GD induction at 38 weeks?

I'm currently 32 weeks and have been diagnosed with GD. This is my 5th child, and my 1st with GD. So far, my glucose levels have been consistently good eating a healthy diet. When I had an ultrasound at 30 weeks, they estimated that the baby was in the 70% in size (or about 3.5lbs), which they indicated was approaching dangerously large. My blood pressure is good, all other areas seem to be normal.

My OB told me that he plans to have me induced at 38 weeks to avoid any of the many complications associated with GD - large baby, problems with aging placenta, etc. I'm just not comfortable with that unless tests actually indicate that there are complications. So I have a couple of questions:

Are there tests that can be done toward the end of pregnancy to check for any dangerous complications, particularly placental condition? I have consented to having an ultrasound every 3-4 weeks until the baby is due.

3 of my 4 children were induced because they were late. Is it possible for me to go into labor naturally assuming tests show no complications?

If my blood sugar levels are consistently good, is there any reason to go into panic over possible complications? If the baby is not getting excessive amounts of sugar, shouldn't she be developing at a "normal" rate - all other areas appearing to be normal? My OB seems a bit overzealous to induce to avoid complications and it makes me nervous.

Thank you. I read your GD article on ivillage.com and it was very reassuring!
By: Moselle

I’m so pleased you found my articles on GD helpful! Let’s apply what was in them to analyze your situation. Starting with the facts of your individual case, you have had 4 previous births, which I presume were all vaginal, you are eating a healthy diet, and other than some degree of what should properly be called “carbohydrate intolerance,” you are healthy. Now with that background in mind, let’s look logically at the problems your ob has threatened will occur if you don’t agree to an early induction.

Starting with birth weight, the size of the baby has far stronger relationship to maternal weight before pregnancy than to the mother’s blood sugar levels, so if you are a high-weight woman, that is the primary issue determining birth weight. If that is true in your case, it was probably true for one or more of your previous pregnancies. Having had four previous babies vaginally, it is highly unlikely that you won’t be able to birth this one. And in point of fact, even untreated gestational diabetics only have odds of 20% to 30% of having a baby in the top 10% of birth weight instead of the background 10% odds.

Moreover, fetal weight estimates are highly inaccurate. You might as well flip a coin as go by the ultrasound results if you are trying to predict which babies will weigh more than 8 lb 13 oz (4000 grams), the usual definition for “macrosomia” or big-bodied babies. On the other hand, the ob’s belief that the baby will be too big is a more important factor than the baby’s weight. There are a couple of studies that show that the c/sec rate is much higher in cases where the ob thought the baby weighed over 4000 grams than when the baby was actually in this weight range, but the doctor didn’t suspect it.

If your ob is saying that inducing will prevent shoulder dystocia (the head is born, but the shoulders hang up behind the pubic bone), you should know that studies do not find that inducing labor decreases shoulder dystocia or birth injuries, but it increases the c/sec rate. What will help is birthing in a hands & knees position (Bruner JP et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43).

Moving on to the “aging placenta” claim, in years gone by, it was policy to induce women with pre-pregnant insulin-dependent diabetes early because there was a higher risk of losing the baby at the end of the pregnancy. However, with much better insulin regimens to control blood sugar, even these women are going to term nowadays. Running higher than normal sugar levels in late pregnancy hardly puts you in the same category with a poorly controlled, long-term, insulin-dependent diabetics. In any case, you are controlling your sugar. If your blood sugars are normal, then there is no basis for thinking this pregnancy will be any different than your previous pregnancies.

Looking at the other side of the ledger, there are serious potential harms to inducing at 38 weeks. Some studies suggest that even women with prior vaginal births are at higher risk for cesarean surgery if they are induced with an unripe cervix and that cervical ripening agents do not help. And even more concerning, babies induced early are at greater risk of ending up in intensive care with respiratory problems. Were I you, I would be particularly worried about this risk since you say your other labors were induced because your baby was supposedly overdue. It sounds more to me like your babies just need to “bake” a little longer before they are “done,” which means that inducing this baby at 38 wks would pose a greater risk for you than for a woman whose pregnancies tend to run 39 wks.

Agreeing to have fetal surveillance tests is an option, but it has hazards too. In a healthy woman, which you are, a “positive” result, a result that indicates the baby isn’t doing well, is much more likely to be a false positive than a true one. But once there is concern about the baby, no one will (or should) be willing to ignore it. Because of this, you will want to decide carefully whether to get on this train because once you do, you won’t be able to get off.

In the end, no option can guarantee a good outcome. The best you can do for yourself and your baby is to make informed decisions based on knowledge of the pros and cons of all your options, including doing nothing. It is difficult to achieve that goal when your ob gives you a one-sided picture and one that is not reflective of what the research says at that.

