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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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    Dec 17
    2008

    Longstanding T1 diabetes, fighting off induction pressures

    Archived User

    Hi there! I hope you will get a chance to answer my post. I am a great admirer, and I have your two famous books, but they mostly address healthy low-risk women, which I am not exactly.  I'm wondering if you have had better luck with the research than I have had, because I am facing major stress from my medical team. I'm sorry if this is a little rambling; I'm still so upset.

    Tonight I narrowly avoided induction after my doc tried to scare the living daylights out of me. I would love to switch to a birth center or midwife but I am risked out by the fact that I've had T1 diabetes since 1993, so I am forced to deal with high-risk doctors in a hospital, or go it alone. Too scared to go it alone! I have no complications and my blood sugars are pretty decent, although as a T1 there is always a bit more of a rollercoaster. I wasn't planning to get pregnant as soon as I did so my first A1c was 7.0%, but since then I have consistently been under 6.0%. Last A1c was 5.7% and I don't have a lot of lows. I am currently in my 38th week, and I am not dialated whatsoever as of today. I am sure that if we tried induction it would fail. I am trying to go about this in as natural a way as possible.

    I am not at all afraid of macrosomia. I have had ultrasounds for growth every three weeks and we are always in the 25th percentile, so even the doctors can't scare me with the idea. (My husband is a little dude and I'm not huge either but I have nice babybirthing hips.) I have biophysical profiles every week, plus two non-stress tests a week, which I detest, since my little girl doesn't like to move and nearly fails them unless I dose her with caffeine before I go into the tests.

    I have had enormous amounts of testing done, and amnio too. There are very few things that could actually be wrong with this girl at this point. I have had a zillion ultrasounds and I'm sure there are no major congenital malformations. There are some minor things u/s doesn't pick up. I am mostly worried about her having hypoglycemia after the birth, and I'm worried about shoulder dystocia, of course. Aside from that I think we are fine as long as we are left to cook as long as necessary. I quizzed my doc about all-fours (I read Ina May) and of course he has never heard of the Gaskin maneuver and said we would never do it -- I have prepped my husband and my doula that we are pushing on all-fours and that is that. They will flip me no matter what the doc says.

    But I have these docs breathing down my neck about "unexplained stillbirths." They keep telling me I can't go to term because diabetics have these unexplained stillbirths, but they can't tell me what my risks are, and it's as though they believe induction is risk-free, which we know is not at all true! The best I could find in the research is that about 3.9% of all diabetics, controlled and not well-controlled, have stillbirths. They did not break them out into groups at all. I don't think that is a good enough reason to induce, since this baby is kicking fiercely every night and always passes her BPPs with flying colors.

    Today this doc was telling me I ought to induce and I said I wasn't going to do it, so then he insisted right then and there on an NST, which he said we failed due to late decelerations. He said he was very concerned about the wellbeing of the baby, despite our perfect BPP YESTERDAY and being scheduled for an NST tomorrow. Then he told me to go straight to the hospital for another (do not pass Go, do not collect $200), which we passed just fine (after a double espresso).

    MY point, which this doc will not listen to, is that if he thinks there is fetal distress now then he will certainly guarantee more of it with Pitocin against an unripe cervix.  It's a cesarian waiting to happen. I am trying to find support for my position, maybe to add up my risks that I would incur with induction and probable c-section so I can compare them to my 4% chance of stillbirth (obviously a stillbirth is something more final than a uterine scar or breastfeeding problems so it's sort of apples to oranges but at least if I had NUMBERS then I could make an educated case for myself, they way one does when comparing risks of amnio vs. risks of down syndrome et al).

    In my opinion, these "unexplained stillbirths" are not really unexplained. Usually the reason is chorioamnionitis (in T2s), ketoacidosis, placental abruption, IUGR, or suboptimal blood sugar control (defined as HbA1c >7.5%, much higher than mine) or severe malformations. I don't see how induction is going to help any of these! Possibly with ketoacidosis but I don't plan on putting her through that in these last 2-3 weeks. If we were worried about severe malfomations then the damage would have already been done in the first trimester.

    I have read these:

     

    Audit on Stillbirths in Women With Pregestational Type 1 Diabetes, Diabetes Care, vol. 26, No.5

    Differing Causes of Pregnancy Loss in Type 1 and Type 2 Diabetes, Diabetes Care, vol. 30, No. 10

    http://www.medicalnewstoday.com/articles/99061.php

     

    Can you further me along at all? They almost didn't "let" me go home tonight. Should I think about maybe refusing all this testing, since it seems just to build a case for induction, as long as kick counting is good and blood sugars are good?

     

    Thanks so much for any guidance or studies you can point me to,

    Leyali

     

    Henci Goer

    Apologies for not getting to your post sooner. As you say, I mostly focus on care for healthy women, and while I've done a fair amount of reading on gestational diabetes, as you probably know, GD is a whole different animal from Type 1. (For other readers, GD is a matter of too much of a good thing. Pregnancy hormones keep insulin from doing its job of getting glucose into maternal cells, which makes the extra glucose in the blood available to the baby to fuel fetal growth. Women with GD make normal or even above normal amounts of insulin, but run blood sugars on the high side even for pregnancy. With Type 1 diabetes, the pancreas is making too little or no insulin.) I don't know how to be helpful to you except to say that you seem very clear on what you are doing, and it is your right to make an informed refusal as well as to give informed consent. You are also right in that your care providers almost certainly are not considering the potential harms of inducing labor, only what they believe to be its benefits, nor are they likely to be considering how the odds of having a problem may be modified by the facts of your individual case. The best I can suggest is that you and your partner have a conference appointment with your doctor in which you make clear that while you respect your doctor's expertise, you are exercising your right to make the ultimate decisions about your and your baby's care. Here is a link to a pamphlet put out by the Joint Commission, the agency that accredits hospitals: Know Your Rights. Bring a copy along.

