Henci,

I am currently 33 weeks pregnant,  trying for a VBAC after an unnecessary first c-sec  (“failure to wait”) and currently I have gestational diabetes.

Up until this week, my blood sugars have been controlled through diet alone, but now it looks as though my fasting numbers are too high (above 100) and my OB wants to put me on insulin. I would be fine with this except that she claims that once I am on insulin, the baby must be delivered by 39 weeks. I can’t understand why it would be necessary for an induction or RCS at 39 weeks if my blood glucose is controlled. I am having trouble finding evidence-based guidelines that are a high level of evidence and specific to woman with gestational diabetes that is well-controlled.

Can you give me any insight or point me to some literature? As long as I have no other risk factors and my blood glucose is controlled, would I be irresponsible to refuse an induction at 39 weeks or even 40 or 41 (assuming NSTs shows everything is fine with the baby)? I'm wondering if maybe insulin increases the rate at which the placenta degrades?

Any feedback would be greatly appreciated.

Thank you,

Andrea 

Between what is on the thread itself and links out within the posts, I think this thread on gestational diabetes will cover most of what I have to say on GD and induction .

Having a prior c/sec intensifies the reasons not to have an elective delivery at 39 wks, or, frankly, at any time. Inducing labor with a uterine scar is a "batting 0 for 2" proposition. It poses both increased risk of scar rupture and reduced probability of vaginal birth, especially with an unripe cervix and regardless of use of agents or procedures to ready an unripe cervix for labor. Scheduling elective cesarean surgery is an even worse idea. Every subsequent surgery exposes you and your baby not only to the risks of the current surgery but increases the risk of life-threatening complications of placental attachment in any future pregnancies. Even if you do not plan any more children, that is something to consider because many a woman has changed her mind or decided to carry through with an unplanned pregnancy.

I do not know whether requiring insulin changes the equation, although it seems logical, as I wrote in the other GD thread, that if your blood sugars are normal, then you would be at no greater risk. If there is increased risk--and I would want my care provider to give me solid evidence that there was--you will have to weigh it against the risks of planned delivery. If you decide on induction, you can minimize your risk of undesirable outcome by not inducing until the cervix is ripe.

I hope this helps.

-- Henci