Gestational Diabetes: Choice of Provider

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 particular web section 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

 

If you are diagnosed with gd, will you need to change providers? Can you still see a midwife if you have gd? Where should you deliver? What kind of additional care and instruction will you need? What other health professionals might you end up needing? How do you hire a doula? All of these are important questions, and this section is an introduction to the issues involved. However, as in all of gd, there remain controversies about just what is the most beneficial level of care and intervention. The way YOUR provider decides to handle your gd could differ immensely from the way another provider might handle the same case. Again, Kmom urges readers to do their own research and consult their providers and to become a PARTNER in their own care.

 

Providers: Who to See?

Once you are diagnosed with gd, must you change to a high-risk care provider? Must you see an endocrinologist or diabetologist? Or can you still stay with your usual OB or midwife? The answer is------it varies! Most women stay with their usual provider (OB, etc.) while also consulting a Registered Dietician and/or Diabetes Educator, although a few providers do all the treatment themselves, including dietary counseling. Those who need insulin may also consult with an endocrinologist and in some cases, transfer to the care of a high-risk OB. Most patients (except those with a family doctor) will also need a pediatrician (and it's helpful to have this well in advance in a gd pregnancy). In addition, the services of a perinatologist may be needed under certain unusual circumstances. But in most cases, the first and most important question facing a gd mom is: who should be her primary provider now that she has gd?

 

Primary Provider: OB or Midwife or Family Practice Doctor ?

In most cases, a mom with gd remains with her primary provider (OB, family practice doctor, or midwife) unless complications occur. Most gd moms do not need to transfer to the care of a high-risk OB or specialist in diabetic pregnancies unless her gd is especially severe, significant complications occur, or it is thought that her diabetes may have unknowingly pre-existed prior to the pregnancy. Her primary provider may want to consult with a specialist at some point or involve a diabetes education center, but most gd mothers remain in the care of the provider who had been caring for them up to the point that gd was diagnosed.

Some women are told that if they get gd, they cannot continue to see a midwife, but must be in the care of an obstetrician. This is incorrect. It depends on the circumstances of the gd and on the philosophy of the midwife. Some will immediately refer you to the care of an OB if you develop gd, but many more will continue to care for you themselves, or co-manage your case with an obstetrician. If at some point you need insulin, most midwives will transfer your care to an OB, but a few will continue to co-manage your care with the OB. The same holds true for most family practice physicians; most will continue to manage your care themselves as long as the condition remains mild and easily controlled with dietary means alone, but most will transfer your care to an OB or at least consult with an OB or endocrinologist if you need insulin or experience other complications (like high blood pressure or pre-term labor).

The advantage of having an OB is that they are specially trained to deal with the specifics of abnormal pregnancy, whereas midwives and family doctors are more trained in normal pregnancies. An OB may also be more up-to-date on the latest research on gd and its treatment, though many midwives and family doctors do keep up with research literature too. Furthermore, should problems develop, a woman would be less likely to need to switch providers if she already is with an OB, something that is very important to some women. And OBs are more likely to employ procedures such as prophylactic (preventative use of) insulin in order to reduce macrosomia, and some women are more interested in pursuing this kind of treatment. They are also more likely to use more extensive prenatal testing, something some women just feel more safe with, although the proper amount of prenatal testing is still being debated (see below). If you feel this way, perhaps you would be most comfortable with an OB.

The advantage of using a nurse-midwife or family physician in a gd pregnancy is that they tend to be much less interventive, using things like insulin, early induction, constant electronic fetal monitoring during labor, and elective c-section much less often. In fact, the c-section rate (elective or otherwise) is sometimes as much as 1/2 or more lower in midwifery or family practices, depending on the study you look at. O'Brien and Gilson (Journal of Nurse-Midwifery, 1987) found a c-section rate for midwives in one gd program of 9% versus a comparable rate of 18% or more for many OBs treating gd in the same time period. [Kmom note: OB c-section rates for gd pregnancies vary from 9% to over 40% or more, though the most common rates seem to average between 21% and 33%; see Hod et al., Diabetes Reviews, 1995.] Even when the c-section rates of the patients who were 'risked out' of midwifery care in this program were added to the total, the O'Brien study still found an overall c-section rate of 11%, much lower than most OB rates for gd. Other possible advantages of using midwives is that they have much lower rates of episiotomy and other invasive techniques, plus midwives also tend to be more supportive and less biased in their treatment of women of size. However, of course, there are a variety of midwives out there, and there are 'bad apples' in any barrel. Selecting a midwife for your care does not guarantee you excellent, unbiased care.

