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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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    Apr 15
    2010

    Can I still refuse insulin without hurting my baby?

    Archived User

    Hi,

    As I sit here in tears after a recent call from my doctor, I am hoping someone out there has been through this same senario.

    I have been diagnosed with GD and have been controlling it excellently with diet. My midwife says as long as I continue to do so, I will have no problem staying with her and having my natural, non-medicated birth. However, I also have a low platelet issue, which they did have to start me on prednisone with my last one (he is now 2 yrs old) to bump it up for the birth. (That birth was completely uncomplicated and natural all the way.)

    A call from the doctor just now says they want to put me back on prednisone (platelets are at 68,000) and I will need to go on insulin because it will raise my blood sugars. I have fought so hard to keep them from doing any kind of treatment (refused the nonstress tests and BPP's as well), because I know from everything I've read on this website that it only makes me more at risk for intervention.

    Can I go ahead and take the prednisone and refuse the insulin treatments? Once I start insulin, I lose my midwife and have to go to an OB. There is no such thing as an enlightened OB around here and I'm so afraid they will just want to induce or even worse have a c-section.

    Please if anyone can offer some words of advice I would sure appreciate it. I wish with all my heart that I had found Henci's articles before I had the stupid GD test....I would have refused it. :(

    Thank you,

    Michelle

    Archived User

    I would like to add that I am planning a hospital birth with a midwife.

    Thanks again,

    Michelle

    Henci Goer

    Pregnant women experiencing complications should be able to get the treatment they need without being forced to give up having mother-friendly care. I can't think of a good reason why your midwife would not be able to care for you during labor in a hospital where, should it become necessary, there is the ready ability to consult with or transfer care to a specialist and immediate access to the hospital'sdiagnostic and treatment  resources.

    The best strategy I can think of is to try to get the hospital to make an exception. Start with asking your MW what she suggests. If you don't get anything useful from her, find out who has the power to make an exception and schedule a meeting with that person, you, and your partner. At the meeting, start with the old salesman's trick of making a statement that can't be disagreed with, for example, "I know we all have the goal of a healthy baby and healthy mother. It stands to reason that goal can best be achieved by care in which I get the treatment I need for the complications I am experiencing but avoid treatments or restrictions I don't need. I would like to combine the best of both worlds by continuing my care with my midwife while having the peace of mind of knowing that the doctors and hospital resources are there if I need them. I understand that hospital policy makes that a problem, but I am sure that by doing some brainstorming together, you will be able to help us achieve that goal." Another salesman's trick: if you get an answer you don't like, wait. Say nothing. The silence will be uncomfortable and often leads to the other person making another suggestion. Wait until you get one you like and then agree. Now it's the other guy's idea. If you start to cry, turn it to your advantage. That's the cue for your partner to say, "You can see how important this is to her. Surely, we can work something out." If neither idea works and you are stuck with an ob whose judgment you can't trust, here are a couple of recommendations:

    • Hire a doula. Just having someone in your corner can help if you are being leaned on.
    • Barring an emergency, make an informed decision when agreeing or refusing an intervention. Induction, BTW, is never an emergency.
    • Ask for a nurse who is comfortable with women who want natural childbirth and to avoid intervention and who will help you make decisions by explaining your options. Repeat at each shift change.

    The good news is that this isn't your first baby, which makes it harder for you to be bullied. 

    I hear what you are saying about the GD test, but if diet does not control your blood sugar levels, I can't see that it makes sense to refuse insulin and have them be out of control. And I don't think refusing insulin would solve the problem of them risking you out of midwifery care. Now they would have a "noncompliant patient" on prednisone with high blood sugars. Ditto for refusing prednisone. Then they would have a "noncompliant patient" at risk for hemorrhage. 

    Anyone out there have any other suggestions?

    Please let us know how things play out.

    -- Henci

    Archived User

    Thank you so much for your reply Henci!

    It means a lot to me that you took the time to do so, I would imagine you are a very busy person. :)

    I spoke with my midwife this morning and she does not think that my platelets are low enough to start on prednisone just yet. (They are at 68,000). For the last pregnancy they bounced between 60,000-80,000 even when I started taking prednisone, so she agrees with me that it is too early to jump right into prednisone treatment.

    I have an appointment scheduled with the hematologist this coming Thursday and will let him know what she said. He does not know about the GD diagnosis, so I will be letting him know about as well.  He is usually pretty easy going, so I don't think he will force the issue.

