by KMom
Copyright © 1998 KMom@Vireday.Com. All rights reserved.
DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider. This web section on gd is designed to present more than one view of a controversial subject, pro and con. It should be re-emphasized that nothing herein should be considered medical advice.
CONTENTS
Care after a gd pregnancy is fairly routine. Once the placenta is delivered, your body is free of the hormones that interfered with your insulin sensitivity and so the gd almost always goes away (about 90% in one study, more in others). A few women will continue to be diabetic (about 2% in the same study), although now they are called type II diabetics (NIDDM). A few more women (8% in the cited study) will have what is called Impaired Glucose Tolerance (IGT), which basically means you are in a borderline state just below diabetes (for example, a fasting level above about 110 mg/dl is considered IGT). Because of the small risk of the diabetes staying, many providers recommend that you be retested about 6-8 weeks post-partum, just to be sure (see below), and then every 1-3 years afterwards (preferably yearly) to be sure the diabetes is not returning. In a few cases, depending on the severity of the gd, testing should be done even more often than yearly. You should also have your blood lipids (cholesterol, etc.) and blood pressure checked frequently; many women with insulin resistance also have problems with blood lipids and blood pressure as well.
If you used insulin during pregnancy, you do not need any now that you have delivered. You do not have to follow any special diet anymore, either, although of course good habits are always a good idea due to future risk of type II diabetes and you should strongly look into improving lifestyle factors. The risk of developing type II diabetes depends on many risk factors such as ethnicity, central fat distribution, severity and time of diagnosis of gd, activity levels, family history of diabetes, polycystic ovarian syndrome (pco), and many lifestyle factors. There are, however, things that you can do to prevent, delay, or minimize your risks of diabetes. It is vitally important to be familiar with this information. (See websection on GD: Risk of Future Diabetes.)
If you are breastfeeding (and this is a very good idea for a gd mom), you will need to be sure that you are getting enough extra calories and fluids and such, so continuing to follow a pregnancy diet is generally a good idea. Do not try to diet right away (if at all, see discussion in Risk of Future Diabetes section). You will probably find that breastfeeding, on its own, will promote some weight loss with very little effort, although this is not a sure thing, of course. However, restricting your food intake can affect your milk supply or make you run down even if you are not breastfeeding, so you will want to be sure to continue to eat well and healthily.
If you have ANY problems with breastfeeding, be sure to consult a professional, internationally board-certified lactation consultant (IBCLC) as soon as possible. Anecdotally, there is a fairly high rate of breastfeeding problems among women who have had gd, due to factors such as highly interventive births, separation of mother and baby, supplementation of baby due to hypoglycemia and other reasons, medical ignorance and mismanagement, lack of or superficial support for breastfeeding, interference of labor drugs with baby's sucking mechanism, run-down health of mother, recovery from c-sections, doctors prescribing birth control pills, and possibly pco/hormonal difficulties, etc. Breastfeeding presents so many benefits to the gd mother that it should be strongly promoted and supported for gd moms, but the reality is that it is often gravely neglected after a gd pregnancy and active information and support for it is extremely minimal. Seek out help from a breastfeeding professional (instead of a doctor or nurse who may have incomplete knowledge of how to solve breastfeeding problems), and don't hesitate to get help quickly. Quick support is often the difference between 'success' and 'failure' in breastfeeding.
Above all, avoid bottles if at all possible while you are seeking help. Bottles are a quick way to breastfeeding problems, especially if used in the first few weeks of life. If you need to use them for working, they can be introduced later, but they can greatly complicate breastfeeding during the initial weeks. If supplementation becomes medically necessary (and don't hesitate to supplement if it does), it can utilize other methods that pose less interference with a baby's sucking mechanism, such as syringe, finger-feeding, flexible cups, etc. Although some babies can successfully switch from bottles to breast and back, many cannot and you cannot predict ahead of time which babies will have problems and which will not. Therefore, it's best to try to avoid bottles if at all possible, and to use alternative methods should supplementation become necessary. (For more information on breastfeeding after a gd pregnancy, see the websection on GD and Breastfeeding: A Special Relationship.)
Many women experience an emotional let-down after pregnancy, but especially after a gd pregnancy. The emotional impact of a potentially harmful condition on your baby, the tremendous guilt felt by many gd moms, the stress of maintaining a strict dietary and testing regime, and the aftermath of an often-difficult and overly intervened-in delivery places great stress on gd moms. When added to the stresses of being a new mother for the first time or trying to deal with older children while nurturing a newborn and yourself, it can be overwhelming. Add in the fears of future diabetes and pressure from doctors and diabetes educators to diet and lose weight as soon as possible, and it can become truly suffocating. Although it is an area that has not had sufficient attention, gd moms frequently have long-lasting emotional repercussions afterwards. Their post-partum state must integrate not only physical but emotional recovery, an issue virtually ignored by most providers.
Birth Control is an important decision after any pregnancy, but particularly in women who have had gd, as it is very important to avoid accidental pregnancy. Some birth control methods are unsuitable for women with past gd, and some are not compatible with breastfeeding, so be sure to research your choices well. Recommendations in this area are changing based on new research, so be sure you and your doctor are up on all the latest information when you make your choice. (See the websection on GD: Birth Control Decisions for more information.)
Finally, if you needed a c-section, meticulous care of your incision site is very important (both as a large woman and as a person who may have Impaired Glucose Tolerance), and recovery from the c-section may be time-consuming and draining. Allowance of adequate time for recovery and additional help around the house is important for moms who have had c-sections. Furthermore, emotional recovery can range from immediate to quite long-term, depending on the woman.
Women who have had a gd pregnancy, no matter the outcome, often have significant physical and emotional healing to do, along with the difficult tasks of mothering a newborn. However, little attention is usually paid to this healing process by the medical community, or it is shrugged off as simply garden-variety Post-Partum Depression. While there are some excellent childbirth resources devoted to emotional recovery from childbirth, Kmom knows of none that specifically address the concerns of gd mothers. It is up to us, the gd patients, to inform, nurture, and heal ourselves.
The incidence of c-sections after a gd pregnancy is fairly high, although many factors come into play, such as degree of intervention favored by your provider, incidence of macrosomia, utilization of inductions/augmentation to labor, elective sections, degree of glycemic control, etc. In a review of 14 studies, Hod et al. (Diabetes Reviews, 1995) found that the c-section rate varied from 9% to 41% in gd pregnancies (the 9% study was probably unusual, since most studies cited were much higher). The mean c-section rate for these 14 studies of gd patients was 27.8%, as compared to a rate of about 20% for c-sections in the US in all pregnancies (early-1990s). Other individual studies not cited by Hod have had c-section rates even higher than 41%, though rates between 20-40% are most common. Choice of provider makes a difference, with gd pregnancies handled by midwives and family practice doctors much less likely to have c-sections (about 1/3 - 1/2 the rate), even when considering only low-risk gd patients with good control (see section on GD Providers: Who to See? for further details).
In some studies, early induction added to the c-section rate greatly while in others it improved the c-section rate; whether the mother needed insulin was also a factor in deciding whether to induce, as was her cervical ripeness (Bishop Score). Macrosomic infants were delivered by more c-sections (many elective, some from failed inductions, some from traumatic births) although again, the way the mother was 'allowed' to labor probably influenced outcome for macrosomic babies too. If a mother with a large baby is forced to labor in inefficient positions and with many restrictions (or to labor before her cervix is ready or her baby has achieved optimal positioning), problems often occur, but due to the mindset of gd, all are blamed on the baby's size or the gd, instead of on obstetric mismanagment or a combination of the three.
Recognition of the role of physician management in the high rate of c-sections in gd is only now just beginning to gain recognition but still remains largely unexamined. A landmark study which observed this was done by the Toronto Trihospital Gestational Diabetes Investigators (Naylor et al., Journal of the American Medical Association, 1996) which found a clearly increased c-section rate even when other risk factors such as macrosomia were reduced significantly. They stated that "While detection and treatment of GDM normalized birth weights, rates of cesarean delivery remained inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment...the diagnosis of GDM itself shifts obstetrical practice style toward cesarean delivery--a hypothesis motivated by evidence that operator discretion is an important and reversible determinant of cesarean delivery...without measures to limit interventions for women with GDM coming to term, conventional care may lead to needlessly high cesarean delivery rates in this population."
It is quite difficult at this time to determine what percentage of c-sections in gd moms are truly necessary and what are not, and to what degree various obstetric interventions and procedures add to or reduce this high c-section rate. This is an area ripe for further research but just beginning to gain a bit of recognition; nearly all research currently considers interventions universally benign or beneficial and neglect to consider iatrogenic (doctor-caused) problems. In Kmom's opinion, this is a significant blind spot in the majority of research being done and a major criticism of the research literature.
Physical Recovery from a C-Section
Some women find the physical recovery from a c-section to be very difficult indeed, while others do not find it hard at all. The difficulty of recovery can also vary from one c-section to the next, depending on a wide variety of factors. It is important to understand the physical recovery that you experience, while instituting measures to try to heal more efficiently. For some women it is a long slow process, with long-lasting or even permanent implications for their bodies, while for others it is a quick and fairly simple process physically. Either scenario (and many others in-between) is normal and valid.
Breastfeeding after a cesarean can be more challenging, and success rates can be lower than after vaginal births. Studies show that the most critical issue for breastfeeding success after a c-section and/or diabetic pregnancy is early and frequent breastfeeding (Asselin and Lawrence, Clinics in Perinatology, 1987). In addition, this can help lessen or treat the baby's tendency towards hypoglycemia and jaundice after a diabetic pregnancy, as well as help speed the mother's healing process. However, as noted above, significant barriers are sometimes placed in the path of gd mothers who want to breastfeed. Pursuing regular, frequent feedings as early as possible, utilizing the support of a professional lactation consultant who can help with positioning and latch-on concerns, and avoiding articifical nipples and unnecessary supplements as much as possible are critical to breastfeeding success. The football hold is often more comfortable after a c-section and sleeping with the baby can greatly ease the process of regular feedings without aggravating your incision by repeated lifting of the baby. In addition, thrush (a yeast infection) must be carefully watched for when breastfeeding after a c-section, especially after gd (see GD and Breastfeeding section for more information on these issues).
If you have had a c-section, you will want to know exactly what kind of incision you had. Most large women have 'bikini-line' or transverse lower-segment incisions (horizontal incisions that go from side to side just above the pubic bone). A few surgeons feel that up-and-down vertical incisions ('classical') are preferable in very large women, but this should be closely questioned, since once this incision is performed, you will probably have to have repeat c-sections for any other future birth, and these incisions are more subject to sudden uterine ruptures, a potentially life-threatening occurrence. There is some evidence that they may also be more prone to infection and other problems in some women. A bikini incision is generally perfectly appropriate in larger women despite their abdominal fat, and many large and even supersized women have had them with no problems. It is the most desirable incision for women desiring future children, since Vaginal Birth After Cesarean (VBAC) is much safer with this incision.
Occasionally, other incisions are used; an 'inverted T' incision combines the lower segment bikini incision with a small vertical cut extending up from the middle of it in the shape of an inverted T. This may be done if the baby's lie is awkward or there are other problems. Information on VBAC with a T incision is limited; some doctors feel it should not be attempted after a 'T' incision, while others will support it and there are a number of women who have had a VBAC after a T incision. Opinions on its safety and appropriateness vary, but there is limited medical evidence either way on it. Another incision that is possible is a vertical incision ( no T!) up and down but in the lower segment of the uterus (a classical incision is in the upper segment of the uterus, which is much more prone to rupture under stress). Again, this incision is controversial and medical evidence on its safety for VBAC is limited. Again, there are women who have had successful VBACs with lower-segment vertical incisions, but its safety is unknown and most providers will be reluctant to support a VBAC attempt in that case. Finally, it is important to note that the OUTER incision on the skin may not match the INNER incision on the uterus itself; it is important to find out exactly what type of incision you have internally so that you have this information for future reference.
Larger women with c-sections must be extra careful since they can have greater tendencies towards infections in the incision because it may fall under a fold of fat (called an 'apron' or 'pannus'). In addition, women who have Impaired Glucose Tolerance (in essence, borderline diabetes) often have difficulty with slow wound healing or high rates of infections. Thus the care of a C-Section incision is extremely important in the gd mom. Usually the incision is closed with surgical staples and when the staples are removed, steri-tape is criss-crossed across the incision. These strips then gradually come off over the next week or so. When you shower, it is very important to dry the incision site extremely thoroughly afterwards. This is the greatest form of infection prevention you can make, aside from the usual antibiotics and such. Many doctors will also have you treat the site with hydrogen peroxide although some do not recommend this. Ask your doctor what he/she prefers.
