD diabetes, making it appear that GD is the culprit. And as I point out in the two articles I’m sending you to, your ob is also not considering the very real harm of being diagnosed as a gestational diabetic. You can read them to find out more about that.  

One thing the OB offered that I am considering was to use a glucometer to monitor my sugar, rather than taking the GTT.  We didn't discuss details of this because at the time I dismissed the idea.  But I've looked into it a little and it sounds like it might be a decent compromise- regular glucose testing is less likely to yield a false positive, I don't have to drink some nasty solution, and I'll be the one writing down the numbers.... so if they are borderline but I'm comfortable with them, I can always write down a number that is a little more within my doctor's comfort zone.  I'm going to have to talk to my uncle about this a little bit- he's an endocrinologist who specializes in diabetes, and he also happens to have diabetes.  He's also pretty low-intervention as doctors go, and has three daughters who have been through this whole pregnancy thing.  I don't think he'll convince me to take the GTT, but he might be able to give me better information about blood sugar levels and GD.

This sounds like a reasonable compromise. You might want to review the articles I'm sending you to with your uncle as well.

Another factor is that I am not planning to stay with my current OB, although I don't think she knows that yet.  I'm only going to her because it's what my current insurance covers.  But I'm moving across the country in a couple of months and already have a midwife who will attend my homebirth.  So I'm not worried too much about this OB trying to induce me or anything like that.  I asked my midwife what she thought about taking the GTT.  She agreed that it wasn't really necessary for me, but said that she encourages her mothers to do the test so that they have it on their charts, in case a hospital transfer is necessary in labor.  She said that doctors in her area get nervous when they don't see a GTT on the patient's chart, and will assume that's the reason for the hospital transfer, that the baby is too big to come out through the vagina and so they go straight for the cesarean.  She doesn't require GTT to homebirth with her, and she has worked with women who have tested positive for GD and they have had successful homebirths with her.

I'm not following your midwife's reasoning. If you have tried everything you can at home, and the labor is not progressing, and you have transferred to the hospital for this reason, then that problem will need to be dealt with. Its cause would be irrelevant at that point. Nor is the solution necessarily a cesarean. Any out-of-hospital midwife will tell you that the majority of transfers for lack of progress are vaginal births. As for an “automatic cesarean,” a stuck labor is never an emergency.  Regardless of the ob's preference, you would still be able to discuss your options and make an informed decision.  Moreover, what if you tested positive for GD? I've got a bunch of studies showing that when the ob believes the woman is carrying a big baby (more than 4000 g or 8 lb 12 oz), which the ob would with the GD label, the woman is much more likely to end up with a cesarean than when the baby actually weighed in this range but the ob didn't suspect it.

My next appointment with my OB is next week, and I want to have my mind made up before I see her.  I'm definitely not doing the GTT, but I might take home a glucometer as she suggested.  I'd really like to just say no to the whole test, but I know this doctor is going to lay the pressure on thick.  I guess I see the finger pricking as a way to get her off my back, but not give in entirely.  I'm hoping my uncle will completely agree with me, but I know that he might not, which is why I haven't called him yet.  Even if he tells me to take the GTT that won't change my mind, but if he fully supports me it will make me feel more justified in fighting my doctor.  The fact is, in addition to being an expert on diabetes, he's known me my entire life, and knows that I really am pretty healthy.  He also knows the particulars of his and my mother's diabetes (she sees another doctor but often consults with my uncle).

In the end, I know that this is my decision and I don't need to convince my doctor.  When we argued last time she tried to make it seem like I do need to convince her, but I know that I can still say no, even if she is always able to stump me on every point.  And I don't trust that she has my best interests in mind, so I actually don't feel like discussing this further with her, I just feel like making a decision without talking to her.

Sorry for this long and rambly post.  If you have any suggestions or comments on my situation I would be open to them.  I only have one specific question: if there were really something wrong with me and the way I metabolized sugar, wouldn't I have some idea?  Wouldn't I sort of feel it?  I would feel hungry all the time, I would have trouble working out, I would feel tired, lethargic, something!  But I don't, I feel as good as ever, just pregnant.  And wouldn't they find something in my urine or blood pressure to suggest that I was at risk for GD?  I mean, is this test really necessary if all signs point to me being healthy?  I have been doing 45 minute erg (rowing machine) pieces.  Not as hard as I did pre-pregnancy, but I know for a fact that this is something that most non-pregnant women would find challenging or impossible (I used to).  Doesn't that count for something?

No, you wouldn’t necessarily feel any different, but, yes, your healthy lifestyle definitely counts.