-- Henci
By: Henci Goer

Thank you very much! Your comments are very reassuring, and I feel much more confident in discussing these issues with my OB. I'm hoping he was just having a bad week and was feeling a bit "gun shy", but I realize that in the end, I get to make the final decisions as to how to approach my baby's birth. I'm also reading your book "The Thinking Womans Guide" and I sure wish I'd read this years ago. Better late than never! By: Moselle

I also have been diagnosed with GD. This is my 2nd child and I did not have it last time. I am scheduled to be induced at 38 weeks. I only have the GD, but my blood pressure is slowly creeping up. My baby is said to be just a little above average in size. If you want to be sure about any health issues associated with GD, you can ask your practitioner for a biophysical profile. In this test they check the amniotic fluid level as well as the flow through the umbillical cord and then they put you on a monitor to check for acceleration and decceleration of baby's heart as well as movement and contractions. I think the reason for my scheduled induction is because of my blood pressure. Good luck. 

I read your post with concern. Please reread my post about the potential harm to your baby of induction at 38 weeks and the hazards of fetal tests of well-being. Were I in your shoes, I would not be willing to agree to induction at all--let alone at 38 weeks--for anything less than complete conviction that the potential benefits of ending the pregnancy before its natural time outweighed the potential harms. Based on your post, you aren't even sure of the reason why it is being recommended, and even your guess is that the reason has to do with something that might--or  might not--pose a threat in the future. If you do not already know it, I suggest you find out your care provider's overall cesarean surgery rate. The number will tell you whether your care provider practices according to the best evidence. Numerous studies have shown that the cesarean rate can safely be 12% or less in a general mix of women, so a rate of 15% or so or more tells you that your care provider's policies and practices aren't in line with best practice. Then you can decide whether you want to stay with this person or find someone whose policies and practices are. If you decide to talk to someone else, I recommend downloading "Having a baby? Ten questions to ask" from the Coalition for Maternity Services website.

-- Henci

Henci, that is great advice. As I said in my post, my Dr. has a few reasons to induce me at 38 weeks. If one doesn't have a good reason it just simply shouldn't be done. Test, ultrasounds, and physical evidence state that my baby would be safer out of me than in me. I have GD, severe anemia, high blood pressure, and an incompetent cervix. Never a good combo. But if one cannot even understand why their Dr. is considering an early induction, they should definately question it. Each person knows what they are comfortable with. It seems the original poster is not comfortable when I am obviously comfortable. Good luck. 

I'm glad you clarified for me. The key thing is to make an informed decision based on an understanding of the pros and cons of one's options, including doing nothing. I hope everything went well for you and your baby.

-- Henci

i was tested for GD twice and came negative both times the first test was the normal one then they tested a second time because when i was 32 weeks along he was already almost 5lbs I also had a cerclauge put in jan 7th at 22 weeks because of a weak cervix. I just had the cerclauge taken out today and when they weighed him he was 8lbs 5 ounces i am only 36 weeks but i cant breath right i cant walk my feet go numb i cant sleep at night sitting is even extremely uncomfortable the doctor who put in my stitch suggested doing an amniotic fluid test to see if his lungs were fully developed so they could induce me my OB who i saw shortly after having my stitch taken out since both doctors are in the same building was strongly against it and said he could induce me at 38 weeks i read the post about the complications and chances of a c-section but this is my first child and i dont think i will be able to handle an 11-12 lb baby any ideas 

I'm sorry you are so uncomfortable, but don't let it sway you into a decision you may come to regret. First of all, ultrasound weight estimates are notoriously inaccurate, so you don't want to go by that. Second of all, inducing labor would put you at high risk of ending up with cesarean surgery, which puts you, your  baby, and any future babies at higher risk for severe complications--not to mention that if you are uncomfortable now, wait until you are recovering from major surgery while trying to care for a newborn. Finally, early delivery puts your baby at risk for breathing and feeding problems. Basically, "when the fruit is ripe, it falls from the tree" is the best thing policy. The optimal birth for you and your baby is a spontaneous labor and birth when your baby--for it is your baby who determines when labor should begin--decides he or she is ready to come out. Impatience now, and, for that matter, in labor, is your enemy.

In the meantime, consider how you could increase your comfort. For example, there are special pregnancy girdles that help support your belly, which could relieve some of the pressure on the circulation in your legs. You could use extra pillows to build yourself a nest that props you up, or if you sleep on your side, put a pillow between your legs. Try to nap. Simplify your life. Get help with chores if at all possible. Pamper yourself. And keep reminding yourself that it won't be much longer. No one is pregnant forever. It just feels that way sometimes.

-- Henci 

I am curious about the cerclage and how it was determined you had a weak cervix? I am just asking because it sounds like you are having a very intervention happy OB.

Also, US to determine baby's size is very very inaccurate and I would never make a decision based on that. And if you get the 'your pelvis is too narrow' speech, take a look at this great article:
http://midwiferytoday.com/articles/pelvis.asp?q=drugs


Have you looked into chiropractic care for discomfort? This often has great results, as does belly binding like Henci mentioned.

Hope you feel better soon and have a great birth!

maria.
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