To further help dry the incision site and prevent infection, the single best thing to do is to use a cool blowdryer on it. After your shower, gently pat dry the area with a towel. Continue getting ready for a few minutes to let the site air-dry a bit, then take a hair blowdryer (on a 'cool' setting--warm may encourage bacterial growth) and blowdry the area thoroughly (or stand in front of a cool fan). Lift the apron area if necessary to expose the incision completely, and spend quite a bit of time with the blow dryer on each section of the incision. Do this religiously several times every day, and especially after a shower. If things are looking reddish, itchy, or weeping, you will want to contact your doctor, and consider adding another session or two of blow drying per day. You may need someone else to help with the baby during this time (or do it during baby's nap), but it is very important that this routine of blowdrying be followed, as an incision infection or separation can be very serious. A bit of proactive care in the beginning can often prevent many problems later. Many doctors are unfamiliar with this technique or fail to recommend it to their heavy patients, but it is quite effective in preventing many of the incision infections larger women can be prone to. This is an extremely important prevention step; don't neglect it!
It's also worth noting (although Kmom cannot confirm this information at this time) that it has been reported by some size-acceptance activists that supersize patients may need a larger dose of antibiotics as a preventative. Although most supersize women who have had c-sections do not experience wound infections, some do, and an extensive infection can lead to very serious complications and problems. Most doctors do not give larger doses of antibiotics to very large people, and perhaps this is one factor (among others) in why we have higher rates of wound infection as a group. Also, Impaired Glucose Tolerance may possibly influence this as well, since diabetics (or borderline diabetics) are often quite slow to heal and frequently experience wound infections. You may want to ask your doctor to do some research on the subject of high-dose prophylactic antibiotics in the supersize or large patient and consider the matter further, especially if you seem slow to heal or are experiencing redness, weeping, or other signs of possible infection. You may have to be quite assertive in getting your doctor to pay sufficient attention before problems reach crisis proportions; several large women have anecdotally reported problems in getting their doctors to take incipient wound problems seriously until it got out of hand.
(Kmom's story: One piece of bad advice you should not follow, however, is to 'tape up' the pannus/apron with surgical tape in order to keep it off of the incision and 'give it air to heal'. This was one clunker told to me by a recovery nurse after my second c-section, even though my 'apron' is not that extensive; it was a really bad idea. The tape caused tremendous pain, even with a very short duration of use, and the damage to the delicate skin was significant, long-lasting, and almost more painful than the actual incision and recovery! No matter how well-intentioned the advice, it was given in ignorance about the most optimal management of recovery of large people, and nearly caused more severe problems than it solved. Be very cautious about such advice!)
You will probably find post-partum that you have a more significant and 'droopy' apron/pannus (belly) than you had before pregnancy. This is quite common among larger women, and although some of it will tighten up and reduce as you recover post-partum, most larger women find that it never resolves completely. This is often true in large pregnancies in general, but may be especially pronounced in large women who have had c-sections, since there is often long-term effects on abdominal tone. It is very important to go easy in exercising this area until all the nerves and tissues have had a thorough chance to heal; doing too much too soon can permanently damage the area. After the initial recovery of 6-8 weeks, there are exercises that can be done to help firm up this area more, though you will probably never completely regain the exact muscle tone you had before. It is important to be careful to exercise correctly in this area; consult your doctor or physical therapist (though some pay little or no attention to the issue), or read the book Essential Exercises for the Childbearing Year by Elizabeth Noble (available from www.amazon.com). In a few women, the abdominal muscles separate significantly during pregnancy and afterwards never quite come together. This is called diastisis recti and can sometimes be helped by exercises. In tough cases, the muscles may never completely close and sometimes an umbilical hernia occurs. Although in rare cases, problems can occur with this, it usually is not a cause for great concern. If exercise does not help (and sometimes it makes it feel worse), then the only real treatment supposedly is surgery, which of course is going to be reserved only for the rare case in which it is really needed.
One exercise you should start immediately postpartum, however, is kegels. Even though you have had a c-section, you need to still work on this area. Simply carrying a baby is a stress on these perineal muscles, and larger women can sometimes be more prone to uterine prolapse as they age; kegels may be a simple and easy way to help prevent some cases. Furthermore, if you labored at all with your child, there was probably some pressure on the bladder area, sometimes especially harshly in labors that involve a malpresentation of the baby, such as a posterior (backwards) lie. You would do well to continue to strengthen this area; bladder incontinence or weakness is often a long-term problem of pregnancy and especially of difficult labors. If this continues to be a problem for you, even with a religious program of kegels, you may need a referral to a physical therapist for extra help.
You may find that you have a great deal of edema (fluid build-up) in your hands and feet/legs shortly after birth. This is very common in labors that have been induced or that have used a lot of IVs. It is a very common side-effect of pitocin, plus if you had an epidural, extra fluids by IV are pushed in order to counter the possible sudden drop in blood pressure that can happen with epidurals. The long-term consequence of this, however, is lots of edema afterwards in some women, depending on the timing of the IV and the type used, etc. There is very little to be done to relieve this edema post-partum except to wait for time to resolve it. Medications cannot be used, since they would also interfere with breastfeeding supply. Mild exercise and immersing the affected parts in warm water can help the process along some, and the mother should continue to push fluid intake post-partum, despite the edema. Eventually, the edema will pass, sooner for some (within a few days) and slower for others (several weeks). Just be patient, and alternate soaking, walking, and cold packs (frozen peas are great) on uncomfortable areas as needed.
Different c-section mothers report differing problems in recovery. Some women find standing up straight to be extremely difficult in the first few weeks, while others have no problems with it at all. For some women, turning over in bed or getting out of bed is much harder than actually walking, while others find the walking afterwards much harder. Some women prefer to lie flat after a c-section while others find lying flat extremely uncomfortable. Many breastfeeding manuals recommend lying down flat to nurse after a c-section, thinking that this will be more comfortable on the incision area, but some moms find this more painful and do better sitting up with lots of pillows to support the baby. There is usually no problem with sitting up after an epidural anesthesia for the c-section surgery, but depending on the doctors and the type of medications used, women who used spinals for their surgery may need to lie flat and start nursing that way in order to prevent a possible 'spinal headache'. On the other hand, new medications and techniques are being used, and the old dictate that women with spinal anesthesia HAD to lie flat for a day or two after the surgery does not hold true as much anymore. Ask your care providers if it's possible to raise the back of the bed somewhat so that you can nurse the baby more easily; whether it's possible, again, will depend on the type and amount of drugs used in your spinal. If it's possible beforehand, you can request that they use combinations (if at all possible) that will not require you to lie flat.
(Kmom's Story: For Kmom, sitting up and using the football hold with lots of pillows was far more comfortable and easier since nursing lying down is very difficult when well-endowed. Although Kmom had a spinal with her second c-section, she was not restricted to being flat afterwards, and was able to sit up somewhat in order to facilitate early nursing using the football hold. This made getting nursing started MUCH easier.
In fact, Kmom found that for weeks after her c-sections, the only way she could sleep comfortably at all was to be propped into an almost-sitting position, either on the couch or (in time) on her own bed with a ton of wedges, back rests, and body pillows. Fortunately, however, this problem with sleeping position and a bout with severe edema after her 1st c-section were her only real recovery problems in either c-section; otherwise she had fairly easy recoveries. However, for some women, the discomfort period is quite prolonged. Each woman's recovery will be different.)
If there was a great deal of blood loss or trauma during the surgery, some women become anemic afterwards, a problem few doctors watch carefully enough for. Aside from the obvious problems this can cause in a woman's recovery, it can also affect her milk supply significantly for breastfeeding (Willis and Livingstone, Journal of Human Lactation, 1995), yet VERY few doctors know this. Anemia is actually a very common cause of supply problems, but one that is totally overlooked in most cases. If you are having troubles with fatigue, feeling faint or weak, or with breastfeeding supply problems, please be sure to have your iron levels tested. Iron supplements (herbal or traditional) and modifying food intake can usually take care of the problem if it is caught early enough.
As far as food goes, you should not slack off in your attention to proper eating post-partum. A woman who is breastfeeding needs as much or more calories in the first few months as she did when she was pregnant. In addition, some sources feel that women who have had a c-section need a slight increase in calories as well in order to help with recovery and healing. If you have been on a somewhat restricted-calorie regimen before, you need to be sure you are getting adequate intake for this post-partum period. La Leche League recommends that no woman who is breastfeeding consume less than 1800 calories minimum, and most women immediately post-partum need much more than that. So it is vitally important not to diet or to let others pressure you into limiting your intake in this very important period. It is also important to up your consumption of fluids (preferably WATER) during this time to help flush out the edema and keep up your fluid levels for breastfeeding, and to consider adding a vitamin C supplement to your diet, which may help promote tissue healing.
Even if you did not lose a lot of blood or experience significant anemia, you need to emphasize iron foods in your diet, since you did have surgery and some blood loss is involved. Foods that are great sources of iron include legumes, beef, dried fruit, eggs, and particularly seeds such as pumpkin and sesame (sea vegetables are also an excellent source, if you have access to them). In addition, other food nutrients play a role as well in restoring your hemoglobin levels, so be sure to consume a well-balanced diet. It is important to know that iron absorption is decreased if you eat your iron foods with milk or other sources of calcium; iron absorption is increased if you eat your iron foods with vitamin C foods such as oranges, strawberries, and broccoli. So pay attention to how you schedule your foods together as well as what you eat.
The hospital stay after a c-section is usually 3-4 days, providing there are no complications. It is definitely possible and greatly desirable for baby to room in with you; it can even sleep with you in bed, provided you use railings and lots of strategically placed pillows. This prevents you from having to lean over and get baby from its warming bed; it is the twisting of this kind of lifting that can be especially problematic in surgery recovery. A few doctors do not recommend that you pick up baby at all after a c-section, but most are fine with lifting just the baby as long as proper positioning is used and twisting motions avoided, etc. Sleeping with baby really makes this much more convenient and should be strongly considered as soon as mom is not groggy anymore and can safely supervise baby. Kmom did not sleep with baby after her first c-section and caring for baby was problematic at times. After the second c-section, Kmom brought the baby in bed with her almost immediately after coming out of recovery, and found things were much easier and less stressful that way. It also helped the bonding process. However, if it is possible for the husband/partner to stay overnight in the hospital room too, it should be strongly considered in order to provide additional help to mother and baby. Nurse staffing has been cut so much at some hospitals that adequate assistance for c-section mothers may be hard to come by. Having the father there can help fill in the gaps and also promote father-child bonding too. Baby can sleep with either mom or dad, though nursing is easier if baby is right there with mom.
It should be noted that thrush (yeast infection of the baby's mouth and the mother's nipples) is a special concern after a c-section, due to the high amounts of antibiotics often given during and after surgery. If the mother's blood sugar remains high at all or she consumes a lot of sucrose (sugar) once the dietary restrictions of gd are lifted, she may be particularly prone to developing thrush. Any pain, redness, burning or itching of the mother's nipples, or white patches seen in baby's mouth may indicate that thrush has developed and needs to be treated. There are a number of options for treatment, but it is critical that both mother and baby be treated simultaneously, since it is very common for one to reinfect the other, making the process an ongoing and stubborn battle. The mother's bras, too, should be laundered very frequently to prevent re-infection from that source as well.
Lifting anything other than the baby is definitely to be avoided for a month or more. So much tissue and nerves have been cut that it takes real time for it to regenerate properly. Trauma to it in the recovery period can cause it to heal improperly and may cause long-term problems. Be very careful to avoid stressing this area. So many women feel so much better a week or two into recovery that they tend to overdo and cause problems in their long-term recovery. Most doctors recommend avoiding driving and any real activity for several weeks after the surgery, then a slow readjustment to a more normal schedule. Be careful not to overdo when you have a sudden jump in feeling better a few weeks into recovery.
Some women are surprised that they have lochia (post-partum bleeding/fluids) even after having had a c-section, but lochia occurs regardless of whether the birth was vaginal or not. The amount and type of lochia post-partum is often a guide to whether or not you are overdoing; a sudden increase in amount or redness or clots often indicates that a mom is overdoing, although it can also sometimes indicate infection or other problems and should always be discussed with your provider.
Most providers check on the c-section mom daily in the hospital, and then again 2 weeks after the surgery. If all is well, the final check usually occurs 6-8 weeks after the surgery, at which time post-partum glucose testing (see below), a pap smear, and birth control issues (see section on GD: Birth Control Decisions) are usually taken care of. By this time, the initial period of healing should be complete and the mother should be feeling close to normal, but it is important to remember that full healing takes longer than that and the mother should be careful not to overdo and allow herself time to recover completely. Other women may take far longer than 8 weeks to feel relatively normal; each woman should be encouraged to recover at her own pace.
