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    Aug 25
    2011

    Type 2 Diabetic - Induction by 40wks?

    Archived User

    Hi Henci!

    I was diagnosed with Type 2 Diabetes in January and conceived in April just after getting my blood sugar under control (after it being at near-comatose levels).  I had my first child in 2000 and she was 9lbs 14oz and I carried her a month over her due date.  I was young and now looking back on things I realize that the doctors and nurses did not take the time to give me options that they should have, nor did they keep adequate monitoring of my baby as she grew so we would know (a) that the due date they first gave me was wrong (everyone went by implantation date instead of actual last menstrual date) and (b) she was so large.  Her size shocked everyone involved and I had a very difficult labor and delivery.  Combine that with the fact that my spine is not straight enough to allow an epidural to be effective and the fact that they gave me Pitocin at just about five hours after the start of labor (they decided labor wasn't proceeding fast enough), as well as the fact that I hemorrhaged after giving birth to my daughter due to the uterus no longer contracting (enough so that they had to give me 4pts of blood before I left the hospital)...and you have a very difficult and traumatic first labor experience.

    Bottom line, after telling my OB all of this, she informed me that they would rather induce labor and not let the pregnancy go beyond 40 weeks.  She said that she's concerned about placenta viability and the size of the baby.  So far, his growth is normal, but that can apparently change (what, with my having an ability to create larger babies anyway and that having been prior to being diabetic).

    My question is this: With being now 31 and now diabetic, is induction really necessary?  I would prefer to have as natural a birth as possible (including no pain meds and would rather not induce), so I would like to avoid induction if possible.  Is it outlandish to ask my OB to NOT induce?  Or is this a sufficiently high-risk pregnancy that I have to go ahead with the induction process?

    I should add that my blood sugar is being nicely monitored and kept at correct levels via use of insulin, and my diabetes doctor and nurse are VERY happy with my ability to keep it under control and at my health status.  They're very pleased that I'm doing so well!  So, this isn't a case where things are out of control or crazy...it's going very very well.

    Thank you so much for letting me know!

    Rosie

    Henci Goer

     Logically, if your blood sugar is under good control and you have no other health problems such has hypertension, then there should be no reason to put you at higher risk for placental insufficiency and therefore to treat you any differently from any other healthy woman whose blood sugars remain within normal range without need for extra insulin. If the concern is the size of the baby, birth weight is far more strongly associated with maternal prepregnant weight than her blood sugar. This means that if you are a plus-sized woman--which your story suggests you might be--your baby is likely to be bigger than average regardless of your blood sugars. So let's focus in on what maximizes your chances of a safe, healthy, normal birth of a plus-sized baby. 

    Let me start by saying that the problems with your first birth might have been inevitable, but how your labor was managed could well have contributed to or caused your problems. Pitocin (oxytocin) in high doses is strongly associated with postpartum hemorrhage. You do not say whether your ob cut an episiotomy or whether you had a vacuum extraction or forceps delivery, but these, too, increase bleeding. As for starting Pitocin, slower progress is normal with a bigger baby. It isn't clear whether there was truly a need to get things or going or what was needed was more patience. Moreover, labor progress can be inhibited when the woman is in an environment that provokes fear and anxiety, she lacks good labor support, is kept from eating and drinking, and has little or no freedom of movement in the dilation phase and is not free to choose her pushing position. 

    The good news is that you birthed a baby of this size vaginally at your first birth. That means you have a wonderful pelvis and a terrific uterus and are almost guaranteed to be able to birth a baby of the same size or bigger with greater ease at this next birth! Here is some general information on what makes for a safe, healthy birth. When expecting a baby of size, the recommendations of having labor start on its own, mobility, avoidance of epidural analgesia, pushing according to your inner urges in the position(s) of your choice have even more importance. In addition, giving birth on hands and knees or side-lying is the best way to minimize the chance of shoulder dystocia (the head is born but the shoulders get caught behind the pubic bone). Should it occur, turning to hands and knees is the best way to prevent adverse outcomes for baby and mother, as this study makes clear. You may also want to feel out your ob's confidence in your ability to birth a big baby. I have a bunch of studies of ultrasound weight estimates (which are often inaccurate) consistently showing that when the doctor believes the baby is going to be large (over 8 lb 12 oz), the woman is far more likely to deliver via cesarean surgery than when the baby is actually in that weight range, but the doctor didn't suspect it. You are in a better position by virture of having birthed a prior big baby vaginally, but you are not out of the woods. You want a birth attendant who thinks you can birth this baby on your own until proven otherwise.

    So the answer to your question of whether you can refuse induction at 40 wk is "yes." You have the right to refuse any treatment. Whether you decide that is the best thing to do is up to you, but certainly, as you have told your story, it would not be unreasonable to do so and could serve you better. If you decide to agree, you can minimize the likelihood of induction-related complications by refusing induction with an unfavorable cervix. Cervical ripening agents and strategies do not decrease the excess risk of cesarean with an unripe cervix, which, while smaller in a woman with prior vaginal birth, is not zero. You can insist on the oxytocin dosing protocol that comes on the package as many obs use one with higher doses and dose increases at shorter intervals, which increases risk of overly long, overly strong contractions causing fetal distress. You can ask that the drip be turned off once you are in active, progressive labor. Many women will continue on their own once the pump is primed, so to speak. (The drip can be restarted if contractions die away.) Finally, if you are a woman of size, "The Well-Rounded Mama" offers solid information and good advice.

    ~ Henci


    All Times America/New_York

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