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    Questions? Ask Henci!


    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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    Archived User
        Ms. Goer,

    I am a 30 year old woman pregnant with my first child.  I am currently 29 weeks pregnant, and have read and studied your book, "The Thinking Woman's Guide to a Better Birth," as it has always been my intention to have a completely natural, drug-free birth.  I am also attending Bradley Birth classes with my husband, and attend a midwife-led childbirth education class twice a month.  However, I was diagnosed with gestational diabetes at about 20 weeks, and have been on insulin almost two months.  My sugars are well regulated and my baby is perfectly healthy.

    Last week I went to my regular OB appointment, only to be told that their policy for GD women in labor is NPO (not even water), and a continuous IV drip of alternating glucose and insulin to regulate my blood sugar and prevent hypoglycemia in the baby postpartum.  I am so upset about this because, first and foremost, it makes no sense!  I am perfectly willing to allow them to check my sugar as often as they like, but believe that I am perfectly capable of regulating it without the IV if they will allow me to do so with oral intake.

    My question is this: Do you have any research you can refer me to regarding women with GD and natural childbirth?  I need to know at this point if I can convince my hospital to allow me the birth that I want, or if I need to find an alternative setting for my birth.  Unfortunately, I am in Georgia and there are no free-standing birth centers in the entire state -- the closest is in Tennessee.

    Thank you so much for any advice or information you can provide.

    Jaime WInfree
    Henci Goer

    What you say about regulating your own calorie intake vs. insulin makes sense to me. At this point you are the most knowledgeable person about what works and what doesn't. (Side note: My brother is an endocrinologist, and I have heard him rant on exactly this point: Hospital staff screwing up the blood sugars of diabetes patients because they won't let them take care of their own sugar regulation while in the hospital.) You do have the right to make an informed refusal. Here are a couple of federal government sources on that:

    Here are the Medicare/Medicaid regulations, and most hospitals accept Medicare/Medicaid funds:

    "A hospital must protect and promote each patient’s rights. . . . The patient’s rights include . . . being able . . . refuse treatment. . . . The patient has the right to be free from all forms of abuse or harassment"

    Department of Health and Human Services. Chapter IV -- Centers for Medicare & Medicaid Services, Department of Health and Human Services: Part 482--Conditions for participation for hospitals. In: National Archives and Records Administration; 2005. Access at: http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr482_06.html

    And here are HIPAA regulations (and you thought HIPAA was just about privacy of medical records):

    "In order to ensure consumers' right and ability to participate in treatment decisions, health care professionals should:

    • Provide patients with easily understood information and opportunity to decide among treatment options consistent with the informed consent process. Specifically,
    • Discuss all treatment options with a patient in a culturally competent manner, including the option of no treatment at all. . . .
    • Discuss all risks, benefits, and consequences to treatment or nontreatment.
    • Give patients the opportunity to refuse treatment. . .
    • Abide by the decisions made by their patients . . . consistent with the informed consent process."

    Office of Personnel Management HIPAA Consumer Rights and Responsibilities. Appendix A. Consumer bill of rights and responsibilities. Chapter four: Participation in treatment decisions. Access at: http://www.opm.gov/insure/health/cbrr.htm#chpt4

    About the larger issue of this hospital's willingness to work with you so that you can have a normal, natural birth, I would be willing to bet that the IV/no oral intake restriction won't be the last of the procedures, tests, and restrictions you will have to fight, and if you aren't starting with care providers who share your philosophy of striving for a normal, natural birth, you won't be able to trust their judgment as to what interventions may be reasonable and necessary.

    Unfortunately, too, the picture is not so bright as regards your out-of-hospital options. As an insulin-dependent diabetic, you would likely be disqualified for a birth center even if one were available--not that you should be in my (nonmedical) opinion. If you have no medical complications, and your sugars are under control, I don't see that you differ from any other woman. The only risk according to the research is that you have somewhat higher odds of having a bigger than average baby, and out-of-hospital midwives are likely to do a much better job of handling that without you ending up with a preventable c/sec or instrumental vaginal delivery than conventional hospital-based practitioners. I don't know what the situation is for home birth midwives, but you could probably find out more on this by going to the Citizens for Midwifery website at www.cfmidwifery.org and asking them. They are based in Georgia. One thought: if Tennessee is reasonable, there is always the Farm. 