Many women experience long-term effects from their surgery, and this is well within the normal range of responses afterwards. Back troubles from the epidural or spinal anesthesia are somewhat common, though usually not completely debilitating. Most women never completely regain their previous abdominal tone, and a few experience a signficant worsening of it; diastasis recti (separation of the abdominal muscles) is fairly common but should be discussed with your provider.
Some women experience some pain, itching, or numbness at or around their incision site permanently. It may come and go, or it may be more constant. Long-term, this incision site may tend to become a prime site for yeast infections of the skin (itching, burning, etc.), especially in larger women with significant 'aprons' or those who have had gd, so careful cleaning and care of the site may be particularly important (try an occasional periodic doses of Betadine once the incision is healed up). Internally, the site may itch or hurt or feel like it's being pulled. Adhesions and scar tissue commonly form after a c-section, and these may cause discomfort, especially in a subsequent pregnancy. Many c-section mothers experience long-term itching and pulling and feel a great deal of worry over what is 'normal' and what is not.
Sometimes it is difficult to know what concerns are part of the normal recovery process and what are abnormal----for example, some itching during recovery is quite common but in some cases may indicate an incipient infection that needs attention. If in doubt, err on the side of caution and consult your provider. It is better to be too cautious and be wrong than to ignore a potential problem and have it grow into a serious complication. Again, you may have to be assertive to get your provider to take your concerns seriously.
Conversely, some doctors treat a large woman who has had a c-section as a walking time-bomb, ready to explode into infection and other complications; it's important to note that while there are higher rates of complications among larger women (especially infection), most large and even supersized women who undergo c-sections do NOT routinely experience problems. Again, it may be appropriate to use higher prophylactic levels of antibiotics in larger women, especially those who are supersized, and the issue should certainly be discussed with your provider, especially should ANY tendency towards red, itchy, or weepiness in the incision site occur. But don't assume that your wound will get infected simply because of your size.
It is important to try to prevent unnecessary c-sections in larger women (and all women!) due to possible risks, and to be vigilant in prevention should a larger mother need to have a cesarean, but it is certainly not true that the majority of large women who have c-sections develop problems. Most do not. And it is also important to remember that women of average size also sometimes experience problems after a c-section too; do not assume automatically that any problems you experience must be due to your size. We have enough guilt in our lives already; don't internalize blame for this too! Just deal with your recovery realistically as it comes and leave the blame outside the door.
The important lesson to learn here is that there is a wide variety of 'normal' responses in physical recovery in women of all sizes. Do not let your doctor treat you as if you are a ticking time-bomb of complications and infections, but neither should you let them ignore any possible concerns you may have. Be assertive in your recovery and demand sufficient time and care, even post-partum. You may also wish to go over in detail the birth and the process that led up to needing a c-section. This may provide important information for planning for future births and is often important in the process of emotional recovery too. Doctors are usually fairly adept at assisting in physical recovery but their attention to emotional recovery issues is often woefully inadequate.
Emotional Recovery After a C-Section
Anecdotally, it seems to be a very common scenario for a gd mom to be induced early or at term and have a very difficult labor and birth, often ending in c-section. A c-section after a long, drawn-out induced labor can be particularly difficult emotionally and physically. In addition, there is often a need for others surrounding the mother to negate her trauma or minimize her disappointment at having a surgical 'birth'. C-section mothers are often told "at least you have a healthy baby" or to be thankful for the life-saving surgery. And of course it is true that a healthy baby is the top priority, and if the c-section was truly necessary, it's far better than the alternative! However, even when the surgery was necessary (and not all is), a woman often needs to mourn the birth she wished she could have or was not allowed to have, and to acknowledge the difficulty of the birth.
Spouses in particular tend to pressure a woman to "just get over it already" because of their own emotional needs or discomfort with how the birth progressed. Supporting a woman through a difficult labor and subsequent surgical birth is extremely trying emotionally, and many spouses feel inadequate, frightened, and powerless in the process. Having the surgeon take over and 'get it all over with' is frequently a relief to them, though the process of witnessing even parts of the surgery on their loved one is quite distressing. As a result, many spouses are relieved to be past the experience and are so overwhelmed by the new baby in the house that they just do not want to discuss the birth or wish to simply put it in the past. They often find it difficult to empathize with the mother's emotional needs.
In contrast, many women feel the need to go over and over the birth in their minds, especially if the birth was traumatic in any way. This need to discuss the birth repeatedly can create a great deal of tension with the spouse, who generally wants to forget the experience or is ready to move on sooner than the mother is. Other relatives such as the mother's own mother may be less than sympathetic (coming from an age of extreme intervention in childbirth and having little sympathy/interest in more natural childbirth) or they may simply be swept up in the thrill of getting to know their new grandchild and unable to understand less-than-total joy at its birth. It is normal for mothers to need to re-live the births of their babies, whether the birth was traumatic or not, but the effect is often markedly stronger in women who had difficult or traumatic births.
Sometimes this effect is muted for a while; the mom ignores her c-section or difficult labor entirely or feels like she is fine with it, consumed as she is in caring for her new baby. She may emotionally need to create more distance from the birth, to devote her time totally to baby care, or may simply feel as if she has moved on. Only later do many of these women become aware of a deep and searching need to relive and discuss and second-guess their babies' births, even ones that were totally necessary. Often the woman who is 'fine' with her c-section at first experiences the delayed effects of grieving the loss of her ideal birth later on, frequently on an anniversary of the baby's birth or when the woman is ready to start conceiving another child. This is very common and is a natural time to work on integrating the previous birth into herself.
On the other hand, some women never do experience this need to re-live or second-guess their c-section, which is also fine. Not every woman is stressed by her c-section, and although many who feel 'fine' about it at first do go on to question or mourn it, some do not. Women who are 'okay' with their c-section should not feel guilty or pressured into angst! Each woman is unique in her process of accepting her birth experience, and no response is 'right' or 'wrong'.
However, some women have such difficult births that they even experience Post-Traumatic Stress Disorder (PTSD). A sudden emergency/'crash' c-section, one that was difficult, or one that required a great deal of drugs or general anesthesia often involves higher rates of PTSD. This Post-Traumatic Stress Disorder often manifests itself in flashbacks and dreams, physical sensations or stimuli causing intense anxiety or recollection, jumpiness, and increased incidences of Post-Partum Depression. In fact, the relationship between traumatic births and PPD is an under-researched area but anecdotally seems to be strongly linked. Some childbirth activists suggest that some cases of PPD may actually be unrecognized cases of PTSD, but since PTSD is usually studied only in the context of war or abuse, little research is available on it and most information is anecdotal or observational. The connection seems clear enough, however, to validate that PTSD often does follow traumatic birth and is under-recognized and under-treated.
Some mothers who experience traumatic births have difficulty bonding with their babies at first. Sometimes they consciously blame the baby for the experience, but usually they just have difficulty connecting with the infant, or are too pre-occupied with what has happened to them to be able to open their hearts fully. Often, the high rates of depression surrounding c-sections and difficult births impede the bonding process. It doesn't mean that these mothers don't love their babies or are poor mothers, just that what has happened to them is overwhelming and difficult to deal with. In addition, since most c-section moms do not get to see the baby emerging from their bodies, the baby may seem unreal or as if it's the wrong baby. This state does not persist forever, and most moms who have trouble bonding eventually experience a breakthrough and bond just fine-----but they may mourn forever the time lost to them. Sometimes the process takes days, sometimes weeks or months, but usually at some point, the mother finds the opportunity to 'fall in love' with her baby after all.
On the other hand, some women who experience traumatic births bond fiercely and immediately with their children. Trauma and difficulty do not always impede bonding; sometimes it has just the opposite effect. These women are often intensely connected with their children, and the level of bonding can be quite fierce. The trauma in these cases only helps to focus the mother's attention on her child, and the effect may be so strong that other concerns may drop away. Recovery in the more extreme cases here may involve relaxing enough to loosen vigilance or to include others within their tight world of focus and concern. However, for most, it's just another perfectly legitimate response to a tremendously challenging situation, another way of coping. Each woman needs to deal with the trauma in her own way, accepting her response as normal and human, and moving beyond it into healing and closure as time goes on.
Although it's dangerous to over-generalize, it does seem that women who are able to breastfeed successfully often experience less severe levels of PPD and quicker bonding after a traumatic birth, while those who find breastfeeding difficult or give up quickly may find it more severe (Laufer, AB, Journal of Nurse-Midwifery, 1990). This may be related to hormone levels (since women who do not or cannot breastfeed tend to 'crash' more quickly and do not get the moderating benefits of prolactin and other hormones to help transition them), or it may simply be emotional. It should be noted that the success rate of breastfeeding after c-sections and traumatic births is lower than after normal birth (Perez-Escamilla, 1996) since conditions that surround these deliveries often interfere with breastfeeding, there may be less support from the staff, or the mother may be separated from baby more. But it's worth pointing out that the many women who experienced traumatic births or c-sections yet were able to preserve breastfeeding report the experience of breastfeeding to be one of their best acts of self-healing; this was Kmom's experience, as noted below. As always, however, individual responses vary and all are valid; no criticisms should be inferred.
Mothers who experienced great difficulty in breastfeeding and gave up or who had to supplement because their supply was impaired often feel great guilt, frustraton, or anger. The reasons for their difficulties may vary widely. Some may not have been adequately prepared emotionally or physically for breastfeeding, and may have lacked adequate instruction, information, and support about starting or preserving breastfeeding. Some were very likely sabotaged by medical mismanagement, and some may have experienced a lack of support at home or from family members. Others may have undiagnosed physical causes, such as maternal hemorrhage, anemia, retained placental fragments, hypothyroid levels, or birth control pill prescriptions that cause their supply problems. To have the great frustration of having to deal with gd in pregnancy and then not be able to fully breastfeed afterwards can sometimes magnify the grief and frustration intensely. These women are quite likely to be able to succeed at breastfeeding again with another child, given adequate information, care, and support, but still need to grieve and vent about their difficult experience this time.
However, it is important to note that there are a few women who are not able to breastfeed, either partially or at all, even when extremely well-prepared and supported. These dedicated women do everything possible to ensure success, get plenty of timely professional help, pump religiously to increase supply, etc., yet are never able to produce enough milk to fully sustain their child. No one knows exactly how many are truly unable to breastfeed since medical mismanagement is so common, but. there is a very small percentage of women whose breasts never change during pregnancy and who never get any milk, and there is a slightly larger group who get some milk but not enough to fully support feeding their baby without supplementation. This is probably hormonal, but no one quite understands what happens in these cases.
Among these mothers are some women with PolyCystic Ovarian Disease. Although no one has really documented exact numbers, one lactation consultant estimates that up to 20% of women with PCO will have trouble breastfeeding their babies and will need to partially or fully supplement, yet many others with PCO are able to breastfeed without supplementation. No one understands why some women with PCO are able to breastfeed without problems and yet others cannot; a best guess is that since PCO is probably a group of related syndromes instead of one well-defined disease, time and research will probably find that these women's PCO is somewhat different and thus manifests itself differently. Unfortunately, nearly all research into PCO in the past has covered reproductive issues; PCO researchers are generally very uninterested in lactation issues. In the lactation research community, there is beginning to be some acknowledgement of the problem, but the information is mostly anecdotal and speculative. So help at this time is significantly lacking.
PCO mothers should be strongly encouraged to breastfeed, since most of them do so successfully and it has many potential benefits for mother and child, but they should be extremely well-educated and proactive about breastfeeding, receive careful help and monitoring from lactation experts, and be vigilant for signs of dehydration or failure to thrive, just in case. They should not give up easily since many women experience transient breastfeeding problems after a c-section or induced birth, and these difficulties may indeed be able to be resolved fairly easily. Problems at first do not necessarily predict breastfeeding 'failure'; many women experience and overcome initial problems, including supply concerns. Furthermore, even if their supply problems are long-lasting and not easily resolved, many women who cannot fully breastfeed their babies are able to partially supply their needs, and any amount of breastmilk a baby gets is greatly beneficial for its antibodies and protective immunity properties. How long to sustain this must be left up to the mother involved; it is not always an easy process and the benefit to baby must be balanced against the stress that is placed on the mother. Kmom would encourage these mothers to nurse their babies as much as they can for as long as they can, but if the process becomes too stressful, each mother must be encouraged to do what is best for the mother-child pair as a unit. In some cases, this may include weaning if the process becomes too stressful. Support for this agonizing decision must be offered freely and without reserve; these moms should never be made to feel guilty. Options and support for continuing should be made available, but if the mother decides not to because of the tremendous stress involved in both nursing and supplementing, that decision must be respected.