I guess part of the problem is that I'm proud of how strong & healthy I am, and I feel like all this testing is undermining my confidence in my body.  I'm doing great, leave me alone, doctors!

You're last paragraph says it all. Conventional obstetric management is fear based. Fear distorts judgment on the part of care providers and women alike, and it undermines women's confidence at a time when they most need to feel confident and competent. I'm not saying that things never go wrong in pregnancy or labor, but working from a model that assumes that they are likely to does incalculable harm to the health and wellbeing of mothers and babies as witnessed by our outrageous nearly 1 in 3 cesarean surgery rate. Physiologic care, which assumes correctly that things rarely go wrong and that when they do, most of the time patience and simple measures will put them right, has been shown time and time again to produce the best outcomes with much less use of risky medical interventions.

-- Henci

Hi All,

Henci, thanks for the "Deciding to induce labor is Never and emergency.'' I like that and will use it when appropriate in my classes.  I'm an independent Lamaze educator (about 1 year, 50 moms total so far), and that will help.

FYI for moms diagnosed with GD -- I also have had three babies, and was diagnosed with GD for my first two.  I was 37, 39, and 41 years old when I had my kids: 10 lb, 10 oz boy, 9 lb 6 oz boy, and 8 lb girl.  Several thoughts  --

-- If nothing else is going on with the mom (no other risk factors --and age is NOT a risk factor), an official diagnosis with gd that is well-managed is no reason to induce, whether or not the docs/midwife think the baby will be big. 

-- if the docs/midwife think the baby will be big, ultrasounds can be off at least 1 lb in either direction anyway.  Some studies/people say more. 

-- Even if you do have a big baby, you can still deliver the baby vaginally.  Just get good support and plan to do it.  I'm of medium build and got all my babies out vaginally thanks to my own persistance and really good support from my doula and especially the nurses, who (I think) didn't want to see another cesarean.  I think my doc would have preferred a cesarean, but that didn't happen.  It was difficult -- I had a long early labor followed by an epidural and 4 hours of pushing and an episiotomy with tearing, but my next birth was pain med free and the one after that was also pain med free and pretty strong/fast (like later labors and births often are!)  There have also been a few moms in my classes who were told they were going to have large babies, ended up having a cesarean, and their babies were around 7 or 8 lbs. 

-- Ask the context/what are the numbers -- how often have you seen this in the last year?  This is a good question for partners to ask, while the mom might be reacting to some difficult info from a dr or midwife.  I encourage partners to go with the mom more often as the due date approaches as that is when care providers styart talking about wanting to do things. 

-- I ask my class participants if any of them have had to manage the care of an elderly parent or someone else, and I compare decision-making about birth to that.  There can be a lot of decisions to make and a lot of new information to absorb, but we can do it.  Sometimes the information is contradictory or confusing, with multiple practitioners coming from different perspectives.  I encourage them to think of themselves as comsumers, not patients. 

-- I also talk about  what it's like to challenge experts, and use the example of the kinds of decisions we might have to make later as parents, such as, me having a boy and what if later on, he has tons of energy and the teachers think he has ADD but I think he just needs more recess time?  Decisions about birth are just the beginning of decisions we'll make as parents for the rest of our lives, taking into account all that we know about a topic and about our selves, our families, and our resources.  Which brings me to a major point I make in my classes --

-- No one else knows all that we know about our selves, our resources, our families, and more.  We are the best person to make the best decision for our selves, our babies, and our families.  Not our docs/midwives, not our friends, not me as the childbirth educator, not the acquaintance who stops the pregnant mom on the street and then tells the mom about her challenging birth experience.  No one else.  It really is all about the mom, because she is the best person to know everything and to care for her baby both inside of her and when the baby comes outside! 

Of course, I could go on, but won't.  Henci, thanks for managing this forum and for keeping the postings of all the moms/participants. 

I recently read the book Pushed, and thought it was a pretty good book if anyone wants to know more about the larger issues of maternity care in the US.  It might be helpful for moms who want more background on likely interventions, where they come from, and more.  I thought the book might only make me so angry (make me feel like a victim, for example) that it would take a long time to de-tox after it in order to give my classes, but I wasn't too incapacitated by it -- it seemed pretty balanced. 

Best wishes to all the expectant moms reading these forums -- you can do it!  (Now back to preparing for my class tomorrow and nursing my little one!)  :-)

Lucy

I feel like I should add one little thing, lest people think I'm one of those people who always argues with doctors and never lets them do their job-

I have not refused a single test up until now.  I had an ultrasound at 22 weeks- all the organs are fine & well developed.  I do all the other testing, I even submitted to the AFP (against my better judgment) and it came back completely normal.  So no, I'm not against modern medicine, I just think that this whole GD thing is ill-conceived.  Not everything the doctors cook up is good.

