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.

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

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. :)

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

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.

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

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

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

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    

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.

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