Since there is a significant subgroup of gd women who have PCO (often undiagnosed), there may be a subgroup of gd women who have trouble breastfeeding, despite excellent preparation and dedication on their part. It should be emphasized that most gd women ARE able to breastfeed, and since breastfeeding may offer special benefits to the gd mother and child, it should be advocated strongly. However, it is also vital that gd experts realize that there may be a few moms who need to supplement in addition to breastfeeding, and that women with PCO and gd should be given the maximum possible expert support during the early breastfeeding period yet also careful observation. In Kmom's opinion, routine supplementation as practiced in the past should be ABANDONED, and support staff should be slow to resort to supplement, since it DOES interfere with breastfeeding success (Blomquist, HK, 1994). However, infants of gd moms (especially those with pco) should be monitored carefully and should probably have careful post-hospital monitoring available to them (some insurance policies cover a home visit by a nurse in the first week, an excellent idea). An extremely proactive approach to elminating medical barriers to establishing breastfeeding needs to be taken, while still carefully monitoring for dehydration as well as hypoglycemia and jaundice. If supplementation becomes necessary, medical personnel need to make every effort to do it in such a way that it does not interfere with breastfeeding (avoiding bottles and using syringes, tube/finger feeding, or cup feeding can get baby the needed supplementation without causing nipple confusion which can strongly impact breastfeeding in many babies). Much more research attention to these issues needs to be paid by experts in the future as well.
Emotional support for gd women after birth is sorely lacking, even for those who end up with a relatively normal birth experience. For those women who endure a gd pregnancy, a traumatic induction, c-section, and then who also have trouble breastfeeding, the emotional devastation can be particularly difficult. The sense of betrayal by one's body can be intensely acute, and there may be little support and even blame from medical personnel and family. These women's difficulties need to be acknowledged and supported, and a safe place to vent is important. Unfortunately, resources for this are few and far-between at this time. One new online resource, however, is available for those who have had great difficulty breastfeeding, MOBI (Mothers Overcoming Breastfeeding Issues). A webpage with more information can be found at http://web.wt.net/~mobi/ or you can email smc@wt.net.
Kmom's Story --(summary: difficult induction, traumatic c-section [not for the faint-hearted to read!], some problems breastfeeding but success in the long run, path to emotional healing)
My first delivery (the one with the gd pregnancy) was extremely traumatic, so I am acutely aware of these emotional recovery issues. After a long, extremely difficult induced labor with great pain and a 'failed' pushing stage (she was posterior and got stuck), I had a c-section. The anesthesia was not sufficiently strong, however, and I felt the surgery intensely. I passed in and out of consciousness from pain and had to be tied down because I fought the surgery; no additional meds were given until the baby was delivered, at which point I was given an emergency general. Although I had no name for it then, I did experience some PTSD for some time afterwards, with nightmares of hands crawling all over me and holding me down for torture. The memory of having to endure surgery with nearly full feeling haunted me for years afterward and impacted future births. The lack of understanding from my relatives over my disappointment in the birth was not easy to deal with either (though my husband was supportive, unlike many), and the total lack of empathy from medical personnel was especially difficult. After all, I had a healthy baby, 'what more do you want?'. {How about a loving and gentle birth experience???}
The betrayal by my body I felt especially acutely, and the rigid food protocols in gd interfered with my recovery from years of dieting. Here I thought I had healed my body and psyche regarding my size, only to have it betray me yet again during the most important job of all---having a family. The rigid and regimented eating plan destroyed years of retraining myself to eat by hunger cues instead of by imposed rules from outside sources, and I found myself strongly craving 'forbidden' foods, even though previously I had little to no desire for these foods. Voices of doom about how I would probably need insulin for my next pregnancy and would soon develop type 2 diabetes depressed me, and I feared a repeat performance--or worse!--of this difficult pregnancy next time. I was both depressed and angry yet gratified when I found out that the handling of my gd pregnancy was NOT necessarily the only course I could have taken (had I only known), and that my c-section experience was likely unnecessary. There was hope for the future of avoiding a repeat performance, but it was terribly frustrating that I'd had to go through that experience when it was probably unnecessary.
Despite the many difficulties in my first 'birth', in time there was also healing and recognition of some blessings too. Although my access to my daughter had been significantly delayed (and I will forever mourn that lost time), I was lucky enough to be one of the ones who bonded immediately and strongly, despite all obstacles---and there were many! My child was healthy and energetic and has showed excellent developmental skills; she has been a remarkably healthy child. Some of my best healing came from being able to breastfeed my child successfully, despite many difficulties and barriers in the beginning; I was amazed at how healing I found it, since I really wasn't all that enthralled with the idea of nursing in the first place. Being able to do this felt tremendously right, like my body was finally able to carry out a task correctly and wasn't quite so dysfunctional after all, and the thrill of seeing my child absolutely thrive on my milk and nothing else was very empowering.
My second pregnancy was very scary in that I was afraid my gd would recur earlier and more severely. I was extremely proactive in that pregnancy and rejected the previous advice given to me to not worry about eating when I was nauseous ("the baby will get what it needs"). By eating regularly and carefully, I was able to avoid the extreme nausea of the first pregnancy and probably the blood sugar swings that happened with it; by exercising and eating well and regularly I was able to keep my blood sugar in the normal range. I gained a lot more confidence in my body when the gd did not recur, instead of the doomsday predictions everyone had given me. Without the pressure of the stringent gd restrictions on me, I was able to go into labor normally, labor naturally and without drugs, and had a wonderful labor, which I found tremendously empowering. However, in the pushing stage, the baby was found to be in the posterior position and stuck; we still ended with a c-section. All of my horrid fears from the first surgery haunted me as we prepared, but the surgery went much better this time because we used a spinal and careful attention was paid to my feedback. The staff was much better this time about keeping the baby with us and delaying unnecessary tests and procedures until later, and no bottles were given this time. I was awake and able to nurse right away in recovery, which completely eliminated all the difficulties we encountered last time. Unfortunately, I was still not 'permitted' to see the birth of my baby and was not able to hold him right away, and emotionally, it was hard not to get my much-desired VBAC. I still have dreams of a gentle, loving birth (instead of a surgery) and being able to connect with the baby right away, but this birth was still far and away better than the first.
I also now know that there are many things that can be done to prevent or correct a posterior presentation, which will make a VBAC much more likely in the future. However, even if another c-section became necessary next time, I still believe it's possible to have as close to a truly gentle and loving birth as possible during surgery; even a c-section doesn't usually HAVE to be so clinically cold and impersonal. My goal for my next birth is to have that gentle, loving birth as much as possible, whatever the circumstances are, gd or not, c-section or VBAC.
Integrating the disappointments of previous births has not always been easy, but it has happened. With time came the recognition that the trauma of my experiences also created a tremendous opportunity for learning and emotional growth. The desire to heal from the experience led to a lot of reading and research on my part, and I created this website in order to communicate some of the information I had found and to make something positive come out of the negative parts of the experience. It led to a new assertiveness and self-respect, and a determination never to settle for undignified or disrespectful treatment again, and to always question and research my health care issues. It also led to an increased emphasis on health and proactive prevention of problems for my future (though probably not quite in the way most gd researchers would prefer, since I chose to concentrate on good eating and lots of exercise to improve my blood sugar instead of another dieting yo-yo). And emotionally, this crisis was the springboard for a great deal of emotional lessons and healing. The cost of the lessons was quite high and I can't be glad of it, but I can integrate the lessons learned and even be grateful for the impetus it gave me to take charge of my own care and become a more proactive person.
However, I recognize that everyone's experiences are different and not everyone will feel that way. Some women heal very quickly from traumatic births and are able to shrug it off easily; other women take years to recover. For those who are bothered by your birth experiences, you are NOT alone. There IS support available for recovery from difficult births; read on for more information.
Towards Recovery
There are many things you can do to help yourself recover emotionally from a c-section or traumatic birth experience. What helps you personally may differ from what helps someone else, and it may also change over time. Some women need time and space to concentrate on baby before dealing with their c-sections; others may need to heal emotionally in order to connect with their babies. Some benefit from support groups such as International Cesarean Awareness Network (ICAN), either in person or on-line, while some prefer to do individual work at home by themselves, with a therapist specializing in birth issues, or with a self-help book.
One outstanding resource that Kmom highly recommends is the book, Rebounding from Childbirth by Lynn Madsen, a psychologist who also underwent a difficult birth experience. It can be ordered from www.amazon.com or other online book sources. It is truly excellent; Kmom recommends reading it in small doses and coming back to it from time to time to refresh your healing. Another outstanding book is Transformation Through Birth by Claudia Panuthos, which is even better than the Madsen book (Kmom can't recommend it highly enough!). Unfortunately, it is out-of-print now and hard to find, although Cascade Books (Birth and Life Bookstore; [503] 371-4445 or 800-443-9942) has a limited supply available for sale. However, the difficulty of finding it and the ease of availability of the Madsen book is why many people choose the Madsen book first. Both are of excellent quality; the Panuthos book is the best but the Madsen book is very good as well.
Emotional healing is often a long-term project. It often brings up other issues from your life, or makes you deal with unpleasant memories from the past. Personal issues of long standing are often intertwined with birthing issues; it is usually very difficult to see these at first but time and perspective may enable you to see patterns you were unaware of. Often, issues surrounding your own birth or childhood come up, thorny issues that defy easy solutions or quick platitudes. Abuse, violence, control issues, even dieting and body issues can become intertwined with your healing process. Don't expect quick, easy answers; healing usually occurs on a number of different levels, from the simple to the intricately complex, and over a longer time period than you might expect. Sometimes it takes years to gain enough distance and perspective from the event that you can clearly see the lessons learned in that time. Give yourself that gift of time.
You may do some healing in the beginning and then move on to other tasks thinking you are done, but then something triggers your need to deal with the birth again, and you re-encounter the healing process again. The healing process often proceeds in a 'spiral' pattern like this. Often, an anniversary or special occurence in your child's life will trigger your 're-reaction', and you will find yourself once again asking for more details about the birth, reliving it, second-guessing it, or just re-telling it. This is a totally normal response! Many people have noted this pattern among women healing after a difficult birth experience. Don't feel guilty for responding in a normal pattern. Don't wallow in self-pity or allow yourself to hold on to your grief forever, but don't be surprised if it takes a long while and occurs in stops and starts. Emotions are very tricky things; they do not heal cleanly and as straight-fowardly as nerves and tissue and muscle.
One important thing to realize is that your spouse may not understand the need to periodically rehash or relive the circumstances of the birth. It is your job to emphasize to him that it is a very important (and normal) part of the healing process to need to review the birth again and again. He needs to understand that his job is to listen, help you recall, sympathize, comfort, and hold you, but it is not to help you solve anything or get you to move on. Men tend to be programmed to do this when trying to help, and it's the opposite of what most women need after birth. Men tend to need to listen, offer a course of action to solve the problem, and then move on. That's fine; it works for them. However, they need to understand that YOUR course of healing may be different, and that what most women need is a sympathetic ear, one who will listen nonjudgmentally over and over again, as long as is needed. He needs to know that his healing is important (and many spouses have a lot of buried emotions after a c-section they may find easier to ignore than to address) but that your healing is very important too, and that you need his support to heal in your way, not his. Some women get over it very quickly, and some women take years to get over it. It is the woman's responsibility to help her husband understand what he needs to do to support her while she heals; she should not feel guilty for asking for his help, but neither should she expect him to read her mind. It's important to recognize how hard it is for the partner of a c-section mother to go through that experience; really examining it can be very threatening or scary for the spouse. However, recovery is about personal AND mutual healing, and it can actually greatly aid the communication in your marriage to pursue discussing these issues carefully.
Don't expect your spouse to be your only support, though; supplement his input with the care and understanding of an online support group or a journal or a counselor. Read all you can about GD, cesareans, recovery from childbirth, etc., and then give yourself the gift of time to heal. You cannot make the experience go away, but you CAN learn to integrate it into yourself and your personal history, to accept it as yours without necessarily accepting all the circumstances around it as good. Only then can you move on.
Considering Another Child/VBACs
Oftentimes, the woman has largely healed from the birth only to experience a 'relapse' when contemplating another child or at some point in the next pregnancy. This is quite normal. Most women need lots of extra support and understanding at this time, both from her partner and her provider. The fear of another traumatic birth can be very, very strong. Some women react to this fear by avoiding any possible repetition of the previous birth at all by electing to have a repeat c-section, despite its greater rates of problems for mother and baby. Oftentimes it is the induction/drugs used last time that they fear most, and they hope to avoid the problem by bypassing labor entirely. Although most women should be strongly encouraged to labor normally next time (since their chances of a normal birth are quite high--70-80% in most studies), some women may opt to bypass this for various reasons. Their provider should attempt to address the mother's fears and concerns and point out that a normal labor is actually safer and better for mother and baby, but must recognize that in some cases, a mother may be best served emotionally with a repeat c-section. It should be emphasized that these cases should be few and far between and every attempt should be made in the interim to address the mother's fears that keep her from wanting to labor and birth normally, but it is unrealistic to insist on too rigid a standard. For some mothers on some occasions, it may be a psychologically better choice to elect a repeat c-section, though every effort should be made to first address the mother's issues before electing this other choice.