I also have a reason to be wary of false positives.  I once told a doctor that I thought I might have arthritis in my knees.  I was thinking osteo-arthritis.  Anyway this doctor thought he should rule out rhematoid arthritis.  He gave me a blood test and found that my ANA levels were very high, which is a marker for a possible rhematoid disorder.  He told me that I might have lupus or rheumatoid arthritis or a number of other things.  He had me completely freaked out, because he didn't explain the statistics well.  He left out the little detail that 50% of the people with high ANA have absolutely nothing wrong with them, and no one knows why their ANA would be elevated (see doctors don't know everything).  After a lot of stress and a few more blood tests, all serious medical problems were ruled out, and it was decided that there was nothing wrong with me.  I just likely am developing osteoarthritis in my knees.  Thanks, doc, that was so helpful!

So I'm really wary of anything with high false positives.  At least in the case of rheumatoid arthritis, that was a real disease with real implications and problems with real treatments (I think)- it would have been better to find if it I in fact did have that problem, or lupus.  But GD isn't even a real disease, and finding it doesn't necessarily make things all better.  There are so many stories of women diagnosed with GD who then go on to control their sugars through diet, and then their doctors STILL want to induce them.  What the hell is the point of the diagnosis, then?  Why even bother, if it still leads to a lousy outcome?

Henci, thank you for being an advocate for mothers and babies, and for your clear reasoning on this subject.

Based on my research and my belief in and understanding of my own body, I decided to refuse the glucose tolerance test.  Basically, I'm pretty sure that I don't have diabetes or problems with glucose, and I don't want to risk a false positive.  Plus I think the test itself is rather yucky.  I was a competitive athlete for 3 years before I got pregnant, and I still eat pretty well and exercise regularly (though not nearly as intensely!).  My mother & uncle are both diabetics, but they developed diabetes later in life when they were obese and not active, so I don't think their experience necessarily pertains to me.  My mom also did not have GD for either of her pregnancies, and I was born very healthy through natural childbirth, 7 1/2 lbs at 43 weeks(!).

At my last appointment with my OB, the subject of GTT came up, and I told her that I was going to decline the test.  She listened to my reasoning and of course disagreed with me, and said she felt that I should be screened.  She did say that it was my right to refuse, but she really argued her point very heavily.  One of her concerns was that I could be insulin dependent and not know it, and my baby could be born with blood sugar problems and need testing and all that (she even said that my baby could have seizures if left with untreated blood sugar problems, which made me think this woman is really laying the scare tactics on thick).  I feel that the chances of that happening are much smaller than the chances that a GD diagnosis will somehow harm me & the baby and get in the way of me having a normal, natural childbirth.  But I think she is trained to worry about the 1 in 1,000 chance that something might be wrong and not the 1 in 50 chance that all this testing & intervention could cause something to go wrong- it's just the way most doctors are.

One thing the OB offered that I am considering was to use a glucometer to monitor my sugar, rather than taking the GTT.  We didn't discuss details of this because at the time I dismissed the idea.  But I've looked into it a little and it sounds like it might be a decent compromise- regular glucose testing is less likely to yield a false positive, I don't have to drink some nasty solution, and I'll be the one writing down the numbers.... so if they are borderline but I'm comfortable with them, I can always write down a number that is a little more within my doctor's comfort zone.  I'm going to have to talk to my uncle about this a little bit- he's an endocrinologist who specializes in diabetes, and he also happens to have diabetes.  He's also pretty low-intervention as doctors go, and has three daughters who have been through this whole pregnancy thing.  I don't think he'll convince me to take the GTT, but he might be able to give me better information about blood sugar levels and GD.

Another factor is that I am not planning to stay with my current OB, although I don't think she knows that yet.  I'm only going to her because it's what my current insurance covers.  But I'm moving across the country in a couple of months and already have a midwife who will attend my homebirth.  So I'm not worried too much about this OB trying to induce me or anything like that.  I asked my midwife what she thought about taking the GTT.  She agreed that it wasn't really necessary for me, but said that she encourages her mothers to do the test so that they have it on their charts, in case a hospital transfer is necessary in labor.  She said that doctors in her area get nervous when they don't see a GTT on the patient's chart, and will assume that's the reason for the hospital transfer, that the baby is too big to come out through the vagina and so they go straight for the cesarean.  She doesn't require GTT to homebirth with her, and she has worked with women who have tested positive for GD and they have had successful homebirths with her.

