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    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

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    May 04
    2007

    gestational diabetes - induction at 39 weeks?

    Archived User

    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!

     

     

    Henci Goer

    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> opUpMenu2_Set(Menu12423867);" target=_blank>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, University of Florida, Jacksonville, Florida 32209, USA. [login to unmask email]

    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

     

    Archived User

    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??

    Henci Goer

    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

    Archived User
    Let's hope you don't have an asphyxiated, hypoglycemic infant. Why are you going to an obstetrician in the first place if you don't want to follow their advice? It's not all about you. Do you want a stillborn? Face the fact that  you are not having a normal pregnancy. be happy that you don't live in a third world country with sky high infant mortality rates. Don't be so selfish.
    Henci Goer

    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 

    Archived User
    I am also pregnant with my first child and I have gestational diabetes and I was keeping it under control for the duration of my 3rd trimester I am now 35 weeks only a couple days from 36 and they are just now putting me on insulin for control of my mourning sugars and my doctor says he is going to induce me at 38 weeks.  I haven't gained but 2 pounds in the last 5 weeks since I started the diet so I know she probably has gotten that big in fact I lost 3 pounds all togeter.  So is there any reason besides big baby why he would want to do that?  I'm not much knowing when it comes to induceing it seems like it would be convenient but I keep on reading all these bad things with inducement should I try to convenice him not to induce me if I get an unltrasound and she isn't that big?
    Henci Goer

    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

    Archived User
    Henci,

    In our area, the OBs and even CNMs play the "failing placenta" card with GD moms to coerce them into induction. Is there any research evidence to suggest that placentas calcify or "fail" more often with a GD diagnosis? I would be interested in an analysis of the literature, as they do talk about "the studies," and even those CNMs who would not induce for "big baby" do seem genuinely concerned with BPPs and induction for GD moms, because of this placenta/stillbirth concern.

    Thanks,
    Jessica (doula and childbirth educator)
    Henci Goer

    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 

    Archived User
    I'm sorry, I had to laugh at this remark.  I was living in a country in the MIddle East where they do not tend to monitor babies as well as we do here in the USA, or the wellbeing of the mother.  Now that i am back here in the land of the Free, I thank God that we have doctors who are overly-cautious and offer epidurals and pain meds when needed.  It is much better to be safe than sorry.  You are right, it is not all about the mother, it is about the baby and doing what is best for him or her.
    Henci Goer

    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

    Archived User

    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.

    Archived User

    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!

    Archived User

    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?

    Archived User

    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

    Henci Goer
    Posted By n/a on 11/03/2008 9:09 PM

    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.

    It sounds to me as if you are taking a sensible and prudent approach to your care. I've given out this link many times, but it doesn't hurt to repeat it again: Informed Consent, Informed Refusal. I think you'll find it helpful as you navigate through making decisions for yourself and your baby.

    In case you do not know this, you are in a different category from what is usually termed "gestational diabetes." GD usually shows up in the third trimester as the placenta puts out more and more hormone to suppress the mother's insulin, making more glucose available to fuel fetal growth. High blood sugar early in pregnancy is more serious. Keep that in mind when reading general information on GD. The good news is that you are doing well without need for insulin, although I am sure you are aware that this could change as the pregnancy advances. Even so, if your sugar is well controlled by whatever means, I don't see how you would differ from a woman who doesn't need extra care to keep her blood sugar levels where they should be.

    -- Henci

    P.S. If you are a plus-sized woman and continue to have problems with high blood sugar after you have the baby, losing weight sensibly may be all you need to bring sugar levels under control.

     

     

    Henci Goer

     

    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

     

    Henci Goer
    Posted By n/a on 11/05/2008 4:36 PM

    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?


    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

    Henci Goer
    Posted By Lucy Juedes on 11/07/2008 12:23 PM

    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

     

    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 

    Archived User

    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.

    Henci Goer

    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

    Archived User

    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. :)

    Archived User
    [I've been trying to post this since Saturday. I finally realized it was having trouble with Google Chrome! Back to Internet Explorer...]

    Hi Katy,

    Wow. I don’t know where to start except by saying that you are actually pretty fortunate. You have the benefit of time to weigh the risks and benefits. If this had been a bedside decision while you were already in labor, you would probably have to do your due diligence AFTER your baby was already born.

    One thing… are you sure about the GDM diagnosis? You were in the normal range at 30 weeks. The closer a woman gets to giving birth, the less accurate the results of GDM testing are. From what I understand, there isn’t consensus on what the cut-off should be for routine tests. What would the point be for re-testing after you had already had a negative test at 30 weeks? It sounds odd to me and maybe Henci will address the research on GDM issues when she replies.

    Could you be further along than you think you are? Ultrasounds are not accurate predictors of fetal weight, so the 34 week estimate might be off. Have you considered that your due date might be earlier than you think it is?

    Have you already read ACOG’s Practice Guidelines on fetal macrosomia? It reads, “In cases of term patients with suspected fetal macrosomia, current evidence does not support early induction of labor.” In 2005, a huge retrospective analysis was done in California on 267,228 vaginal births and found 1,686 cases of shoulder dystocia—a rate of 0.6%. The study showed that when the triad of Pitocin, induction, and birth weight greater than 4,500 g (9 lb., 15 oz.) was present, shoulder dystocia was 23 times more likely to occur. This suggests that induction of babies that are actually macrosomic might cause shoulder dystocia (Ouzounian, 2005).

