First let's get the gestational diabetes issue out of the way.
There is no evidence that what should more properly be called
"carbohydrate intolerance of pregnancy" in an otherwise healthy
woman increases the likelihood of fetal distress in labor.
Having had a prior cesarean delivery is a more complicated
issue. The two studies we have on the topic agreed that the
most reliable symptom of uterine scar rupture is a
profound slowing of the fetal heart rate (FHR) either continuously
(bradycardia) or during contractions (decelerations).
Theoretically, then, continuous EFM could improve outcomes by
shortening the time between recognition of the problem and
delivery. The studies disagreed, however, on whether
continuous EFM would improve outcomes. One found more newborn
morbidity with delivery in after 17 min when abnormal FHR was the
only symptom while the other did not. (Often, although less
reliably, scar rupture is accompanied by other symptoms such as
heavy bleeding and severe pain.) Still, the benefit was minimal
even in the study claiming to find it. Of the 5 infants
delivered after 17 min, 4 required mechanical ventilation, but
within 24 hrs, they had recovered. The 5th, delivered 32 min
after diagnosis, had "asphyxia," which sounds awful, but is a
catch-all term for low blood oxygen. No information is given on the
eventual outcome for this baby. What we don't know, though, is
whether the infants delivered by 17 min in good
condition would have developed problems with further delay or
whether the infants delivered after 17 min likewise would have had
more serious problems with additional delay. Even so, if
continuous EFM had no harms, it would make sense to use it as a
precautionary measure, but that isn't the case. Several other
harmless events can cause FHR decelerations such as rapid descent
during pushing or maternal positioning or epidural analgesia
causing low blood pressure, and these false positives could lead to
unnecessary surgery. In addition, trials of continuous EFM in the
general population have shown that EFM increases the likelihood of
cesarean and instrumental delivery.
Where does that leave you? I think your best bet is to find a
solution you can live with and that won't get you labeled a
"difficult patient." EFM needn't confine you to bed nor does being
in bed confine you to one position. You can stand, "slow dance"
with your partner by rocking from foot to foot, sit in a chair or
on a birth ball, kneel upright in the bed or on get on all fours in
the bed with a birth ball supporting your upper body and head, etc.
I searched on "positions for labor" and picked the Mayo Clinic
one, but there were others as well. And it wouldn't be
unreasonable to insist on being detached for brief periods so that
you can use the toilet or take a turn or three around the room. A
doula could be
a big help with ideas, and I strongly recommend hiring one. She can
also help you and your partner with some of the emotional issues
that may arise in a VBAC labor.
I hope this helps.
E, Gauthier RJ. Neonatal morbidity associated with uterine rupture:
what are the risk factors? Am J Obstet Gynecol
Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after
cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD:
Agency for Healthcare Research and Quality; 2003 March 2003. Report
No.: AHRQ Publication No. 03-E018.
AS, Leung EK, Paul RH. Uterine rupture after previous cesarean
delivery: maternal and fetal consequences. Am J Obstet Gynecol