My next appointment with my OB is next week, and I want to have my mind made up before I see her.  I'm definitely not doing the GTT, but I might take home a glucometer as she suggested.  I'd really like to just say no to the whole test, but I know this doctor is going to lay the pressure on thick.  I guess I see the finger pricking as a way to get her off my back, but not give in entirely.  I'm hoping my uncle will completely agree with me, but I know that he might not, which is why I haven't called him yet.  Even if he tells me to take the GTT that won't change my mind, but if he fully supports me it will make me feel more justified in fighting my doctor.  The fact is, in addition to being an expert on diabetes, he's known me my entire life, and knows that I really am pretty healthy.  He also knows the particulars of his and my mother's diabetes (she sees another doctor but often consults with my uncle).

In the end, I know that this is my decision and I don't need to convince my doctor.  When we argued last time she tried to make it seem like I do need to convince her, but I know that I can still say no, even if she is always able to stump me on every point.  And I don't trust that she has my best interests in mind, so I actually don't feel like discussing this further with her, I just feel like making a decision without talking to her.

Sorry for this long and rambly post.  If you have any suggestions or comments on my situation I would be open to them.  I only have one specific question: if there were really something wrong with me and the way I metabolized sugar, wouldn't I have some idea?  Wouldn't I sort of feel it?  I would feel hungry all the time, I would have trouble working out, I would feel tired, lethargic, something!  But I don't, I feel as good as ever, just pregnant.  And wouldn't they find something in my urine or blood pressure to suggest that I was at risk for GD?  I mean, is this test really necessary if all signs point to me being healthy?  I have been doing 45 minute erg (rowing machine) pieces.  Not as hard as I did pre-pregnancy, but I know for a fact that this is something that most non-pregnant women would find challenging or impossible (I used to).  Doesn't that count for something?

I guess part of the problem is that I'm proud of how strong & healthy I am, and I feel like all this testing is undermining my confidence in my body.  I'm doing great, leave me alone, doctors!

I am 17 weeks pregnant and was diagnosed with GD at just 5 weeks after a one hour glucose. Thus far, insulin free and managing with dietary adherence alone, it has been a learning experience and this is something I have not been faced with before (first child at age 38). I can see various points of view. I am taken back by anyone who suggests that a mother who challenges or questions any medical procedure being performed on herself hence her unborn baby is untrusting and selfish. I think any intelligent person does her research and aks the pertinent questions needed to provide her with the secuirty she needs to know she is making the best decision for the best all around outcome possible for both herself and baby. While I praise most doctors for their efforts, doctors are human and not only NOT infallible but not without bias and sometimes their own motives as a result of those biases. I am learning more about the process through forums like this and my own experience with a parinatologist, dietician, treatment team. I hope that people will use the forum productively and intelligently with an open mind instead of feeling compelled, whatever your view may be to attack someone. How many people do you think have followed erroneous advice by their medical practitioner only to result in a medical error. Take a look into that. I follow my doctor's advice as well as the dietician and nurses, but I also use common sense and when something seems questionable, I ask and challenge. Any good treating physician will address your concern and feel ok about that. I personally feel that because patients in this GD category have been flagged as high risk, the doctors we encounter are very vigilent and sometimes hypervigilent in treatment, partially because they want the best outcome but as Henci pointed out because they do not want to take any risks that will jeopardize their professional standing.

I beg to differ. It is all about the mother because the mother and baby are an indivisible unit. Take care of the mother, and you take care of the baby. Split them into two units with conflicting needs and you harm both. Moreover, when society values the baby over the mother, it makes her into a container for something more precious than she is. Down that road lies forced cesarean surgery because some doctor says it is better for the baby which really means he thinks it will be better for him because he might be sued. Down that road too is depriving pregnant women of life-saving drugs because they may harm the fetus.

As for your statement that doctors here do better for babies or mothers, by any measure, including that of newborn outcomes, conventional obstetric management is an abysmal failure. Let us take, for example, electronic fetal monitoring (cardiotocography), perhaps the "monitoring" you are referring to. It has no benefits for mothers or babies, but it increases cesarean surgery rates, which not only harms mothers but has potential harms for the baby of the current pregnancy and babies of any future pregnancies, not to mention that women who planned to breastfeed who have cesareans are less likely to breastfeed--yet another harm to the baby. Those epidurals and pain medications you praise all have potential harmful effects on babies as well.  

You are entitled to your opinion, of course, but it does not jibe with either human rights, medical ethics, or what the research establishes as safe, effective care.

-- 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 

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

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 

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

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??

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

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!