Most mothers, however, should be strongly encouraged to aim for a VBAC (Vaginal Birth After Cesarean), since it is statistically much safer and more desirable for most mothers and babies. However, it is extremely important to choose a provider that is totally supportive of VBACs, has a high success rate with them, and is totally committed to helping you have one. Many health providers pay lip service to VBACs but in reality are lukewarm to them and place so many constraints on them that they never have a real chance for success. It is VITALLY important to carefully research and understand VBAC issues and choose your provider accordingly, not just automatically select the provider you had last time. You must also be willing to consider switching providers should they seem to be supportive at first but show doubts, place constraints on your labor, and suddenly propose interventions late in the process. Unfortunately, knowing how to help and not hinder a VBAC is still not well-understood by many practitioners, and the economics still strongly encourage interventions, inductions, and repeat sections. So choice of provider is an absolutely critical issue in VBACs.
An excellent guide to questions to help you select a good VBAC provider can be found in the superb book, The VBAC Companion, by Diana Korte (available from www.amazon.com). This book is a must-read for anyone trying to decide about VBACs. Another good book is Natural Childbirth After Cesarean (available from La Leche League, www.lalecheleague.org). Online, there are a number of VBAC resources available, including the outstanding ICAN organization (International Cesarean Awareness Network). Its mailing list and support group can be joined by sending an email consisting solely of the word 'subscribe' (but without the punctuation) to ican-request@fensende.com, or you can visit its excellent webpage at www.childbirth.org/section/ican.html.
Another resource can be Vaginal Birth After Cesarean by Dr. Bruce Flamm, one of the leading medical researchers into VBAC issues, although a few of its recommendations are outdated or a bit conservative since it was written a decade ago, fairly early in the medical movement towards VBACs. It is also worth noting that there is currently a backlash from the medical community about VBACs and there is a lot of rhetoric in the air, so it may be more difficult to find a truly supportive provider. However, when careful study is made of the issue, VBAC is the best choice for most women and Kmom is convinced that history will bear this out in time, after the anti-movement backlash has run its gamut.
It should be noted, though, that for a few women, VBAC may become an unhealthy obsession. They may place all their faith in avoiding the conditions that led to the first surgery, and may face great stress from having an 'all or nothing' attitude towards their next birth. This can also be an emotional sandtrap. Any woman, no matter how normal her pregnancy and labor is, faces a small chance of an unexpected c-section, no matter what. It is not possible to completely eliminate this possibility; a placenta may abrupt (separate from the uterus prematurely) or a cord may prolapse, etc.----all truly life-threatening occurences that are best served by a c-section. To blindly make a VBAC an all-or-nothing proposition may be too rigid and inflexible. On the other hand, to "try" a VBAC may also be a self-fulfilling prophecy of failure as well. Truly necessary c-sections are very small in number (about 5-10%) and a provider that is truly supportive of and committed to VBACs often has a very high success rate. A woman must walk a fine line between rigid inflexibility towards a VBAC, and self-doubt or a lukewarm commitment sabotaging her 'attempt' at a VBAC. In Kmom's opinion, a woman should work towards a VBAC with everything in her power and expect it, but also have a birthplan for a c-section, should one become necessary at some point. It is better to be prepared for a just-in-case scenario, and there are ways to help make a c-section experience a more natural, healing, and wholesome birthing experience instead of just a cold-hearted clinical surgery. In all likelihood, this part of the birthplan won't be needed, but if it is, it is possible to still salvage some semblance of a decent birthing experience.
However, whatever a woman decides, the most important thing is to find a way to make the birth BETTER than it was the last time, and every woman must personally decide what exactly this entails for HER. More information on VBACs and planning for future pregnancies after gd can be found in the websections on GD: Planning a Subsequent Pregnancy and GD and VBACs: Can It Be Done?.
Emotional Impact of a GD Pregnancy
[NOTE: A more extensive coverage of this issue will be found in the websection, GD: The Emotional Impact, which covers the entire spectrum of emotions during gd, from diagnosis, denial mechanisms, dealing with care protocols, guilt, anxiety for baby, dealing with a difficult labor or c-section, anxiety over planning a subsequent pregnancy, and fear of future diabetes risks.]
The emotional impact of a gd pregnancy is an area that has received scant attention from researchers until just recently, and the recent attention has largely been superficial. In their haste to be sure that baby's outcome is as favorable as possible, doctors often overlook the tremendous stresses involved for the mother. A few sources have acknowledged the stress involved in gd; those addressed to the mother tend to be patronizing and condescending rather than reassuring yet honest. Among those addressed to fellow researchers, few acknowledge the tremendous stress involved in having gd. However, Dr. M.J. Stephenson did touch upon the subject in a 1993 article in Canadian Family Physician. He noted that:
The impact of diagnosis on women is also important. One study [Kmom note: a Master's thesis, not widely available]...demonstates clearly the impact of the diagnosis. The women experienced considerable guilt wondering whether they were responsible for GDM and had considerable anticipatory anxiety of future problems with the fetus. There was considerable life disruption with frequent health care visits and changes in food preparation and eating. This suggests that the diagnosis of GDM affects the experience of pregnancy, and the extent to which these events are perceived negatively and lead to suffering will depend on the patient's and physician's response.
Cynthia Armstrong Persily, RN, PhD, wrote one of the few studies to examine more closely the stress experienced by women diagnosed with gd, although the focus of her study was on how a gd mother's perception of the impact of gd in her life affected her adherence to prescribed treatment protocols (women who felt that gd had a significant impact on their lives were less adherent to treatment protocols). She notes that "behavioral and self-care modifications required of women diagnosed with gestational diabetes mellitus may increase their stress levels beyond those considered normal in pregnancy...Clinicians must consider the impact on women's lives of stressors such as the diagnosis and treatment of gestational diabetes mellitus. The addition of careful diet planning, blood glucose monitoring, as many as three to four injections of insulin per day, additional visits to the health care provider, and increased fetal assessment may overburden some women who already are experiencing stress." She suggests that the daily availability of a perinatal clinical nurse specialist or other health provider to provide support and answer questions and concerns could minimize some of the stress experienced by gd women.
Because the anxiety that a gd diagnosis can cause has been used as an argument against universal screening or aggressive treatments by some gd critics, a few gd researchers have set out to prove that gd diagnosis does not impact a woman's mental health or emotional adjustment (Spirito et al., 1989; Langer and Langer, 1994). They found that a gd diagnosis did not affect a woman's mood or emotional state, and found that women with strict control actually felt better than those without strict control. Additionally, they found that women put on intensive therapy regimens adapted well too, and "achievement of glycemic control contributes to patient reassurance." However, this flies in the face of other studies that found that gd status significantly affected a woman's self-perceived health and worries about the fetus (Kerbel et al., 1997; Feig et al., 1998). The difference may well lie in how the studies dealt with the women. If you are told that you have a disease that may significantly impact the health of your baby or even kill it (the evidence for mortality risk is scant but nevertheless many gd women who question their treatment have reported being told this to scare them into acquiescence), then you will most likely respond with gratitude to the treatment that will supposedly 'save' your child, and will view positively any actions you can take to actively improve your child's prognosis. Furthermore, the objectivity of the researchers is questionable, since some are known advocates of extremely aggressive gd treatments; they may have unconsciously set up the studies in a way that elicited the responses they wanted.
Of course, this argument can be applied to the studies that found significant emotional impact from gd diagnosis; they could have been set up in such a way that they elicited results that confirmed their authors' bias against routine screening or aggressive treatment. Both sides need to be examined critically for author bias. However, anecdotally, women with gd report a great deal of anxiety and trepidation for their own health and their children's health. The anecdotal evidence of this is so strong that it seems justified to assume its validity over the results of 2 contradictory studies, at least for now. Taking positive steps to help ensure even blood sugar control may help some feel temporarily empowered and involved in their child's treatment, but for many the treatment and rigidity of treatment protocols is more anxiety-producing than empowering, though of course they will put the perceived needs of their child's health first. But long-term, most gd women seem to experience considerable anxiety and depression over their own health and the health of the child born to the affected pregnancy. For severe cases, the possible impact on long-term health certainly justifies the emotional burden of the diagnosis; the question is whether the significance of diagnosis in mild cases is enough to justify the emotional burdens and anxiety.
In Kmom's own personal, non-expert opinion, the emotional burden of gd is quite significant and is a normal, healthy response to the stress of diagnosis and treatment. Kmom questions the unconscious bias of studies that show otherwise, since anecdotal reports of anxiety and burden are so strong. Kmom's own experience and the many gd women she has spoken with online clearly support the studies that show significant emotional impact of diagnosis and stringent treatment protocols. This should not be taken lightly or dismissed easily. That doesn't mean, however, that gd screening and treatment should be abolished simply because it negatively impacts the emotions of the women involved; if the health burden is proven to be great enough, the tradeoff is justified. It is a worthwhile and important question to ask whether minor variations in glucose tolerance really present enough risk to justify the emotional and economic burden involved in intensive treatment, but it's important to note that at this time evidence exists to both support and refute this stand. Only time and further study will show whether the tradeoff is justified, but to dismiss the concerns of gd women as non-existent or not a real burden is insulting and arrogant. Emotional response and burden will vary among women, but the diagnosis and treatment protocols of gd DO have an impact emotionally, and often long-term. This must not be under-estimated or dismissed as inconsequential, even if treatment of even mild cases turns out to be justified.
Emotionally, many women who are diagnosed with gd experience a grieving process similar to that outlined by Elisabeth Kubler-Ross in her pioneer work, On Death and Dying. The five stages commonly cited include denial, anger, bargaining, depression, and acceptance. The stages are not usually experienced in a clear linear progression and many people experience them in periodic cycles or spiral progressions. Most gd women experience these in one degree or another. Though most find dealing with it distressing and stressful, most are able to deal with it in a mentally healthy way in spite of the circumstances. A further discussion of this emotional grieving process can be found in the websection on GD: The Emotional Impact; the effect of anger and depression are most pertinent to this postpartum section and will be focused on here.
Anger is a perfectly reasonable response to a condition that can be so anxiety-producing, yet it must be allowed to be expressed and channeled into a positive direction. A gd mother may blame an outside source for the problem, may feel angry at her child for 'causing' the problem, or more commonly, may direct her anger inwards towards herself. This is especially prevalent in large women, who often feel like their bodies have failed them yet again and may be ashamed that they have what is popularly perceived to be a 'fat' disease. The prevalence of size bias and harrassment by many medical providers can add to the anger or depression a larger woman with gd may feel, too. Few providers bother to point out that thin women get gd, too, and that many fat women, even supersized ones, do not get gd. A genetic tendency towards diabetes must be present in order for a woman to get gd; being fat or gaining a great deal of weight in pregnancy may add to the tendency towards insulin resistance, but it is not the sole cause of it. The issue is far more complex than that, but the fact is that many large women feel tremendous anger, depression, and guilt over being large and having gd.
Acceptance, of course, is the mecca that providers want us to aim for, where we accept with open eyes the possible risks of gd without overreaction and panic, and just do whatever is necessary to get a healthy baby and improve our health for the future. However, acceptance does not have to mean an unquestioning slavish acceptance of every health dictate from the provider; it means informed, calm, and intelligent questioning and decision-making so that we are involved in our own health care decisions. Remember, though, that people rarely progress conveniently from one stage to the next in a neat and orderly manner; most lurch about, awkwardly trying to come to terms with all the stress, treatment requirements, measurements, and decision-making required to effectively deal with gd. Don't worry about trying to 'handle' gd; just take things as they come, try to minimize what stress you can, and concentrate your energies on being as healthy as possible.
Emotionally, recovery from a gd pregnancy can be difficult. The stress of all of the treatment regimens some providers insist on, the fear or pressure of needing insulin, the anxiety of worrying over the health of your baby, the pressure of disapproving friends and family (who may blame your gd on your size), the stress of an early, induced, or difficult labor, the emotional and physical recovery from a possible c-section, the stress of trying to establish breastfeeding under the circumstances, and the mourning of the ideal pregnancy and birth you did not get to have, etc.----all of this can take a significant toll. Sometimes, it's not apparent just how much of a toll can be taken until after the baby is born.