    Please keep us posted on what you decided to do.

    --Henci

    Archived User
        Thanks so much for the info.  I have since spoken with my midwife (hospital based) and several Bradley instructors, who in turn have spoken with at least one other physician.  This Dr. says that if my sugars are regulated (by me) that the insulin/glucose drip will not be necessary, but that I will need a continuous IV for fluids anyway -- which, again, makes no sense.  If I can stay hydrated without the IV, why should I need it?

    My plan at this point is to ask that they start a heplock upon admission -- to make them feel better -- and then check my sugars and hydration and only start the line if they feel I am not doing an adequate job on my own.  I am meeting with the perinatalogist who is managing my diabetes on Friday and plan to discuss this and the other monitoring procedures they have in mind for labor.

    On a positive note, I did find a management plan on the Internet from The Royal Women's Hospital in Victoria, Australia (where the medical establishment is obviously more on the ball), which details clear instructions for using ORAL INTAKE to manage blood sugars in labor, as well as preventing and treating post-natal hypoglycemia in the baby.  I am planning on taking this with me on Friday and showing it to the dr.

    Although I have found the amount of resistance I have encountered extremely frustrating (It's like they think no woman ever gave birth without an IV, 10 monitors, and an epidural!!), I am so pleased to know there are people like you who are willing to help those of us committed to natural, drug-free births achieve them.  Thank you again.

    Jaime
    Henci Goer

    Posted By n/a on 05/12/2007 12:36 PM
        Thanks so much for the info.  I have since spoken with my midwife (hospital based) and several Bradley instructors, who in turn have spoken with at least one other physician.  This Dr. says that if my sugars are regulated (by me) that the insulin/glucose drip will not be necessary, but that I will need a continuous IV for fluids anyway -- which, again, makes no sense.  If I can stay hydrated without the IV, why should I need it?

     

    Why indeed? "Evidence Basis for the Ten Steps of Mother-Friendly Care" found "no evidence of benefit" for routine IVs. You can download this document for free at http://www.ingentaconnect.com/content/lamaze/jpe.

    My plan at this point is to ask that they start a heplock upon admission -- to make them feel better -- and then check my sugars and hydration and only start the line if they feel I am not doing an adequate job on my own.  I am meeting with the perinatalogist who is managing my diabetes on Friday and plan to discuss this and the other monitoring procedures they have in mind for labor.

     

    I hope the meeting goes well.

    On a positive note, I did find a management plan on the Internet from The Royal Women's Hospital in Victoria, Australia (where the medical establishment is obviously more on the ball), which details clear instructions for using ORAL INTAKE to manage blood sugars in labor, as well as preventing and treating post-natal hypoglycemia in the baby.  I am planning on taking this with me on Friday and showing it to the dr.

     

    Good searching! I poked around the 'net to see if I could find something for you but didn't come up with anything.

     

    BTW, the best way to prevent neonatal hypoglycemia is to breastfeed within the first hour after birth. Colostrum is high in sugar, protein, and other nutrients. But if your sugars are under control, your baby should not be at any greater risk of diabetes-related neonatal hypoglycemia than the baby of a normoglycemic woman. Neonatal hypoglycemia is a rebound reaction to being exposed in the womb to a high sugar environment. The baby makes extra insulin in response, and after birth, when the baby is cut off from the mother's blood sugar, the excess insulin can cause the baby's blood sugar level to crash. 

    Although I have found the amount of resistance I have encountered extremely frustrating (It's like they think no woman ever gave birth without an IV, 10 monitors, and an epidural!!), I am so pleased to know there are people like you who are willing to help those of us committed to natural, drug-free births achieve them.  Thank you again.

     

    It is entirely possible that staff at your hospital have never seen a birth without an IV, monitoring, and an epidural except as a dangerous aberration to be avoided, i.e. the woman who arrives at the hospital with the head crowning.

     

    Thank you, and I am glad to have been of assistance.

     

    -- Henci

     

    P.S. Given your frustration over their resistance, I still think it may be better to switch than fight.



    Jaime

     

    Archived User

    Jamie,

    Could you please provide a link to the Royal Women's Hospital protocal for management of blood sugar with oral intake during labor?