    Again, thanks for your reply, and I will let you know how it plays out. :)

    Michelle

     

    Henci Goer

    I think it's a great idea to conference with your hematologist! What you want is to come up with a treatment plan that best takes care of your needs given your individual case after careful consideration of the tradeoffs of your various options. The most important thing you can do to optimize both physical and psychological outcomes from this birth is to take charge of what happens to you and insist on being a full partner in decisions that get made about your care. I look forward to hearing the next chapter in your story.

    -- Henci  

    Archived User

    Michelle,

    I have been in practice for 10 years as an OB/GYN and have worked with midwives, doulas, etc.  I have taken care of thrombocytopenia (of which there are many causes) and certainly too many women with gestational diabetes.

    With regard to the diagnosis of thrombocytopenia, I think the involvement of the hematologist is important.  Ask about causes and possible implications for the newborn.  Some causes can lead to a sharp decrease in the platelet count of your child after the birth.

    With regard to GDM, the majority of stillbirths that I have seen were in women with DM in pregnancy who refused blood sugar control.  It is so simple to control and there are CLEAR goals for starting medications.  If you don't want to be on insulin, ask about oral medications.  I use these more than insulin in the patient with mildly abnormal blood sugars.  You did not ask for this complication, it happens because of insulin resistance caused by placental hormones.  You have no control over their effect, but controlling your blood sugars could save your babies life!   Just as you would take the time to put a seatbelt on your child in a car, you should heed the advice to check and control your blood sugars as needed.

    If you don't like the OB who is involved in your care, get another one!  They need to be involved, but you have a choice.  Good Luck!

    Dr. OB/GYN in WI

    Archived User

    Thank you so much for both of your replies! I truly appreciate your time.

    Thought I would just update you on the latest. So instead of sitting here in tears this time, I am so mad I could kick something.

    Met with the nurse practitioner last week on my platelet count. They have come up just a tad (63,000) and I am feeling really really good for the first time during this whole pregnancy. I truly believe that eliminating the foods that were causing inflammation within my body and taking supportive supplements that the naturopathic doctor recommended are helping. Anyway, she recommended that I go ahead and start WinrHo or IVIG treatment. Not knowing anything about these, I told her I wanted to research it and talk with my midwife. She said that was fine, but they went ahead and scheduled me for IVIG treatment. She assured me that this treatment is completely safe.

    Well, for starters, its untrue to say that it is completely safe. It is a category C for pregnancy which means nobody really knows if it's safe or not. Second, out of all the research I have done (hours and hours), a platelet count above 50,000 is considered safe for a vaginal delivery and also for a c-section (under general anesthesia). Third, my midwife is still not concerned with my platelet levels and having her on board with me helps a lot.

    So I called them today to cancel the treatment that they scheduled. I politely asked the nurse to let me know if canceling it would  and rescheduling it for later in the week would cause a hardship because I didn't know what all was entailed in getting it ready, OR if I should just call back when I decide to do it and then they can get it ready. She proceeded to tell me "Well now that you are scheduling your own treatments, why don't you just call us? Is this what the doctor wants?"

    Oh I can't even tell you how mad that made me. I bit my tongue again and politely but firmly told her that my midwife backs me 100% and that it is ultimately up to me what I decide to do. And I told her that I no longer wanted to deal with the nurse practioner and was tired of being made to feel bad about my decisions. I have an appointment with the actual hematologist tomorrow at 11am...

    So, my question is this....as long as my platelets remain at or above the safe 50,000 mark that is talked about in virtually every medical journal out there....am I being irresponsible by fighting these guys tooth and nail? Anyone have any experience with this?

    Oh I'm just so tired of fighting for what I think is right.....  :(

    Thank you,

    Michelle

     

    Archived User

    BTW, my blood sugar continues to be great. I have had no problem controlling it with diet. I continue to check it at least 4 times a day. :)

    Henci Goer

    For starters, I would complain about the nurse practitioner's behavior to her supervisor in addition to insisting that you be assigned someone else. As for whether it is safe to refuse the platelet meds if your platelet count remains above 50,000, if you have a clinician whose expertise and judgment you trust--the hematologist, maybe?--I would make a conference appointment, print out copies of the articles you have found on the internet, and bring them in for discussion. What you want is objective information on the potential benefits and harms of refusing or accepting treatment. If the expert you consult disagrees with what your sources, he or she should back up the opinion with evidence and discuss that evidence with you, explaining why it is more valid. Consider it a red flag if the expert attempts to persuade you by what my Aussie friends call "waving the shroud." If that happens, find someone else. Don't give up the fight for what you think is right! Don't give in to bullying! You have the right to make decisions about your care and that of your child, and everyone is best served by your doing so based on a careful weighing of the pros and cons of your options. Please write again when you have more information.

    -- Henci


    All Times America/New_York

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