Some new gd mothers experience significant post-partum depression, which in part may be related to the stress of the gd or a difficult delivery. Other mothers are able to focus all their attention on their new babies and seem to recover well emotionally only to suddenly be ambushed by unresolved feelings later (especially when considering a new pregnancy). Still other moms are most concerned about the possible health implications gd may have for their baby's future, or may be worrying about the clearly increased risk for diabetes for themselves in the future. Many women experience a significant let-down after 'pushing' to the finish line of delivering their children safely but are left with unresolved emotional homework left over or ignored from the gd pregnancy.
Very little attention is paid to the role the stress of gd may play in post-partum depression. Doctors often tend to ignore gd issues as irrelevant or simply throw drugs at post-partum depression instead of recognizing the importance of counseling and support in recovery from difficult pregnancies or births. Again, an excellent book to help in the recovery process is Rebounding From Childbirth: Toward Emotional Recovery by Lynn Madsen (available from www.amazon.com). It doesn't deal specifically with gd, of course, and occasionally some of its imagery is a bit strange, but overall it is an excellent resource, one of the best Kmom has ever found. Kmom also encourages gd moms to find other gd moms online and share experiences, and also to try to communicate to spouses the worries, guilt, and concerns you have had about the gd experience. Keeping it inside or minimizing it to others can make it worse. Find a support system that understands and will listen, and work on your emotional recovery through the use of sharing, journal-writing, bonding with your child, reading about emotional recovery from childbirth, or even therapy with a counselor that specializes in birth issues. Remember that it may take months or years to recover emotionally; recovery doesn't have to take place overnight or even right away, but it shouldn't be neglected either. Childbirth is one of the defining moments of many women's lives; a difficult pregnancy or birth experience can have a long-lasting impact on a woman's emotional life. Don't ignore the issue; be proactive about healing.
Even though your baby has been delivered, you may not be quite done with glucose testing yet. Although nearly all women with gd get rid of it after the birth when the placenta is delivered, a very few do not (they probably had borderline or undiagnosed diabetes before the pregnancy). For this reason, another glucose tolerance test (GTT) is often recommended about 6 weeks or so after the birth. This time, however, the glucose load is 75g instead of the 100g load you took during the pregnancy (100g is a special load, used only in pregnancy; 75g is the standard load for non-pregnant diabetes testing). The test usually lasts about 2 hours (some sources say 3 but 2 is more standard) and if any of your results go over 200 mg/dl or your fasting level is over 126 mg/dl (the old guideline was 140), you are diagnosed with type II diabetes (NIDDM).
You will need to discuss whether you should take this 6-week follow-up test with your doctor. Research differs on who should take this follow-up test or whether it should be part of routine care. Many diabetes centers advocate that every woman with gd take the test, while some researchers advocate that only women who needed insulin, had poor control (any 2 hour post-prandial over 150 mg/dl), or who had initial 1 hour test results > 200 take the test. (For example, in one study, 100% of women who needed 100 units or more of insulin failed the post-partum test and were diagnosed with diabetes. However, it's very unusual for gd moms to need that amount of insulin in pregnancy.) Most gd moms probably will pass this subsequent test so it may be an unjustified expense, but in view of the risks of undiscovered diabetes, it's probably smart to rule out continuing diabetes and take this test anyhow. If needed, the test can be delayed a bit beyond the usual 6 week recommendation, as long as it's done shortly thereafter.
Not every doctor follows the 75 g post-partum GTT recommended protocol. Some doctors give no test at all, while other doctors will use a fasting bG test instead. Again, the criticism of a one-time fasting test is that it only provides a one-time snapshot of bG levels and can be affected by things such as illness, stress etc., and that the fasting levels may be normal yet the post-meal levels clearly indicative of diabetes, which would be missed on a fasting-only test. The good news is that when not pregnant, the acceptable fasting levels are much more flexible. In pregnancy, fasting levels were generally supposed to be between 70-100 or so, while outside of pregnancy they can be more variable, though most non-diabetics normally fall into that 70-100 range anyhow. The bad news is that they are not likely to be so high when not pregnant, since the placenta is gone! But really, that's good news, if you think about it.
The old fasting cutoff for diagnosing type II diabetes used to be 140 mg/dl, but this is now newly revised down to 126. If you have two fasting numbers over 126, you are considered to have type II diabetes. Any fasting readings >110 mg/dl are considered in the range of "Impaired Glucose Tolerance" (IGT), which is a kind of borderline diabetic state. Some doctors would recommend prophylactic drug intervention at that level, while others would only recommend increased attention to diet, exercise, and weight control (more on that in another section!). But if you fall within the IGT range, you should plan on formally re-testing your bG levels every 6-12 months at least. Although some people with IGT never progress on to diabetes, chances are that you will develop Type II diabetes sooner rather than later, and remember, the sooner you treat it, the less likely you are to have big, life-threatening complications.
Keep your blood glucose monitor and use it every so often to check your bG numbers informally, too. Because women who have had gd are at a strongly increased risk for developing type II diabetes (NIDDM), it is important to periodically be sure NIDDM is not developing. How often you should check is up to you, but women who had a difficult time controlling their bG numbers in pregnancy and/or who needed insulin should probably be especially vigilant about checking every few months. Sometimes gd will go away after birth but NIDDM will show in these women within the next few years, so it's best to be proactive about checking. For other women whose cases were borderline and easily controlled by diet alone, home monitoring a few times a year or so is probably enough. But it's important to realize that home monitoring is not enough, just a good first step.
All women who have had gd should have follow-up glucose testing every year, either through the 75g glucose test or in a fasting blood draw (doctors disagree which form should be used each year; just be sure to use one!). This yearly testing is very important! Sometimes doctors are lax about doing these tests and you may need to remind them, but please don't ignore this. It's hard to believe sometimes, but in some ways, gd can be a real blessing. Its main benefit is that it is an 'early warning system'; you know that you are significantly more at risk for type II diabetes in the future. Knowing this can potentially help you prevent a lot of problems by catching its development early.
Much of the damage that diabetes does to your heart, kidneys, eyes, nerves, and blood vessels occurs while you have the disease silently, before it is diagnosed. This can go on for a long time because diabetes has no symptoms at first. So if you develop type II diabetes at some point years down the road, you won't know it at first unless you are testing regularly, and so the damage can accumulate. Yearly formal testing (or more often informally on your own meter) can prevent this delayed diagnosis and prevent so much of the damage that diabetes can cause. You want to be around to help raise your child long-term, so you really want to be careful to monitor yourself each year or more. Catching the disease early often prevents the terrible toll that years of hyperglycemia can take on the body. GET TESTED REGULARLY!
In addition, some research shows that blood pressure and blood lipid levels (cholesterol, triglycerides, etc.) in the gd woman can be problematic or start to occur a few years after a gd pregnancy (about 5 years in one study). This combination of problems with blood sugar, blood pressure, blood lipids, and insulin resistance is called "Syndrome X" and tends to be associated with type II diabetes and a number of possible problems down the road. It is very important to check your blood pressure regularly, and to also check your blood lipids at regular intervals for the rest of your life. Don't just accept a total cholesterol count; ask for a complete panel that covers triglycerides, high-density lipoproteins, and low-density lipoproteins (some researchers also feel that very-low-density lipoproteins should be checked too). You need all of these in order to get a more complete picture of your health, and insurances may be more willing to pay for a complete panel because of your past history of gd. In particular, pay attention if your triglycerides are elevated and/or your HDL (good cholesterol) is low, a typical pattern for Syndrome X. Women with PolyCystic Ovarian Syndrome tend to be especially prone to Syndrome X and should plan to be tested religiously. In addition, women who are using birth control pills of any kind should pay particularly close attention to their lipid levels and should probably be tested even more often, according to some sources. Another test that might be valuable is the Glycosylated Hemoglobin test (HbA1c), which measures your average blood sugar over about 2 months or so. This test is better for evaluating overall longer-term control than the fasting or glucose tolerance tests, and may be especially appropriate if considering another pregnancy at some point.
Again, don't panic yourself into a self-fulfilling prophecy in your health. Some women who have had gd never get diabetes, and your cholesterol, blood pressure, and blood sugar may remain just fine for the rest of your life, especially if you take proactive health measures. There is a fine line to be drawn between being vigilant (just in case) and creating a self-fulfilling health prophecy and a feeling of doom that decreases your quality of life. Be proactive; test frequently, exercise daily, and practice good nutrition, but don't overreact or underreact. Try to find the level of response that is sensible under your circumstances.
Naylor, CD et al. Cesarean Delivery in Relation to Birth Weight and Gestational Glucose Tolerance: Pathophysiology or Practice Style? Journal of the American Medical Association. 275(15):1165-70. April 17, 1996.
Landmark study that showed clearly that cesarean rates are higher in gd, regardless of reduction of other risk factors, and that physician management style is probably a factor. "Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment...the diagnosis of GDM itself shifts obstetrical practice style toward cesarean delivery...without measures to limit interventions for women with GDM coming to term, conventional care may lead to needlessly high cesarean delivery rates in this population."
Metzger, BE. Treatment of Mild Gestational Diabetes: Is It Time for a Controlled Clinical Trial? Editorial in Diabetes Care. 11(10):813-16. Nov/Dec 1988.
Reviews a number of studies where intensive insulin therapy has been used and finds that "insulin therapy has not always been more successful than dietary treatment, and corresponding improvements in obstetrical outcomes and reductions in neonatal morbidities have not been found to be consistent." In some studies, intensive insulin use reduced the c-section rate, while in others it either had no effect or actually increased the c-section rate. Calls for a large-scale, multicenter controlled clinical trial with a large number of subjects and rigidly defined protocols.
Meyers-Seifer, C. and Vohr, B. Lipid Levels in Former Gestational Diabetic Mothers. Diabetes Care. 19(12):1351-6. December 1996.
Found that "at 5-6 years postpartum, former gestational diabetic mothers demonstrate changes in lipid levels that differ from control mothers and that specific lipids correlate with cardiovascular risk factors." In particular, the study found increased triglyceride levels, total cholesterol levels, and LDL cholesterol levels in gd mothers, as well as increased glucose levels and systolic blood pressure. However, the abnormal levels were not related directly to fasting glucose levels during pregnancy or need for insulin therapy. Study notes that underlying inherited genetic predisposition to dyslipidemia may be a factor, as well as lifestyle differences such as diet and exercise status, and that the role of these other factors needs to be investigated more thoroughly. .
Kjos, SL et al. The Effect of Lactation on Glucose and Lipid Metabolism in Women with Recent Gestational Diabetes. Obstetrics and Gynecology. 82(3):451-5. September 1993.
Landmark study that shows that even after only 4-12 weeks of breastfeeding, gd moms that were bfing had lower fasting glucose and better HDL cholesterol levels than gd mom who did not bf. Also found that women who did not bf developed early postpartum diabetes at *twice* the rate of those who did bf, both in the diet-treated group and the group that needed insulin in pregnancy. "Lactation, even for a short duration, has a beneficial effect on glucose and lipid metabolism in women with gestational diabetes. Breast-feeding may offer a practical, low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes." And this studied ONLY 4-12 weeks of breastfeeding.
Pettit, DJ et al. Breastfeeding and Incidence of Non-Insulin-Dependent Diabetes Mellitus in Pima Indians. Lancet. July 19, 1997. 350(9072):166-168.
Examined the association between NIDDM and bfing in a population with a high prevalence of NIDDM. Studied the effects of infant feeding methods (for the first 2 months only). Those who had formula only had somewhat higher weights than those who had been partially or fully breastfed. Those who had been exclusively bfed for 2 months had significantly lower rates of NIDDM in all age-groups. "The odds ratio for NIDDM in exclusively breastfed people, compared with those exclusively bottlefed, was .41" (less than half). "Exclusive breastfeeding for the first 2 months of life is associated with a significantly lower rate of NIDDM in Pima Indians." The weaknesses of the study is that it is done in a population known for its ultrahigh rates of diabetes; it is unknown whether these findings would apply to other groups. Also, the number of people exclusively bfed for at least 2 months was not extremely high (144/720, about 20%) which weakens the power of the conclusions. However, it should also be noted that the study only examined those exclusively bfed for *2* months, which may show a lower overall effect than if infants exclusively bfed much longer were compared. [The American Academy of Pediatrics now recommends that infants be exclusively breastfed for at *least* one year, and longer if desired.]
Cordero, L et al. Management of Infants of Diabetic Mothers. Arch Pediatr Adolesc Med. March 1998. 152(3):249-254.