    Three weeks of AFT/NSTs is a lot. You do not have to submit to a final growth scan if you don’t want to. Sometimes it’s better not to know and better that your doctors don’t know. What would you do with the information at this point? What would they? Those are rhetorical questions, by the way.

    I’m finding myself right now spending an inordinate amount of time trying to decide what to say succinctly (and failing at the succinct part). I blog about this a lot but I usually don’t jump in and chat with women directly, but I just answered a similar concern elsewhere last week which will tell you where I’m coming from.

    You are not alone—this scenario is increasingly common. And yes, I think you are correct in saying that they are working really hard to scare the crap out of you. Just wait until they start telling you about procto-rectal episiotomies and the Zavanelli maneuver.

    I was in your shoes four years ago to the day (with two exceptions: they scheduled me a c/s and the pointless GDM test, which they did a few days before I gave birth was “normal but on the high end”) and we had a really hard time fighting off a cesarean. I wasn’t planning on any interventions in labor if I could avoid them, nor was I opposed to surgery if there was an actual need for it. I also had the benefit of time, which I used to read medical journals and articles. It was a really stressful and fairly morbid way to spend the last week and a half of pregnancy when all I really wanted to do was nap and compulsively fold and organize baby socks.

    I also had a Bizarro World experience when a friend convinced me to go spend a few hours with her home birth midwife. The only person in the last week and a half of my pregnancy that gave me any evidence-based information on shoulder dystocia, ultrasounds, macrosomia and birth in general was a home birth midwife. I looked up everything she told me and everything the doctors told me (which was not based on anything but their personal anecdotes) and it blew my mind. I’ve never really looked at the world the same, honestly.

    I also knew intuitively that I had a big baby on deck based on my family’s history and knowing this reinforced my desire to stay mobile and active in labor. I’m really glad I did. If you want to read stories of big babies (4000 g+) born vaginally (in hospitals and at home), there are tons on my site. Unnecesarean—Birth Stories

    My contact info is on the site if you want to e-mail me. I hope you will if you have any questions about my experience.

    Jill
    Henci Goer
    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. :)


    I agree with everything that Jill22 said. You are in a very difficult situation. You have care providers who have demonstrated by their non-evidence based recommendations and scare tactics that you cannot trust their judgment. If you cannot find other care, and, unfortunately, most will not take a new person late in pregnancy, here are some suggestions of mine for maximizing your chances of birthing a big baby vaginally and not being talked into potentially harmful interventions you do not truly need. Anybody else out there please feel free to add to the list.  
    • 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

    Archived User

    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.

    Archived User

    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

    Archived User

    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

    Henci Goer
    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 Goer
    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

    Yes, but what is the etiology associated with stillbirth? Women with diabetes of long standing, almost certainly type 1 (insufficient insulin) if we are talking of women of childbearing age, are at risk because over time, diabetes can damage blood vessels and kidneys, which poses risk to the fetus. Wild swings in sugar levels--sugar control becomes more difficult in pregnancy with type 1 diabetics--can also harm the fetus. With rare exceptions, women with GD do not have diabetes of long standing. They also have a different type, a version of type 2 (insulin resistance). They make adequate amounts of insulin but blood sugars are elevated nonetheless. In fact, most GD women would not be considered to have diabetes at all were they not pregnant. The diagnostic criteria are lower than that for anyone else, and the threshold is arbitrary. It marks neither the onset nor increase in adverse outcomes. And there is another explanation for an association: women with elevated blood sugar are much more more likely to be women of high body mass index (BMI). Women with high BMI are also more likely to have medical problems such as hypertension that increase fetal risk. In other words, GD isn't causal but associated with complications that are the real risk, and, in fact, I have a study from years ago that showed that the excess stillbirth rate in a population of women with GD could be explained by other risk factors.

    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    

    Archived User

    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.

    Henci Goer

    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

    Archived User

    I just have to say that I am so happy I have stumbled into this forum, and especially this thread of posts.  I am 27 years old, pregnant (25 weeks) with my 2nd child. I had GD with my first, and have been early diagnosed with my 2nd. 

    I went into this pregnancy thinking automatic C-section--and if not C-section at the very least induction. I have since decided to educate myself tremendously--the first time I was pregnant I was only 19--and very healthy--jogged frequently, ate decently, and not a large size either.  However, I have gained weight (or more so not lost weight since my son was born 8 years ago).  I am thankful that I have been able to control my blood sugar levels with little medicinal help and diet--I am not gathering up the courage to tell my DR that unless the ultrasound (which of course I've "had to have" done every month) is showing a uber-large baby, that I am against induction, as well as, most interventions. 

    Thanks to educating myself, the scariest part of that is that I now have to tell my mom who is flying from MD that she may not be here when our little Logan is introduced to the world!