Jackson et al. (Journal of Family Practice, 1996) also found lower c-section rates for family practice doctors vs. OBs in their study (11% vs. 33%), and a lower use of insulin (24% vs. 33%), yet their neonatal outcomes remained similar, including macrosomia rates. This calls into question how effective many interventive procedures commonly used by many OBs really are, and how much of the high c-section rate associated with gd care is really iatrogenic (caused by doctor management choices), although much more research needs to be done on this question. Another advantage of a family practice doctor is that care does not have to be transferred between doctors once the baby is born; a family doctor provides a smooth continuity of care and treatment philosophy for both mother and child before, during, and after pregnancy. This can be a real advantage, considering all the tests for gd newborns that may be considered, and may also be a significant advantage in establishing breastfeeding.

Critics contend that hiring a trained surgeon like an OB to attend normal pregnancies is overkill, and that people trained to do a lot of cutting tend to end up doing a lot of cutting, by intention or unconscious influence. Certainly, OBs tend to have much higher rates of c-sections overall; some of this can be explained by noting that they take more high-risk patients. However, even when only low-risk patients matched for confounding variables are considered, the c-section rates of midwives and family doctors are generally much lower. Even gd pregnancies, which some midwifery journals prefer to call 'near normal' pregnancies, do not Ihave to have an OB unless insulin is needed or there are complications; the way the typical OB treats gd may actually end up making it higher-risk, something noted by a few important studies but conveniently ignored in most ongoing research. On the other hand, some patients are uncomfortable with the tendency of midwives and family doctors to be less interventive and more 'hands-off'; some patients prefer the high-tech approach of extensive prenatal monitoring, multiple ultrasounds, early delivery, etc., finding it more reassuring. And of course, it should be noted that overgeneralization is dangerous; there are many OBs out there that are extremely supportive of natural birth and opposed to routine intervention, and there are many 'medwives' out there who are nearly as interventive as the worst of OBs. Again, it is important that a woman decide which approach and philosophy she is more comfortable with and feel secure in her provider choice, whatever it is. A close match in birthing philosophy and compatible care styles is more important than the actual title of the person she chooses to attend her birth.

 

(Kmom's story: I was told, upon being diagnosed with gd, that I could not be seen by a midwife anymore, nor for any future pregnancies. Because my husband's job was transferred out-of-state at about this time, I interviewed and searched until I found what I thought was the most flexible new OB under the circumstances, but still ended up with an extremely difficult (and in my opinion, probably unnecessary) induction at term, resulting in a very traumatic c-section. In the next pregnancy, I found an OB with somewhat more generous standards of treatment, but I still felt too limited by her restrictions, cut-off in my attempts to find out more information on gd and vbac, plus she seemed to have already decided on an early induction well before I even reached the third trimester. At 7 months, I passed the gd test---yippee!---and switched care to a midwife, only to find that she would have treated me without any qualms if I had just gone to her earlier---vbac candidate, gd risk and all! How I wish I'd begun my pregnancy in her care, instead of blindly believing my previous OB's dictate that only an OB could care for a gd patient.