Examined the clinical outcome of infants born to mothers with gd and mothers with pre-existing type one diabetes. Experimented with routine care and normal feedings for these babies (vs. the usual hospital policy of automatic admission to the NICU for observation, testing, and supplementation). Found that most gd babies assigned to routine care did fine, but that breastfed babies had fewer routine care failures that resulted in the baby having to be admitted to the NICU. States that "breastfeeding among women with GDM and IDDM should be encouraged" but does note that many of the routine policies in the past for babies of diabetic mothers (extended admission to the NICU, lapse time to the first breastfeeding, lack of breastpumps and proactive encouragement and assistance) has made bfing rates lower. Actually brags about its 37% rate of exclusively or partially breastfed infants as a satisfactory measure of its 'success'! [Seems like if its lactation program and proactive encouragement were really satisfactory, it ought to have a much higher rate than 37%. Demonstrates that if this is considered high, bfing rates among diabetics must have been particularly pitiful in the past and attests to the many obstacles some diabetic mothers can face.]
Yang, JQ et al. Breastfeeding in Reducing Regular Insulin Requirement in Postpartum for Insulin-Dependent Diabetes Mellitus and Gestational Diabetes Mellitus. Chung Hua Fu Chan Ko Tsa Chih. March 1994. 29(3):135-137.
Looked at the insulin requirement in IDDM and gd moms immediately post-partum. Found a significant decrease of regular insulin (RI) requirement among breastfeeding mothers overall. Among gd mothers who breastfed, insulin requirements disappeared almost immediately, while those that did not breastfeed often required further insulin for 4-7 days postpartum. However, the sample used is extremely small and limits the power of the study. The authors concluded, "BF can reduce the RI requirement of IDDM and GDM mothers in the postpartum period. It is thought that more energy is needed in the process of producing milk, and serum glucose is the main substance for lactose synthesis, thus blood glucose level of BF mother is decreased, and so is the RI requirement. Therefore, mothers with diabetes mellitus are encouraged to breast feed their babies."
Wallensteen, M et al. Acute C-Peptide, Insulin, and Branched Chain Amino Acid Response to Feeding in Formula and Breast Fed Infants. Acta Paediatr Scand. February 1991. 80(2):143-148.
Very technical article detailing c-peptides, branched chain amino acids, and fasting and post-meal bG response in both breastfed and formula-fed infants (small sample). The authors summarize at the end, "these results confirm that in formula-fed infants the insulin response to a meal is enhanced compared to that in breast-fed infants. The finding of similar blood glucose values in the two groups may also indicate an insulin resistance in the formula-fed infants following a meal." In other words, f-fed infants produced more insulin in response to feeding than bfed infants did, yet their blood sugar was the same, implying that insulin resistance was occurring. In insulin resistance, greater amounts of insulin must be produced in order to provide energy to the cells; as resistance increases, more and more insulin must be produced and eventually the pancreas is overwhelmed (if kmom understands correctly).
Kramer, MS. Do Breastfeeding and Delayed Introduction of Solid Foods Protect Against Subsequent Obesity? Journal of Pediatrics. June 1981. 98(6):883-887.
Previous studies examining whether breastfeeding was protective against later obesity tended to find mixed results. This study faults previous studies for methodologic flaws (Type II error, confounding variables, and non-blinding) and conducted its own case-control study of 1172 adolescents. Raw data revealed a significantly elevated risk in 'overweight' subjects of not being breastfed. Delaying solid foods was found to be irrelevant. "We conclude that breast-feeding does protect against later obesity and attribute the conflicting results of previous studies to insufficient attention to methodologic standards."
Kramer, MS et al. Determinants of Weight and Adiposity in the First Year of Life. Journal of Pediatrics. January, 1985. 106(1):10-14.
Examined 462 full-term healthy infants in the first year of life. Examined the roles of various factors in 'adiposity' in the first year. Found that birth weight, duration of bfing, gender, etc. did influence BMI somewhat, though "the ability to preduct which babies will be heavy or obese during the first year is limited" [and Kmom doubts the value of such a task]. However, it did find that even after adjusting for confounding factors, breastfeeding did offer some protective effect against 'obesity'.
Strbak, V et al. Late Effects of Breast-Feeding and Early Weaning: Seven-Year Prospective Study in Children. Endocr Regul. June 1991. 25(1-2):53-57.
"The effect of breastfeeding on some clinical and thyroid function parameters was studied in a prospective longitudinal study from birth up to 7 years of age. At the ages 1-7 years, the obesity rates observed in children breast-fed for less than 3 months were substantially higher than in children who had been breast-fed over longer intervals." [Notes other findings but this is the relevant one here.]
Willis, CE and V. Livingstone. Infant Insufficient Milk Syndrome Associated with Maternal Postpartum Hemorrhage. Journal of Human Lactation. June 1995. 11(2):123-126.
Examines a possible association between insufficient milk syndrome and maternal postpartum hemorrhage. 10 consecutive cases associated with hemorrhage were examined; all of the babies were 'failing to thrive'. 6 of the 10 mothers experienced a significant drop in hemoglobin, and 2 of the 10 experienced very large drops in blood pressure at times (can be a cause of fainting). 5 infants experienced dehydration and elevated sodium levels. "These data serve to heighten awareness of insufficient milk syndrome as a potential consequence of postpartum hemorrhage. Early postpartum review of all breastfeeding mothers and infants is strongly encouraged."
Laufer, AB. Breastfeeding. Toward Resolution of the Unsatisfying Birth Experience. Journal of Nurse-Midwifery. January 1990. 35(1):42-45.
"The act of birth and the way it is managed have great meaning for many women. What may appear to professionals as a routine or remarkable delivery may be perceived by the mother as humiliating, mutilating, or dehumanizing. If the mother has an extremely negative perception of her birth experience, she will suffer a loss of self-esteem, and it is more likely that she will have trouble taking on the maternal role. A successful breastfeeding experience builds up a mothers' confidence and self esteem and facilitates acquisition of the maternal role."
Blomquist, HK, et al. Supplementary Feeding in the Maternity Ward Shortens the Duration of Breast Feeding. Acta Paediatr. November 1994. 83(11):1122-1126.
Compared the breastfeeding rate at 3 months postpartum for 521 babies born in a certain maternity unit. Analyzed a number of factors, including supplementary feedings (mother's milk, donor milk, or formula), to see how they related to 'long-term' breastfeeding rates at 3 months. Using a multiple logistic regression analysis, found that infants given a supplementary feeding had 4x the risk of not being breastfed at 3 months. Other risks also included maternal age <25 years, maternal smoking, and an initial weight loss of 10% or more (who would be likely to be supplemented). "Thus the administration of supplementary donor's milk or formula during the early neonatal period was associated with an increased risk of a short duration for breast feeding, even after adjustment for a number of potential confounders."
Perez-Escamilla, R et al. The Association Between Cesarean Delivery and Breast-Feeding Outcomes among Mexican Women. Am J Public Health. June 1996. 86(6):832-836.
This study examined the impact of cesarean delivery on the initiation and duration of breastfeeding among 2517 Mexican women. Multivariate Logistic Regression was used to determine the odds ratio of cesarean mothers not initiating breastfeeding (odds ratio=.64) or for breastfeeding less than one month (odds ratio=.58). If c/s mothers were able to successfully initiate bfing and nurse for at least a month, a c-section delivery was not found to be related to the overall duration of bfing. C-section was found to be a very significant factor in impacting breastfeeding rates. "It is desirable to provide additional breast-feeding support during the early postpartum period to women who deliver via cesarean sections."
Kjos, SL. Contraception in Diabetic Women. Obstetrics and Gynecology Clinics of North America. 23(1): 243-258. March 1996.
Excellent overview of the concerns and considerations for contraception in diabetic women. Covers women with pre-existing diabetes before pregnancy as well as women who had gestational diabetes but does not lump them together for consideration. Has one brief mention only of breastfeeding considerations when prescribing oral contraceptives; certainly needs to cover more thoroughly the potential effects on milk supply and concerns about hormonal influence on infants. However, this is certainly not an unusual omission in this type of article. A very valuable resource in spite of this.
Kjos, SL et al. Contraception and the Risk of Type 2 Diabetes Mellitus in Latina Women with Prior Gestational Diabetes Mellitus. Journal of the American Medical Association. August 12, 1998. 280:533-538. Available for viewing at www.ama-assn.org/special/contra/library/readroom/joc72148.htm
Most recent research on the use of the progestin-only minipill and its relationship to the subsequent development of full-blown diabetes. Found that mini-pill users had nearly triple the risk of developing subsequent diabetes, while the standard low-dose combination pill seemed to be safe. However, the study concentrated mostly on Hispanic women, who have a much higher rate of development of diabetes anyhow, and many of the participants were also obese, which could affect the results as well. Although this is the first *large-scale* study to look at the effects of oral contraceptives on diabetes, the authors acknowledge that it's not clear how the results should be applied to other ethnic groups.
Engelking, Cynthia and Judith Page-Lieberman. Maternal Diabetes and Diabetes in Young Children: Their Relationship to Breastfeeding. Lactation Consultant Series, La Leche League International. Avery Publishing Group, Garden City Park, NY. 1986. Available from www.lalecheleague.org.
Excellent review of the concerns of a diabetic pregnancy and its impact on breastfeeding practices. Good overview of the possible complications of diabetic pregnancy, though more relevant to type I pregnancies than gd. Covers type I, II, and GD pregnancies, as well as development of type I diabetes in young children who might still be breastfeeding. Written in 1986 so its information is a bit dated on gd, but still a valuable resource.
Mohrbacher, Nancy and Julie Stock. The Breastfeeding Answer Book. La Leche League International. 1997 Revised Edition. Available from www.lalecheleague.org.
The ULTIMATE reference for up-to-date information about breastfeeding and medical issues. Extensively referenced and researched. Very expensive book to purchase for yourself but many local LLL chapters will have this book available in their lending libraries, or one of the Leaders will.
Asselin, BL and RA Lawrence. Maternal Disease as a Consideration in Lactation Management. Clinics in Perinatology. 14(1):71-87. March 1987.
Treatise for OBs, perinatologists, pediatricians, and internists on how to handle lactation issues in women with chronic diseases such as diabetes (mostly type I), severe asthma, kidney disease, and chronic hypertension. Written by 2 doctors/medical school professors with great expertise in lactation issues; excellent resource for the medical professional. Most lay readers will find it a bit dense for their purposes, but a few may find it useful for ideas to share with their health provider about how to preserve breastfeeding in the face of chronic maternal disease.
American Diabetes Association Position Statement: Gestational Diabetes Mellitus. Diabetes Care. Volume 21: Supplement 1, 1998. http://www.diabetes.org/diabetescare/supplement198/s60.htm
Official 1998 position statement on the definition, detection, diagnosis, and therapeutic strategies for gd. However, "Currently there is a committee considering a major revision of this position statement based on the 4th International Workshop on Gestational Diabetes Mellitus."
Metzger, BE et al. Summary and Recommendations of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. August 1998. Volume 21: Supplement 2. Can be found at the following URL, http://www.diabetes.org/diabetescare/supplement298/B161.htm
New recommendations for care from the Fourth International Workshop on GD. Very conservative, extremely interventive protocols are being endorsed now. The above URL contains a summary of overall recommendations; go to the index page to find all the other articles that came out of this conference. The entire issue of this Diabetes Care Supplement is devoted to the topic of GD.
Carr, DB and Gabbe, S. Gestational Diabetes: Detection, Management, and Implications. Clinical Diabetes. 16(1):4-24, 1998 Jan-Feb. http://www.diabetes.org/clinicaldiabetes/v16n1j-f98/pg4.htm
Outstanding article summarizing gd testing, management, and even some of the controversies involved in gd, though from a traditional medical approach. Excellent overview, but may be too technical for beginners unfamiliar with some of the terminology and issues in gd. Those more familiar with gd terms and issues will find it invaluable, and beginners will want to return to it when their understanding increases.
Stephenson, M.J. Gestational Diabetes Mellitus. Canadian Family Physician. April 1993. 39:745-8.
A must-read article for those serious about understanding gd treatment options. Covers fairly both philosophies of treatment, both the maximum and minimum schools of management. An excellent overview of the controversies. This should be one of the first articles read about gd.
Diabetes and Pregnancy, ACOG Technical Bulletin (An Educational Aid to Obstetrician-Gynecologists), #200--Decemeber 1994.
The definitive summary from the American College of Obstetricians and Gynecologists; it covers pre-existing diabetes in pregnancy as well as gestational diabetes. Technical but still readable. This is the 'bible' many doctors rely on for advice, and represents the current standard of care in the field. A must-read for those seriously interested in the subject.
Jovanovic-Peterson, Lois, M.D. with Morton B. Stone. Managing Your Gestational Diabetes. Minneapolis: Chronimed Publishing, 1994. To order, write P.O. Box 59032, Minneapolis, MN 55459-9686, or call 1-800-848-2793.