    Henci Goer

    I am glad you found my Forum helpful. I would add that the research does not support inducing labor for a baby who is predicted to be big. Inducing increases the cesarean rate without decreasing the chance of shoulder dystocia (the head is born, but the shoulders hang up behind the pubic bone). That being said, the fact that you have had a prior vaginal birth means that inducing labor does not increase your cesarean risk provided you a cervix that has gotten ready for labor on its own (Bishop score more than 6).

    While I'm at it, here are some ways of minimizing the chance of shoulder dystocia and of avoiding a cesarean or instrumental vaginal delivery.

    • Have patience. Labors with bigger babies can take longer. So long as you and the baby are tolerating labor, there is no need to intervene.
    • Avoid an epidural. It interferes with your ability to push effectively. There are many effective ways to minimize and cope with the pain of labor. 
    • Give birth side-lying or on hands and knees. These positions reduce the likelihood of shoulder dystocia compared with the usual position of lying on your back.

    These Lamaze videos cover the principles of a safe, healthy birth.

    ~ Henci

    Archived User

    I realize I am coming into this discussion really late...however, I am curious if there is a difference in risks between a gestational diabetic and one who is a true type 2 diabetic? Here's my story.I had gestational diabetes with my second baby (insulin dependant), but about 6 months after having her, was diagnosed a type 2 diabetic. My mother has type 1, and was hospitalized the last few weeks of her pregnancy with me. Basically My endocrinologist thinks it is possible I may have been diabetic before I ever got pregnant. (I was borderline by 3 points with my first child maintained with diet...yet I was 130 lbs 5'2" when I became preg with him and actually did not gain more than 15 lbs the entire pregnancy...)

    I am now pregnant with baby number 3. I was on 3 types of medication before and during this pregnancy (including Metformin) and placed back on insulin at around 10 weeks gestation. I have had a lot of issues during this pregnancy. I was born with a mitral valve prolapse that naturally gets worse with pregnancy but this time I was put on partial bed rest due to chronic hypo-tension (or LOW bp). I began contracting around 27 weeks non-stop and have-on 3 occasions-been given meds to stop/slow labor. I was induced at 39 weeks with my second baby mainly because I had polyhydraminos and she turned breech at 38 weeks. They did the ECV and then decided to induce. This time they want to induce again at 39 weeks because I am a type 2 diabetic. I am on a lot more insulin this time around. As of today (@34 1/2 weeks) I am taking 208 un of insulin per day. 3 times what I took with my second baby. This will most likely increase even more. But, I really do not want to be induced, however she is measuring at 5 lbs 13 oz since 2 days ago....and she is also in a breech position. What are my options? I feel lost because they seem like they would rather me get induced at 39 weeks with now an added possibility of a c-section. Do I have any say? I honestly do NOT want to have another ECV either because there are so many risks with that as well. BTW, My son (my first) was born on his own-no meds at all @ 37w&6d weighing 7lbs 6 oz and 19 in. perfectly healthy. My second (dd) was induced at 39w0d weighing 7lbs 0oz 18 in. (they estimated her being 9lbs 2 oz!!!! boy, were they wrong!). Can I step in and give MY opinion? or will it matter? I am beginning to wonder if they just want this baby out at 39 weeks because they are tired of my issues??? I feel as if asking too many questions gets me a lot of eye rolls and shrugs. they never give me straight answers anymore. they act like since this is my 3rd time (despite my age and my health issues) that I should KNOW the deal. Sorry ifI sound like I'm venting but it's frustrating. Not to mention all the NSTs and AFIs etc....I'm gtting just as sick of them as they are of me! But I want what is BEST for my baby. I'm not so sure what that is any more.

    Henci Goer

    Of course your opinion matters! You have the right to make informed decisions about your care, which you cannot do without your care providers giving you accurate, objective, complete information. Many childbirth educators suggest the BRAIN acronym to their students to help them with this:

    Benefits
    Risks
    Alternatives, including doing nothing
    Instinct/intuition
    No/not now

    Here, too, is a page on the Childbirth Connection website with general information on informed decision-making. I would add to beware of attempts to manipulate your decision such as scare tactics ("You can do that if you don't care what happens to your baby"), anger ("And what medical school did you go to?), or patronizing you ("I see you've been playing around on the internet"). If your care providers are unwilling or unable to provide you with the information you need, then I think that the best thing you can do for yourself and your baby is find care providers who will.

    I don't have research-based data on the effects of type 2 diabetes on pregnancy, but I can tell you that external cephalic version is safe and effective when done carefully and that there is no need to induce after one because few babies turn back, and for those that do, the procedure can be repeated. You do have some options, however, that don't involve manipulating your belly: the Webster technique and moxibustion. For that matter, vaginal breech birth is a perfectly viable option for most women provided their care provider knows what he or she is doing.