    THANK YOU SO MUCH!!

    Sara

    Archived User
        Henci,

    Thanks again for your help and support.  I am feeling much better about my chances of having a "real" birth, despite the obstacles.  I emailed The Farm yesterday to ask them about their management plan/experience with diabetic women in labor, just to have a backup.  Hopefully I will hear from them soon.

    Thanks again!

    Jaime
    Archived User
        Sara,

    The link to the Royal Women's Hospital plan is http://www.thewomens.org.au/DiabetesinPregnancyManagementinLabour.

    For the oral intake plan, click on the link to "Management of Hypoglycaemia."  This will take you to a flowchart that explains how to manage bloodsugars by oral intake first, then by either IM injections or IV infusions as a backup.  The link also recommends the INJECTED doses of insulin for various levels of hyperglycaemia.  They specifically state that IV fluids are not necessary in the management of diabetes in labor.

    Hope this helps.  When/if I hear back from The Farm, I'll post what they have to say as well.

    Jaime
    Archived User

    Thank you SOOOOO much!!

    If you're still planning to use your OB, let me know what he/she says about the protocol.

    Thanks!  Sara

    Henci Goer

    You're very welcome! Let us know if you hear from the Farm midwives and what they say. I'm also delighted to see that your research may be helpful to someone else.

    -- Henci

    Archived User
        Henci -- I received a reply from The Farm today, which was pretty generic.  They suggested eating large meals early in labor, and waiting until about 8 cm to go to the hospital (that could be tricky because we live an hour away!).  They also said what everyone else does about preventing hypoglycaemia in the baby -- nurse right away, which I was planning on doing anyway.  So, nothing earth shattering.

    However, I met with my perinatologist yesterday, and he, believe it or not, is pretty much on board with me.  He still wants to do the weekly NST starting next week (Which means 30 mins. on the EFM and a bio-scan ultrasound), but I suppose I can live with that, and of course will take your advice re: repeat testing if they see a "problem."  He has agreed to let me hydrate and regulate my sugars with oral intake.  He says I will likely be in for a fight with the nurses, but he has begun recruiting the support of several liberal nurses in LDR in the hopes that at least one of them will be one when I deliver.  I plan on writing up my birth plan and having him sign off on it prior to delivery, so that if a nurse gives me a hard time, I can just say, "See -- he already ok'd it."

    All in all, I think I will be able to have an almost intervention free birth, which is my goal.  I might still have to fight with them about EFM in labor, but worst case scenario, I can just take it off, right?

    Thanks so much for your info and support.  I plan on typing up your bibliography on NPO studies to take in for back up.  You are a great help to women who want to have their babies the way God intended.

    Take care,

    Jaime Winfree
    Henci Goer

    Your perinatologist sounds great!

    I have a few suggestions:

    • I think it's a great idea to have your perinatologist sign off so that nurses have confirmation that he has approved your exceptions to the usual rules. Still, birth plans are sometimes regarded with suspicion and hostility by hospital staff. You may be able to defuse this by couching what you want positively and by appealing to the nurses to help you achieve your goal. For ex., "It is important to me not to use pain medication. Any suggestions you have to help me be more comfortable and avoid its use will be greatly appreciated. Please do not ask me if I want pain medication as that may make it more difficult for me. If I change my mind, I will request it myself."
    • When you arrive at the hospital, show your birth plan to the admitting nurse and ask to have the nurse who is most comfortable working with couples who want the style of birth that you do. On the reverse side, if you get a nurse who isn't one you can work with, ask to speak with the nurse in charge and request a different nurse. Don't go into details about why she is a problem, just stick to vague generalities such as "We're just not a good fit," and politely insist on having someone else.
    • If your perinatologist comes through for you, write a letter afterward to him thanking him and to the hospital saying how much it meant to you that staff were flexible and understanding or whatever. Positive reinforcement is a powerful tool. 

    Finally, about continuous EFM or anything else, you can politely assert your right to informed refusal. Reserve this for what really matters to you, though, because it carries the danger of being labeled a "difficult patient."

    -- Henci

    Archived User
        Thanks, Henci.