The midwife was much more flexible in her care, took the time to answer questions more freely, and had fewer restrictions than my OB; I could hardly believe the tremendous difference in caring, respectful treatment between the OBs I'd had previously and the new practice of midwives I was in. It would have been much less stressful to have been under her care the whole time. Even if I had developed gd or even needed insulin in that pregnancy, she would have still co-managed my pregnancy concurrently with her back-up OBs, assuring me the best of both possible worlds, at least in my opinion. It was a wonderful, liberating change. I did still end up with a c-section, even with a midwife, but I had a wonderful, totally natural labor with very few restrictions (VASTLY superior to my previous induced labor experience!), and can rest assured that the c-section this time was due to baby's malpresentation that we could not correct, not due to early induction, artificial labor, unnecessary amniotomy, pushing in poor positions, etc. The c-section this time was a MUCH more humane experience, was far easier to recover from, and although the backup OB we got was very sizist, my midwives helped to fill in the gaps and assure me a caring experience. They also did not interfere with breastfeeding but actively supported it, unlike my previous doctors. They really eased the transition into and out of surgery for me.

Although I remain at risk for gd again in future pregnancies, I have no qualms now about having my pregnancy, with or without gd, handled by a midwife. I feel confident that if my condition became severe, she would either co-manage my care or at least refer me to an OB with more humanitarian treatment standards than many OBs use. In fact, my current plans for my next pregnancy, all things permitting, is to use a practice that combines a midwife's care with my family doctor's care. I love my previous midwives but their practice was too big and I didn't care for the sizist attitudes of their back-up OBs. In this practice, I am assured of having either 1 of 2 people for my delivery instead of taking my chances with any number of providers in the other practice. They only deliver a few people each month so I should get very personalized care, and they have more flexibility in laboring protocols. Nothing in this guarantees that I will have a vbac or non-interventive birth, but I feel that it maximizes my chances, plus I want the freedom and the time during appointments to ask questions without pressure or patronization. I fully plan on a VBAC, but should another c-section become a reality, I feel assured that they and their back-up OB can help me make it as close to a gentle birth experience as possible under the circumstances, even more so than last time. I just feel that, as much as I loved my previous midwives, I just needed a more personal and smaller practice this time, and they understandingly recommended one to me.

Not everyone will be comfortable choosing a midwife or family doctor for their care; some women strongly prefer an OB for their care, which is fine too! Just because Kmom prefers a midwife does not mean one is right for someone else. Each choice has advantages and disadvantages, and Kmom does not mean to imply that good care cannot be obtained from various sources. Women need to feel free to choose the provider that is right for THEM; the point of this section is that there are more choices available than some women are told of. Women should know of ALL of their options so they can choose intelligently.)

 

What If I Want To Switch Health Providers?

What if you are diagnosed with gd, and suddenly your pro-natural birth OB pulls a disappearing act and tells you that you must induce at 38 weeks, must undergo extensive prenatal testing, and may need an elective c-section, despite otherwise reassuring indications? Or what if your midwife tells you that she doesn't plan to treat your gd pregnancy much differently than any other and you feel strongly that you need more testing? Whether to switch providers is a difficult question, but remember that YOU are the health consumer. You have the right to switch care providers at any time during your pregnancy, even right in the middle of delivery if really necessary (and some women have done so). Your doctor or midwife is your paid health consultant and you have the right to dismiss them or find another at any time.

Doing so is not always easy, though. Emotionally, many women are very tied to their pregnancy health practitioners, and some find it very difficult to leave even when the provider is rude or flat-out abusive. Large women in particular often have a hard time leaving providers, even those that are clearly prejudiced and abusive. We have been so trained into being meek and apologetic for our size to providers that we buy into poor treatment or protocols that railroad us straight into c-sections and other interventions. Add in any sort of health question like gd and many larger women are completely afraid to question the dictates of their provider. And of course, many doctors want an unquestioning patient who meekly goes along with any treatment prescribed and are threatened by the thought that patients might find out that their way is not the only way. On the other hand, though, many providers rightly fear that patients will 'go shopping' until they find a provider who will tell them only what they want to hear and perhaps not the full story of risks and benefits. So changing providers is something that must be done with careful thought and caution, yet also trusting in your intuition about a provider.