    As for inducing labor, if you decide that would be best, I can tell you that absent a medical reason to induce sooner, it is recommended to wait until 39 completed weeks (the beginning of the week that ends with your due date) to minimize the chance of respiratory problems. Although this is less of an issue in women with prior vaginal births, waiting for cervical ripeness (Bishop score 6 or more) minimizes the chance of a cesarean for lack of progress. I would refuse misoprostol (A.K.A. Cytotec, "miso") because other agents work equally well and don't have its reputation for causing serious problems. I would also recommend refusing membrane rupture. That way, if the induction doesn't "take," you can stop the induction and go home. Once membranes are ruptured you are committed to delivery one way or another. Also, once you are in progressive labor, the oxytocin (Pitocin or "Pit") drip can be turned off to see what happens, leaving just the plain IV fluid. In many women, especially women with prior vaginal births, labor will continue on its own. If it doesn't, no biggie, the Pit can be turned back on.

    ~ Henci

    Archived User

    Hi Henci!  I was wondering if you know anything about gestational diabetes and a small baby?  I was diagnosed with GD at 28 weeks and managed with diet alone for about 2 weeks, but instantly lost 3 pounds.  My numbers continued to rise even though I was living on salad and less than 15 carbs a meal, so they put me on insulin and I'm now taking it morning and night.  I average about 30 carbs per meal now and the insulin continues to be adjusted as needed and overall my blood sugars are always higher than 120 1 hour after meals.  They range from 120 to 200 depending on what I eat, which 130/140 being average.  I do experience blood sugar lows about once a day even though I try to eat extra protien.  To make matters worse, I suffer from panic disorder and my anxiety over giving myself shots is so severe that I am completely unable to do it.  Luckily my sweetheart of a husband gives me my shots for me, but the timing is not consistent as it depends on his work schedule which changes daily.  I've also noticed that as the insulin has increased, my blood sugar lows have increased and that has also added to my anxiety as I'm constantly worried that I will faint when no one is around and go into some freaky coma and die.

    As for weight... I've only put on 1 pound total in my 3rd trimester for a total of 15 overall (I'm 37 weeks).  I started my pregnany 20 pounds overweight, but nowhere near obese.  As of last week at my 36 week exam, I still only measured 33wks pregnant (3 weeks in a row) so the Dr. ordered an ultrasound.  The ultrasound does show that the baby is measuring between 1 and 2 weeks small depending on which measurement you look at.   Based on measurements, he came in at the 14th percentile and an estimated weight of 5lbs, 7oz.  At the 20 week scan, he was exactly 50th percentile and I know my due date is either accurate or up to 4 days later than where it should be based on LMP and conception dates (we were trying, so everything was calculated). 

    At this point we are not worried about the baby being too big, but actually whether or not he's thriving as well as he should.  My husband and I are not big people, so it makes sense that our baby would not be big, but I'm concerned that with the extreme diet that I am on coupled with the anxiety, baby may not be getting what he needs to grow. 

    Do you happen to know of any circumstances where gestational diabetes can have a reverse effect?  I'm just trying to wrap my head around what may be going on with me.  Although excited that I don't have a lot of weight to lose after the baby comes, it bothers me that the baby is measuring small now.  I'm curious to know if this may be considered normal since most mothers with GD have bigger babies and my blood sugars aren't controlled as good as they could be.  I do see the Dr. tomorrow and will find out what he thinks is best course of action.  Any insight that you have would also be appreciated.  Thanks for your time!

    Henci Goer

    I just read the research, and I am not a clinician, so I cannot advise you personally. However, from what you write, it is clear that something unusual is going on. Type 1 diabetes runs in my family, and my brother is an endocrinologist, which means I am aware that managing insulin can be tricky, and, yes, insulin can cause low blood sugar and small-for-gestational-age babies as can calorie-limited diets, although what makes it even odder is that you aren't experiencing low blood sugar and you aren't limiting calories. If you haven't involved a specialist in insulin-dependent diabetes, I would request a consult with one. You may also want to consult a maternal-fetal medicine specialist if you are just seeing an ordinary obstetrician. Make sure your doctors know about you being prone to anxiety attacks. This could well be part of the problem. One thing I do know is that part of the anxiety response is to flood the body with glucose so that muscles are primed for fight or flight.

    You will probably be needing to make some decisions soon about tests and treatments such as whether to induce labor. The acronym BRAIN can help:

    B enefits
    R isks
    A lternatives (and the benefits and risks of those, including doing nothing)
    I ntuition or instinct (after taking in the information, what do you feel about the baby's condition and what is right to do?)
    N o or not now ("How urgent is it that I decide now?" can help with this.)

    You and your husband will need complete, objective information on which to make any decisions both now and during labor. A touchstone during the information gathering process is to ask yourself, "Am I getting feelings or information?" Getting feelings is a huge red flag. Unfortunately, some caregivers will attempt to scare or bully women into doing what they think she ought to do, which means they will almost certainly be giving you incomplete, no, or even misinformation as well. If that happens, it would be best to find someone else to consult, or, if that is not possible, at least to take it into account, and barring an emergency situation, refuse to allow yourselves to be stampeded into a decision.