    -- Henci

    Archived User

    Thank you for answering! I'm still waiting for the baby (due in two days), and trying to think happy thoughts, especially because I think we will be going well into week 41, at least, and then the pressure will be awful. My Bishop's score is currently 0 so I will hold off the wolves as long as possible.

    Henci Goer

    Here are some suggestions that might help you go into labor on your own or reduce the risk of problems if you decide to agree to induction:

    • Refuse membrane stripping. There is no evidence that it decreases the number of cesareans and some evidence that it increases risk of membrane rupture.
    • Nipple stimulation can help ripen the cervix. There are instructions in the same post.
    • If you have access to a Chinese medicine practictioner, acupuncture is reputed to stimulate labor. Even if it doesn't work, unlike a drug, there is no potential for it doing you harm.
    • Refuse induction with misoprostol AKA Cytotec. This is a pill that may be given orally or inserted into the vagina or cervix. I have a post on the dangers of misoprostol induction on Science and Sensibility, a Lamaze-sponsored blog.
    • Refuse membrane rupture until you are established in active, progressive labor if you allow it at all. As long as membranes are intact, you can stop the induction and go home if it doesn't "take." Once membranes are ruptured, you are on a time clock and headed for delivery one way or another.

    -- Henci

    Archived User

    Hi Leyali,

    I'm a Type 1 diabetic and recently went in for a pre-conception counseling visit, where I was told that I would be induced at 39 weeks, because "That's the diabetic protocol to avoid stillbirth."  (Now I'm starting to see how the c-section rate for type 1 diabetics arrived at its current rate of 70%!  http://www.ncbi.nlm.nih.gov/pubmed/15927506) 

    Interestingly, other research states "A number of centers have reported higher rates of stillbirth or congenital anomalies in type 2 diabetic pregnancy, suggesting that the outcomes of pregnancy in type 2 diabetes can be worse than that for type 1 diabetes."  "More than 75% of pregnancy losses in type 1 diabetes were due to congenital anomalies or prematurity, whereas in type 2 diabetes >75% of losses were due to stillbirth, chorioamnionitis, or birth asphyxia. Stillbirth was significantly more prevalent in type 2 than in type 1 diabetes (P = 0.028)"  http://care.diabetesjournals.org/cgi/content/full/30/10/2603    It seems quite unfair to link the delivery protocols between type 1 and type 2 diabetic mothers--as the medical establishment is apparently doing at this time.

    The doctor I recently visited also told me that I would not need a doula because, "I can garuntee that you will not have a natural childbirth--you're diabetic."  Yikes!!

    I'm dying to hear how your own experience played out, Leyali.  Your first posts here have provided great inspiration, so please do share the rest of your story!  Can a type 1 diabetic actually make it to 41 weeks and still have a good outcome?

    Elizabeth

    Henci Goer

    If I were you, I would look for a care provider who treated you as an individual, not as a Diabetic with a capital "D", and who assumed things would go well until proven otherwise. Being at greater risk for having a problem is NOT the same thing as having it. The problem with the "something can go wrong at any moment" approach is that it tends to become a self-fulfulling prophecy.  One of the ironies of medical model thinking is that the treatments it leads to can often cause the very thing the treatment was intended to prevent. Case in point: inducing labor before 39 completed weeks increases the chance of the baby having serious respiratory problems at birth, not to mention that it increases your odds of ending up with a cesarean because your body wasn't ready for labor. I would also wonder how up-to-date the doctor you consulted was. As you no doubt know, diabetes management has advanced enormously in the past decades, which means what may have been true for diabetic women who became pregnant in, say, the 1980s or even the 1990s no longer applies to a healthy pregnant woman under good control today. As for the statement that you wouldn't need a doula since you wouldn't be having a natural birth, "yikes" is the operative word. I don't know which is worse: the bland assumption that no diabetic woman can birth normally or that doulas are only for problem-free labors. While every woman benefits from one-on-one continuous supportive care in labor from a trained or experienced woman, that care is needed more than ever when the going gets rough.

    I also wouldn't take the statistics you cite for pregnant women with Type II diabetes at face value. Women, especially women of childbearing age who have already developed Type II diabetes, are likely to have other health problems that could contribute to adverse birth outcomes. They are almost certain to be high-weight women and thus more likely to have the diseases that go along with that such as hypertension. They may also have less healthy lifestyles. 

    If we lived in the best of all possible worlds, you would be able to get midwife-led care. A midwife would be your primary care provider, and she would consult with, co-manage, or transfer care to specialists as your specific case required. Even if transfer of care became necessary, she would remain part of the team, making sure that you got high-touch as well as high-tech care. The specialists in this ideal world would use the least medical intervention necessary to resolve problems, always keeping in mind that any intervention should be shown to be effective and that its benefits should outweigh its risks. I hope you can find something that approaches that model.

    -- Henci  


    All Times America/New_York

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