    All great suggestions, which I will follow.  My midwife has agreed to look over our birth plan once we finish it, and I will definitely be having the Peri. sign it.

    It's so ironic the different tacts doctors will take.  I went to my regular OB appt today (they have me seeing one of everyone because of the GD) and she says to me, "Well, you're going to be induced at 38 weeks anyway."  Not because I have a big baby or that there's anything wrong!  Thank goodness I won't be seeing her anymore as of my next visit -- I'll be with a doc at the peri's office!

    Thanks again for all of your help,

    Jaime
    Henci Goer

    Even more ironic is that inducing at 38 weeks is NOT recommended even by those who don't see any problems with inducing labor in general. Even though 37 weeks is officially full-term, babies born before 39 weeks when it wasn't their idea (it is the baby who masterminds the onset of labor) are more likely to end up with respiratory difficulties at birth. So your ob would be doing something that can cause real harm to babies in order to prevent an imaginary one.

    -- Henci

    Archived User
        Oh, Henci -- I've got an even better one for you.

    I met with the hospital anesthesiologist this week to discuss NPO and IV's in labor.  He of course starts out by touting the benefits of the epidural, and then goes so far as to say, "Now, you know, lots of women used to die during what we now call 'natural childbirth.' We've been able to curb that over the years by preventing aspiration via NPO and preventing dehydration via IV"s."  When I attempted to confront him with facts about other coutries and their lack of IV and NPO policies (while simultaneously attempting not to laugh at his clear insinuation that natural birth KILLS women), he didn't want to hear it.  He asserted himself as the expert and made it clear that NPO is the way to go -- but that the hospital policy is to allow oral intake of anything they consider "clears."  We had some discussion on his definition of a "clear," and continued on with his attempt to have me drugged in labor.  I explained to him that I did not want to stand on my head and eat pizza while giving birth, but that an epidural/narcotics were not options for me and I had prepared myself very well for this experience.  He looks at me and says, "Uh-huh, and is this your first baby?"  When I answer in the affirmative he says, "Well, forgive me, but I've heard this story before.  You know, having a baby hurts a lot and you are likely to want some help with the pain, so you need as much info. about epidurals as you can get now so that when you want one, you are making an informed decision."  As if I am not speaking from a place of HAVING a tremendous amount of info. about epidurals, thus my reason for refusing one!   Agh!  At this point I decided to politely smile and nod until the conclusion of our conversation, since he clearly was not going to listen to anything I said. 

    Once again, I never knew what an uphill battle natural birth would be, and I am immensely grateful for people like you who arm people like me with THE TRUTH so that we can achieve the births we want.

    Jaime
    Henci Goer

    Hang tough; you are doing great! This anesthesiologist is suffering from a case of "My mind is made up; don't confuse me with the facts." It's a common problem among practitioners of conventional obstetric management. "Nod and smile" is your best course of action. You are not going to change the mind of someone like that, and in this case, it doesn't matter. You don't have to work with him. What's most laughable is his Alice-in-Wonderland inversion of why to talk about epidurals before labor. The real reason is to become informed of the potential harms as well as benefits and of alternatives to epidurals so that the woman can make an informed choice before she is under the pressure of labor. It isn't, as he thinks, to mount a sales pitch for the product the selling of which is how he makes his living.  

    -- Henci

    P.S. I don't see anywhere in your posts anything about your having a doula. I strongly recommend it. From all you have said, you and your partner are going to need someone in your corner, not to mention all the other benefits a doula can provide. For information on doulas, go to the Childbirth Connection website to the section on labor support at http://childbirthconnection.org/article.asp?ClickedLink=257&ck=10178&area=27 

    Archived User

    A bit late in responding to this thread, but had to comment...

    That's ridiculous.  Women died in childbirth because of infection, hemorraging, lack of basic prenatal nutrition and knowledge about the process (i.e., proper care).  We know that by seeing the cause of deaths in underdeveloped countries. 

    And, how did women die from 'natural childbirth' as a result of aspiration via NPO??  That's an issue with anesthesia, is it not?  Not normal, natural birth (or even just normal life, for that matter).  Same with dehydration.  If that is true, then any random person is at risk for dropping dead at any given time because we are not hooked up to an IV or could aspirate at any given moment.

    Cindy


    All Times America/New_York

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