    ~ Henci

    Archived User

    Hello Henci. I have been following this thread for awhile now but waiting to add my question until the time was finally at hand... Sooo I will try to keep this basic and not over complicated..  I was diagnosed with GD at about 12 weeks into my pregnancy thanks to having glucose in my urine. I had an A1C score of 5.9% with the cut off at 5.7%. I was under managed care from my OB, and the Sweet Success program and their perinatologists. I had frequent ultrasounds and went to all my appts. I was first put on Glyburide which worked for my fasting #'s but I wasn't on a schedule as far as my meals so the Perinates put me on insulin and metformin. I gained a ton of weight and it did nothing for my fasting numbers and I wasn't happy, the Metformin made me very ill. Luckily I lost my job couldn't afford the insulin anymore so they put me back on Glyburide and my numbers have been great my A1C is  even down to a 5.7%. Ok all that being said...  I have had very frequent ultrasounds and they seem to agree with me that the baby is younger than what my  EDD says by about a week or so and it has been so consistently my whole pregnancy.  She is in no danger of being a large baby she is measuring at 6 lbs at 38 weeks no larger chest or shoulders and all seems well enough with her. The placenta looks great too. She has normal growth rates much to my Drs surprise. ( I don't know why I have been well monitored my whole pregnancy instead of dealing with GD at a later date when the damage is usually already been done) So my OB wants to induce at 39 weeks! Next week he wants to induce, not because the baby is big or too small or not thriving. Simply because there is a threat the placenta can fail. My logic tells me if the placenta was going out 1.) it would show on u/s as calcification or the baby would stop growing normally and or 2.) I would start failing my NST tests that I do twice a month.. Last week at my 38 week appt he ambushed me and started with the scare tactics of how it is better for the baby out than in etc etc and scheduled me an induction date for next week even tho I am not dilated or effaced. I guess I am just seeking reassurance I am not over reacting when I go to my next appt because I am going to cancel my induction. I just really feel there should actually be something going wrong to warrant it not the threat something could go wrong...... I just feel like if my body isn't ready and or baby isn't ready as a first time mom and overweight the odds of me going from a natural unmedicated birth to interventions epidurals and c-sections is very high. What do you think?

    Henci Goer

    If you have read this thread, you will know that I have written that logically, there should be no reason an otherwise healthy woman under good control should be at greater risk for a stillbirth. I have not been following the gdm research closely of late, but I have an early study that showed that other factors such as hypertension that were associated with gestational diabetes explained the excess in stillbirths, which makes sense. I also have abundant evidence that inducing labor in first-time moms roughly doubles the likelihood that labor will end in c/sec surgery and that inducing before 39 completed weeks, that is, before the beginning of the week that ends with your due date, puts your baby at excess risk of serious breathing problems, greater difficulty breastfeeding, etc. There are no guarantees in life, but I think you are on solid ground to follow where your own analysis of the situation has led you. Cancelling the induction is likely to make your care providers unhappy and worried, and they have already attempted to use scare tactics on you. That being so, you will want to make sure that decisions now and in labor are based on accurate, objective, complete information on the potential harms and benefits of all your options, including doing nothing.

    While I am at it, you should also know that routine NSTs have not been shown to improve outcomes even in high-risk pregnancies. On the downside, they are not harmless. Like all fetal surveillance tests--amniotic fluid volume, modified biophysical profile--they have very high false-positive rates (the test says there is a problem but there isn't), which leads to unnecessary inductions and c/sections because, of course, once a test says the baby is in trouble, no one in their right mind is going to ignore it.

    ~ Henci

    Archived User

    I’ve written this post 3 times and it keeps getting eaten.. here’s hoping this one goes through!

    I have read all the way through this thread, as well as several others, and have fallen down the Internet rabbit hole of all the links and information that have been posted. I can’t thank everyone enough for giving me all of this information, as it’s made me feel much more confident. However, I do have a question that I was hoping I could get some feedback on.

    I am 40 weeks pregnant (today -- 3/12) and was diagnosed with GD about 8 weeks ago. The first few weeks were rough and my sugars were all over the place, but they have been well maintained for the last few weeks through Glyburide. I have diligently followed all doctor’s orders, including having NSTs and BPPs weekly.

    At my last BPP on Friday (3/9), the baby was measured to be at 9 lbs. The doctor that I saw that day, who I will call primary doc #1 (seemingly out of nowhere) told me that due to the baby’s size, I should schedule a c-section and forgo labor. This caused me to basically become hysterical in the office, because I do NOT want to have surgery. Throughout this pregnancy I have planned to have the baby naturally with no medication, because I am extremely allergic to all major pain medications I’ve tried, and I just think of childbirth as a natural thing that my body is made to do. She told me that due to the fact that I am 3cm dilated and 50% effaced that she wouldn’t think I was crazy if I wanted to try to labor, but that she would cut off my laboring at 24 hours. I just wanted to say absolutely not, but when my husband heard this, he sided with her and wanted me to schedule surgery immediately. We finally agreed that we would wait for awhile to see if I went into labor naturally.

    Today (3/12) I saw primary doc #2. He told me that he didn’t see a need for me to schedule surgery, and was totally cool with letting me labor, because women have big babies all the time. He also said that he doesn’t really like all the increased interventions (BPPs/NSTs) that we have now, because he feels like they aren’t always accurate, and they limit him on what he can do (not using forceps on big babies due to fearing they’ll get stuck, for example). He was MUCH more positive, and I felt so much more comfortable after seeing him that I could’ve cried with relief. Hubby accepted what this doctor said, and is now back on board with how I wanted to do things. Primary doc #2 did say that he’d probably want to induce sooner rather than later, but if I wanted to wait, he was cool with that too.