A good introduction to gd issues by one of the leading researchers in the field, who also happens to be diabetic (Type I) and a mother herself. Be aware her treatment guidelines in this book are quite conservative and not all providers use the same guidelines. Her writings also contain some patronizing and fat-phobic statements (fat people "live to eat rather than eat to live"). But she is an excellent introduction to the conservative approach to gd. She happens to be a very prolific writer in the field, so she tends to dominate the available published material on gd. Many more articles and books are available under her name.
Gestational Diabetes: What to Expect, The American Diabetes Association, Inc. Alexandria, Virginia: American Diabetes Association, 1992. To order, write to the ADA, 1970 Chain Bridge Road, McLean, VA 22109-0592, or call 1-800-232-3472.
The standard intro to the subject, written by the leading authorities on diabetes. A good, easy-to-read summary for those not desiring a great deal of detail. It is, of course, the standard medical approach to gd and does not contain any discussion of the controversies involved in gd. Definitely read this text as one of your first introductions to gd, while also keeping in mind that alternative views do exist.
Goer, Henci. Obstetric Myths vs. Research Realities. Westport, Connecticut: Bergin and Garvey, 1995. Can be ordered online from http://www.efn.org/~djz/birth/obmyth/. A shorter, somewhat different version of the gd chapter appears online at the Midwife archives at FensEnde.com. The URL is www.fensende.com/Users/~swnymph/Midwife/gdhgoer.html.
This excellent book reviews common obstetrical practices and analyzes which practices are truly justified by medical research. One chapter in the book is devoted to Gestational Diabetes, where she examines the history of its discovery, treatment, and variations in protocols. She extensively reviews the medical research available on gd and concludes that many common gd protocols are questionable because they do not sufficiently alter outcome but did increase the incidence of cesarean sections and resulting complications. She is one of the strongest voices critical of the assumptions of the traditional medical view of gd and backs up her opinions with research citations. She sometimes engages in rhetoric and should be less dismissive of research that shows some success with gd intervention, and she does exhibit some size prejudice in her writings. Still, Kmom would highly recommend reading her analysis of the research available to get an alternative view of gd, remembering this is another viewpoint to consider and weigh, and being aware of her assumptions about size and weight loss. A must-read.
Stephenson, M.J. Screening for Gestational Diabetes Mellitus: A Critical Review. The Journal of Family Practice. 37(3):277-83, 1993.
A review critical of the practice of universal screening for gd and the research literature justifying it. Some of the criticisms are a bit picky, but flaws in methodological design are a real issue for gd research so far since so much research is contradictory. For those wanting a more in-depth look.
Jackson, EA, et al. Management of Gestational Diabetes by Family Physicians and Obstetricians. The Journal of Family Practice. 43(4):383-8. Oct. 1996.
This study was conducted to see if there were differences in management of women with gd by family practitioners vs. OBs. Family physicians used less insulin and less drugs for premature labor, and had a much lower c-section rate (11% FPs, 33% OBs), yet the fetal outcome was similar (no significant differences in neonatal birthweight or problems).
O'Brien, ME and Gilson, G. Detection and Management of Gestational Diabetes in an Out-of-Hospital Birth Center. Journal of Nurse-Midwifery. 32(2):79-84. March/April, 1987.
Describes a pilot program to treat mild gestational diabetics in an out-of-hospital birth center. Treatment was by nurse-midwives in consultation with physician consultants (severe cases were transferred to the OB). The population served was 95% Hispanic; the incidence of gd was 10%. The c-section rate for the clients treated by midwives was 9%; if the clients transferred to OB care who then had c-sections were also included in their total, the c-section rate was 11%. It is important to note that this rate was MUCH lower than the c-section rates reported by many other studies, which on average range between 20% and 35%, but in some studies have reached even higher.
Persilly, CA. Relationships Between the Perceived Impact of Gestational Diabetes Mellitus and Treatment Adherence. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 25(7):601-7. Sept 1996.
One of the few studies to look at the impact of gd diagnosis on stress levels of the gd mother, although the primary focus of this study is how the perceived impact of gd on the mother's life affects her adherence to prescribed treatment protocols (it tended to lower the adherence). Speculates that additional counseling and availability of regular easy access to an expert about gd questions may help improve compliance and stress levels.
Spirito, A et al. Psychological Impact of the Diagnosis of Gestational Diabetes. Obstetrics and Gynecology. April 1989. 73(4):562-566.
The psychological impact of a gd diagnosis was examined in 68 pregnant women. No differences were found between women with gd and 50 non-diabetic pregnant controls. Insulin did not have an adverse affect on the emotional status of women with gd. "The results suggest that the majority of pregnant women adapt readily to the unexpected diagnosis of gestational diabetes." It should be noted that at least one of the authors is a noted proponent of gd diagnosis and aggressive treatment; some critics might feel that the study was not truly objective and was set up in such a way to unconsciously achieve the results desired by the authors. However, neither should the study be ignored.
Langer, N. and O. Langer. Emotional Adjustment to Diagnosis and Intensified Treatment of Gestational Diabetes. Obstetrics and Gynecology. September 1994. 84(3):329-334.
Examined 206 women with newly diagnosed gd (compared to 95 nondiabetic controls) to see how intensified treatment affected their emotional status, and to check the relationship between metabolic control and emotional well-being. Found no differences between women with gd (either diet-controlled or insulin-managed) and the nondiabetic controls. "Intensified therapy...does not negatively affect patients' emotional status...Intensified management of newly diagnosed gestational diabetes mellitus does not increase patient anxiety and depression. Moreover, achievement of glycemic control contributes to patient reassurance. Psychological adjustment to the temporary disease state is then equal to that of a nondiabetic individual." Kmom finds this study's sweeping conclusions dubious; only newly diagnosed gd mothers were evaluated and their feelings may change as the reality of diagnosis and care wears on them. Furthermore, it would be relatively easy to bias such a study by overemphasizing or exaggerating the danger to maternal/fetal health and the 'necessity' of intensive treatment. If the mothers felt there was no alternative and their children were in real danger, how else could the mothers feel but grateful and glad to do whatever it took to 'save' their child? Furthermore, one of the authors is another strong proponent of intensive gd treatment. Still, some women don't feel treatment to be that burdensome, and certainly sometimes the risk justifies the potential emotional upset. But to assert that it causes little or no concern is a sweeping conclusion that contradicts the experience of other women, as documented in other studies.
Feig, D.S. et al. Self-Perceived Health Status of Women Three to Five Years After the Diagnosis of Gestational Diabetes: A Survey of Cases and Matched Controls. American Journal of Obstetrics and Gynecology. February 1998. 178(2):386-393.
Study's purpose was to determine the long-term effect on self-perceived health status and the mother's perceptions of her child's health status after a maternal diagnosis of gd. 65 women with gd (and 197 controls) were questioned by mail. After controlling for confounding factors, "cases were more worried about their own health...rated their children as less healthy...and perceived themselves as more likely to have diabetes...The diagnosis of gestational diabetes may lead to long-term changes in how women view their own health status and that of the child born during the affected pregnancy." This study shows a more long-term look at the effects of a gd label on a woman's emotions, and finds the women significantly affected by it. This doesn't have to be all negative---women *are* more at risk for future diabetes after all, and perhaps lifestyle changes resulting from gd diagnosis and education might change their risk. However, this study shows that most gd mothers ARE significantly impacted emotionally from diagnosis.
Kerbel, D et al. Adverse Effects of Screening for Gestational Diabetes: A Prospective Cohort Study in Toronto, Canada. J Med Screen. 1997. 4(3):128-132.
This study examined the adverse effects associated with a false positive SCREENING challenge. (Study does not examine the effects of a gd *diagnosis*, just a false screening result.) "False positive glucose challenge tests are about six times more likely than true positive results in the general population. Pregnant women with false positive GDM screening results experience a significant decline in their perception of their own health. These adverse effects should be taken into account when deciding about a policy of screening all pregnant women for gestational diabetes." Although this study does not examine the effect of diagnosis on emotions, it's telling that a false positive screening test still affected women's emotions.
Javanovic-Peterson, Lois, M.D. The Diagnosis and Management of Gestational Diabetes Mellitus. Clinical Diabetes. pp32-39, March/April 1995.
A very technical journal article covering the basic information in great detail, including lots of information on hormonal influences. Very conservative guidelines are used for deciding when to start a mother on insulin, and 'morbidly obese' patients are recommended to only receive 12 kcal/kg in their diabetic food plan, a level less than half that of average-sized women and which would result in low caloric intakes for pregnancy, which is controversial. Very dense reading, with lots of technical detail, but good for those strongly interested in further detail.
Weller, KA. Diagnosis and Management of Gestational Diabetes. American Family Physician. May 1, 1996. 53(6):2053-7, 2061-2.
A review of gd treatment regimens, though it tends to be much less intervention-oriented than many treatment regimens found in endocrinology and obstetrics literature.
Hod, M et al. Gestational Diabetes: Is It a Clinical Entity? Diabetes Reviews. 3(4):602-613, 1995.
A review of the debate over whether gd is really a problem, with a strongly affirmative conclusion about the dangers of gd and the effectiveness of treatment. Advocates lowering treatment thresholds even further. Has the most astounding list of newborn treatment test protocols Kmom has ever seen listed, and some of the most extensive prenatal treatment protocols for the mother, too. Definitely worth reading for a representation of an extremely traditional view of gd and gd treatment.
Madsen, Lynn. Rebounding From Childbirth: Toward Emotional Recovery. Westport, Connecticut: Bergin and Garvey, 1994. Available from www.amazon.com.
SUPERB book about recovering emotionally from childbirth and pregnancy. A bit flakey and 'New Age' in a few parts, but overall is just excellent. Highly recommended!
Panuthos, Claudia. Transformation Through Childbirth: A Woman's Guide. Westport, Connecticut: Bergin & Garvey, 1984. Available from Cascade Press/Birth and Life Bookstore - (503) 371-4445 or (800) 443-9942.
THE BEST BOOK on emotional preparation for or recovery from birth. Kmom's highest recommendation possible! Unfortunately, out-of-print now, but Cascade Press has a few left. If you can afford it, GET THIS BOOK.
Kippley, Sheila. Breastfeeding and Natural Child Spacing. Available from www.lalecheleague.org.
Kmom has not read this book but has seen some excerpts and references from it. About the use of lactation amenorrhea to space children naturally. Discusses the difference between "ecological" breastfeeding and "cultural" breastfeeding, and how each method affects fertility.
Korte, Diana. The VBAC Companion: The Expectant Mother's Guide to Vaginal Birth After Cesarean. Boston: Harvard Common Press, 1997. Available from www.lalecheleague.org.
THE best book on VBACs around! Superb! Very supportive of mothers considering VBACs, even those who choose not to pursue them. Extremely informative without engaging in excessive rhetoric; excellent questions for choosing a provider to assist in a VBAC and designing a birth plan. Also has a good section with valuable tips on helping to overcome common obstacles to a VBAC, and addresses the emotional issues of c-section and VBAC 'trials of labor' well.
Crawford, Karis and Johanne C. Walters. Natural Childbirth After Cesarean: A Practical Guide. Cambridge, Massachusetts: Blackwell Science, Inc., 1996. Available from www.lalecheleague.org.
Another excellent book about preparing for a VBAC, with an emphasis on the author's own professional expertise and personal experiences. Presents many suggestions for planning a VBAC.
Flamm, Bruce. Birth After Cesarean: The Medical Facts. New York: Simon and Schuster, 1990.
Early book establishing the safety and viability of VBACs, complete with medical references, written by the author of world's largest study on VBAC. Since it was based on information gathered in the 80s and VBACs were considered a fairly risky endeavor then, it tends to be a bit conservative in some of its recommendations (mandatory continuous electronic fetal monitoring, for example) but it is a good overview of VBAC issues from a medical research perspective.
Weschler, Toni. Taking Charge of Your Fertility. Available from www.amazon.com.
EXCELLENT book on understanding your fertility cycles and using this knowledge to either achieve or avoid pregnancy. Promotes the Fertility Awareness Method (FAM), which is similar to Natural Family Planning but without the religious context or required abstinence, for those who do not choose these. Uses the sympto-thermal approach, which involves charting basal body temperatures and observing cervical mucus and position. With adequate education and strict user compliance, the failure rate is quite small and comparable with many of the artificial forms of birth control, though many women conversely use its knowledge of peak fertility times to help achieve pregnancy instead. One of the finest, most useful books Kmom has ever read.
Noble, Elizabeth. Essential Exercises for the Childbearing Year. Fourth Edition. Harwich, Massachusetts: New Life Images, 1995.
Book detailing optimal exercises before, during, and after pregnancy. A valuable resource.
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