    Now we get to my question: I’d like to go naturally if possible, because that’s obviously the best case scenario. However, I see doctors that are in a practice (of 5) and I am really scared that one of those doctors will try to scare us into surgery that I don’t want. I know that I can stand up to that, but I’m not sure my husband can. He’s really worried about the safety of the baby, and appears to go with whatever the doctor says is best. I appreciate this, but I don’t trust the doctors nearly as much. Primary doc #2 (who I feel has my back) is on call this Wednesday (3/14), and then not again until next Thursday (3/22). I know that at some point, they are going to want to induce me, and while I’d love to go naturally, I’m scared to wait too long because I’m scared the baby WILL be too big for me to have naturally. Is it crazy to wait until next Thursday to induce (when the doc I like is on), or should I do so sooner with a doc I’m not so comfortable with? Or do you think I should just keep waiting until my body is ready (keeping in mind that my mom was 3 weeks late with me -- something I don't think I'd be able to convince the doctors or my husband to let happen with me, plus I'd be terrified at how big the baby would be at that point!).

    Thanks in advance for any help or guidance you can give!

    Henci Goer

    I'm sorry you have been having problems with the Forum. At any rate, third time was the charm.

     

    In response to your questions, you are right: in the absence of a compelling reason not to, letting nature take its course results in the best outcomes. Doctor #2's approach is much more in alignment with the research evidence, specifically:

    • Tests of fetal wellbeing such as the BPP and NST have never been shown to improve outcomes, even in high-risk women--which you are not. They do, however, greatly increase the likelihood of ending up with unnecessary interventions because of their high false-positive rates, that is, the test says there is a problem but there isn't.
    • The research evidence does not support fetal weight evaluations either. They are highly inaccurate, but they influence care decisions. I have six studies all finding that when the dr believed incorrectly that the baby was going to weigh more than 4000 g (8 lb 12 oz), the woman was much more likely to have a cesarean than if the baby actually weighed that much, but the dr didn't suspect it.
    • The research evidence does not support either planning a cesarean when anticipating a big baby or inducing labor for this reason.
    • The evidence also does not support preset time limits for labor progress. Here, too, the idea that labor must proceed at a particular pace or end in delivery by a certain time leads to increased use of labor augmentation, instrumental vaginal delivery, or cesarean surgery without improving outcomes while exposing women and babies to the potential harms of those interventions.

    So one question is how do you get dr #2's game plan if you are not assured of having dr #2? One thing you could do is ask this question of dr #2. Second, use this acronym to help you make informed decisions: 

    Benefits
    Risks
    Alternatives
    Intuition/instinct
    No or not now

    You want to know the benefits and risks of what your dr is proposing, and they should be presented as objective, complete, factual information. If you are getting feelings instead of information, that's an indication that you are being manipulated into a decision. You then want to know the same for all your alternatives, including doing nothing. After you have digested the information pay attention to what your intuition or instinct is telling you. And, finally, you have the right to refuse. I recommend that a refusal not be absolute but be followed by a discussion of circumstances under which you would change your mind. During labor, barring an emergency, once you have gotten the information, ask for time alone with your hubby to consider it so that you won't feel pressured to respond without thinking things through.

    It would be best if labor started on its own, but if are like your mom, that could result in more pressure than you may be willing to tolerate. Most medical-model practitioners are pushing for induction at 41 weeks these days, which is unfortunate because the median length of pregnancy (half of women begin labor before half after) in a healthy first-time mother who reaches term may be 41 weeks. By 42 weeks, the old cutoff for postterm, far fewer women have not gone into labor, and the ones who have not are more likely to be on the verge of doing so and therefore more responsive to induction. This brings me to the next point: inducing labor before the cervix becomes favorable (effaced or shortened, anterior, beginning to dilate) greatly increases the odds that the induction will end in a cesarean, and cervical ripening agents have no effect on this. They do a great job of softening the cervix, but they don't reduce the cesarean rate. I'm talking about studies of elective induction here, which means no medical reason for the induction and therefore the high cesarean rate can be attributed to inducing itself, not the possible reasons for it. Still, if you feel induction is your best option, here is what the research supports:

    • Wait for a favorable cervix. (See above.)
    • Refuse the use of misoprostol A.K.A. Cytotec. It does not increase likelihood of vaginal birth, and it sometimes results in catastrophic complications.
    • Refuse rupture of membranes. That way if labor doesn't progress, you can stop the induction and go home. Once membranes are ruptured, you are committed to delivery.
    • Once you are in active, progressing labor, arrange beforehand that they will try turning the oxytocin drip off. In many cases, according to three studies, once the pump is primed, your natural contractions will take over. If they don't, the drip can always be turned back on.
    • This is for your doctor as well as you: have patience. Labor is likely to take longer.

    I hope this helps.

    ~ Henci 

    Archived User

    Henci,

    Thank you so much for your reply... I really can't thank you enough. You've really helped my stress level, and I felt much more confident going into the doctor this week.

    Yesterday I saw the doctor that told me she wanted to do the c-section for a check up (doc #1). It was beyond frustrating. She told me that my cervix is not making any progress, that I'm measuring big, that the baby hasn't dropped, and that her "gut feeling" due to doing this for 20 years is that the baby hasn't dropped because she's not going to fit, and that this is not going to be a vaginal birth. For the life of me I cannot understand how that is supposed to help me when she KNOWS my husband and I have already chosen to try things naturally. How is negativity going to help me? Is that supposed to prepare me mentally or something? Because really all it does is make me angry, scare the crap out of my husband, and now make me somewhat obsessed with doing everything the Internet can think of to help the baby drop.

    I will not be seeing that doctor again. I go in for another check up on Monday (where of course they want to do a BPP and get the baby's weight again... something else I don't think is probably going to help), but I am going to a different location than I've been to before which is almost an hour from my house, because I'm determined to see Doc #2 and ask him your questions. I'm wondering if this other doctor's office will get a different result on the BPP for weight (since they can be so far off), but I'm really interested to hear what Doc #2 has to say in regards to getting his game plan even if he's not the doc on call.

    Hopefully I will go into labor sometime between now and Monday and I will get through labor and delivery with no issues and all of this stress can go away. I just continue to be shocked by the negativity of a doctor that I thought was really positive early on, and frustrated with myself that I didn't do more research beforehand to make sure I was picking the right person to see.

    Thanks again for all of your help!

    Henci Goer

    You're welcome. The sad thing is that Dr #1's "gut feeling" that a woman will end up with a cesarean is likely to be accurate, not because of anything having to do with the women, but because her beliefs become a self-fulfilling prophecy. All her judgments and decisions are shaped by it. And then when her gut feeling is justified, in a vicious circle, it reinforces her "gut feeling" the next time.

    If you end up with this dr, you and your husband will have to stay very calm and centered and not allow yourself to be stampeded into a decision. If a true emergency occurs, it will be obvious. Otherwise, take the time to decide carefully using the BRAIN acronym. 

    -- Henci  

    Archived User

    Hi Henci,


    I wanted to write and follow up with you on how things went. I am thrilled to report that labor and delivery went exactly as I wanted it, and I was able to give birth to my daughter completely naturally and with no medications. I went into labor at 41 weeks 2 days. My daughter weighed 9 lbs 1 oz at birth, and from the time I stepped into the hospital to the time I gave birth was 3 hrs and 39 minutes. Once she decided that it was time to come, she really made it happen. :)  Another fun thing to note is that the doctor that happened to be on call and deliver her was the same doctor that told me that I couldn't do it, and that her "gut" and medical training said I would have a c-section. Things got a little hazy, but I'm pretty sure that after the delivery when she was congratulating me, my exact was response was "I *TOLD* you I could do it!"

    Thanks again for your advice and help... being educated really helped with my overall anxiety and I appreciate it very much!

     

     

    Henci Goer

    Congratulations, and I'm delighted to hear this! I love happy endings! If you are feeling up to it, you might write this doctor a letter telling her how her negativity made you feel and that if you had followed her advice, you would have ended up having major surgery that you did not need. You might want to copy all the doctors in the practice while you're at it.

    ~ Henci

    Rebecca S

    Hi Henci,


    I've just read through the whole thread - it's really informative, thank you. I just wanted to add my scenario - I am 37 weeks pregnant with my first baby, I am 37 years old (so considered 'advanced maternal age'), and have been dx with GD since week 33. I have managed really well to control it by diet and exercise alone, and the drs say I definitely don't need any insulin medication  as I'm managing it so well. However, at my last visit, they did nonetheless talk about induction on my due date, as they don't want me to go beyond because the 'risk factors'. I understand clearly, based on the info in this thread, and what the doula I'm hoping to book, have all been telling me, that the risk factors associated with GD are more or less (or totally?) removed if it is carefully controlled, and therefore there is no real medical need for induction...

    However, I have other risk factors that come into the equation, so am wondering if these will make the dr's talk of a need for induction more correct, or if they have no bearing on the need for induction:

    1) I have also been dx with thrombocytopenia (low platelets), - still waiting for blood work results from hematologist to confirm if it is the pregnancy-related type or a pre-existing type, so haven't been put on any medication for that yet (hopefully won't be).

    (they said the only real implication is that i wont be allowed an epidural because of hemorrage risk and with low platelets, you bleed more profusely, so they won't risk it - but I'm kind of happy about this as I don't want an epidural anyway - also it makes me think, if they do insist on induction, they will necessarily have to proceed more gently as they know they wont be able to shut me up with an epidural if they bring on contractions too fast!)

    2) the fact that i'm considered advanced maternal age

    3) the fact that this is an IVF pregnancy

    4) the fact that I've had previous first-trimester miscarriages (these were discovered to be due to a uterine anomaly - septate uterus - and I had surgery to repair the uterine anomaly)

    5) they also say I've put on excessive weight in the pregnancy - 40 pounds. However, in the last four weeks, since the GD dx, and since I started controlling my diet, I have maintained my weight and not put on a gram!

    So all in all, I wanted to ask your opinion - do any of these risk factors, combined with the controlled GD, mean that an induction is something medically necessary?


    Would really appreciate your perspective.


    Thanks so much,


    R

    Henci Goer

    I'm glad you found the thread informative. What leapt off the page in your post is that you are at risk for excessive bleeding because of a low platelet count. Inducing labor has consistently been found to be associated with postpartum hemorrhage (see below for list of studies), and with your condition, you would be at extra risk for this. Furthermore, inducing labor with an unripe cervix, something that would be more likely if you are induced based on a preset pregnancy duration, is strongly associated in 1st-time mothers with labor ending in c/sec surgery. (Strategies to ripen the cervix do a good job at this, but they don't reduce the excess risk of c/sec compared with labors that start on their own probably because there is more to the uterus being ready to contract effectively than a favorable cervix.) C/sec surgery is also more likely to result in excessive bleeding among its many other potential complications.

    If, after discussion with your doctor, you agree that induction is medically necessary in your case, here's what I would do in your shoes:

    • I would discuss the balance of benefits vs. harms if the cervix isn't ready to go.
    • If it isn't already your doctor's policy, I would insist on using the dosing regimen listed on the Pitocin package (see below), NOT a high-dose/short interval regimen. The dosages on the package are in line with what your body produces naturally, and an interval of at least 30 min before increasing the dose allows it to reach its full effect. Postpartum hemorrhage with induction is strongly associated with what dose you receive and over how long a period: Grotegut CA, Paglia MJ, Johnson LN, et al. Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony. Am J Obstet Gynecol 2010. 
    • I would refuse rupture of membranes. That way, if the induction doesn't "take," you can stop, go home, and try another day, but once membranes are ruptured, you are committed to delivery. 

    ~ Henci

    Al-Zirqi I, Vangen S, Forsen L, et al. Effects of onset of labor and mode of delivery on severe postpartum hemorrhage. Am J Obstet Gynecol 2009;201(3):273 e1-9.

    Al-Zirqi I, Vangen S, Forsen L, et al. Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008;115(10):1265-72.

    Bais JM, Eskes M, Pel M, et al. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2004;115(2):166-72.

    Combs CA, Murphy EL, Laros RK, Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77(1):69-76.

    Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum Hemorrhage Resulting From Uterine Atony After Vaginal Delivery: Factors Associated With Severity. Obstet Gynecol 2011;117(1):21-31. 

    Magann EF, Evans S, Hutchinson M, Collins R, Howard BC, Morrison JC. Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J 2005;98:419-22.

    Rossen J, Okland I, Nilsen OB, et al. Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions? Acta Obstet Gynecol Scand 2010;89(10):1248-55.

    _____________________________________________________________________________

    Pitocin Label Excerpt (King Pharmaceuticals 2007)

    Administration: The initial dose should be 0.5-1 mU/min . . . . At 30-60 minute intervals the dose should be gradually increased in increments of 1-2 mU/min . . . . [I]nfusion rates up to 6 mU/min give the same oxytocin levels that are found in spontaneous labor. . . . [R]ates exceeding 9-10 mU/min are rarely required. Overdosage: Hyperstimulation with strong (hypertonic) or prolonged (tetanic) contractions or a resting tone of 15 to 20 mm H2O or more between contractions can lead to tumultuous labor, uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage, uteroplacental hypoperfusion, and variable deceleration of fetal heart, fetal hypoxia, hypercapnia, perinatal hepatic necrosis or death.

    Rebecca S

    Thank you VERY much for all this highly useful and pertinent information.

    Of course when I discussed this with my dr, she agreed that induction could  lead to increased hemmorhage risk, but only if it goes on for too long - (but of course she didn't say the obvious that induction probably only goes on for too long due to the fact that the baby wasn't ready to come out yet in the first place!)

    The (fairly) positive update for now is that because the GD is under control, they are saying they will they will not induce before the due date, and were fairly flexible about leaving any scheduled induction date until at least a little after the due date potentially...

    Rebecca S

    Just to add, however, the dr did say that once they start induction, if she believes there is a medical need, they will not stop it and will keep going....

    Henci Goer

    I'm glad that your doctor has shown some flexibility; however, the ultimate decision on whether to have an induction or to continue with one (as I wrote previously, discontinuing an induction is no biggie provided membranes are intact) or to have any other test or procedure, for that matter, is up to you, not her. All competent adults have the right to make decisions about their care, and pregnancy doesn't revoke that right. I suggest that going forward, you use the acronym BRAIN to make informed decisions about your care:

    Benefits: What are the advantages of what is being recommended?

    Risks: What are the potential harms of what is being recommended? How likely are they to occur? What other interventions might become necessary as a result of introducing this one?

    Alternatives: What are other ways of handling this same situation, including doing nothing? What are the benefits and risks of the alternatives?

    Intuition/instinct: After you have taken in the information and digested it, what is your gut telling you about what is best for you to do? You don't want to act on gut instinct alone, but once you have the facts, it becomes a trustworthy guide.

    No or not now: Informed consent is meaningless without the potential of informed refusal. If you do say "no," though, discuss the circumstances under which you would reconsider or change your mind.

    I hope this helps. Please let me know how everything goes.

    ~ Henci


    All Times America/New_York

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