Some women feel especially tied down once they are diagnosed with gd. But it is very clear that THERE IS NO ONE WAY TO TREAT GD. You may well get completely different recommendations just by going to several different providers. Many OBs contend that an aggressive gd treatment program of prophylactic insulin, hypocaloric diets, intensive prenatal monitoring, early induction and delivery, and intensive postnatal testing provides the best outcomes for baby. However, many other OBs (and many midwives and family doctors) would disagree, contending that the best outcomes for mother and baby come from a more hands-off approach, unless the gd is severe or there are other complications. One of the hardest lessons to learn is that there is very little agreement on what the most optimal course of treatment for gd is. A woman can either blindly trust her provider's care decisions, or get out there and do her own reading and make decisions in concert with her care provider.

Sometimes, though, even informed mothers and care providers are unable to agree on the best treatment protocol, and then the situation becomes really difficult. After all, the mother thinks, who am I to be questioning the medical experts who have studied this closely? And yet, the 'experts' have been wrong many times in the past (DES, low salt and diuretics for pre-eclampsia, routine episiotomy, etc. etc.) and care protocols do change over time. And even among themselves, the experts cannot agree on uniform treatment protocols or even whether most women should be tested for gd. Had the woman randomly gone to a different provider, she might well have received completely different care instructions. Blind trust in your provider's wisdom can only go so far. Therefore, some women may find themselves in the extremely uncomfortable position of considering changing care providers.

Women who feel uncomfortable with the level of intervention (high or low) dictated by their provider have every right to investigate other care options. Care must be taken not to live in a world of denial, acting as if the gd diagnosis does not have potential for problems, but neither should a woman be a sheep and meekly accept every intervention (or non-intervention) her provider dictates. Care recommendations WILL vary from provider to provider. It is up to the woman to research the issues, listen carefully to her providers' opinions, and help make care decisions. If her provider will not permit her to share in these decisions or if a suitable compromise cannot be reached, then she should switch providers. Some women will end up switching to less-interventive providers, but some women may feel better with providers who use more intervention. Either scenario for switching is potentially legitimate, and the key is that each woman must help decide the level of care appropriate for her case.

It is a deeply emotional and scary thing to consider switching providers in the middle of a pregnancy, especially the farther you get towards delivery. Many women feel guilty for even considering 'abandoning' their care provider (especially if they are 'nice'), even though they may have grave reservations about the restrictions their doctors tell them they must have. Many feel that though they want a mostly non-interventive birth, all their choices have been taken away simply because they have gd, but they are not a medical professional so who are they to question what their doctor deems necessary? We have been trained to think of our doctors as God, and the emotional dilemna when we begin to question our care can be very intense.

Again, what is 'necessary' for gd DIFFERS from one provider to the next, and a woman can and should be involved in her own care decisions. If possible, it's best to try and negotiate some kind of care compromise with your current provider first, but some providers are simply too inflexible and will not bend at all. Other providers will tell you what you want to hear but later will suddenly pull the rug out from under you. Listen to your intuition. If your inner sense is sending you reservations about what your doctor recommends, heed it! If there is no compromising or if you think your doctor is saying things only to placate you but will rescind them later, SWITCH PROVIDERS. Be careful to listen to see if their concerns are valid, of course, but be aware that many other providers may choose to treat the same concern differently. Often an excellent plan is to seek a second or even third opinion, but be sure to see someone outside the practice, or better yet, someone with a different point of view, like a nurse-midwife or family doctor, in order to get a full spectrum of perspectives. Experts routinely recommend getting second and third opinions for other medical concerns, but somehow in obstetrics this practice is frowned upon, a view that may be rooted in unconscious sexism. If you have doubts about your provider or his recommendations, Kmom strongly recommends that you get a second and third opinion. Once you have a variety of viewpoints to consider, you can choose more wisely.

When considering leaving one provider, be sure that you have continuity of care as you switch. This is very important! Depending on the personality of your provider, you can be upfront with them about your reservations and tell them you are seeking a second opinion or you can continue your prenatal care regime with them while you explore other care possibilities and THEN tell them if you decide to switch. Some providers are totally understanding at the idea of a second opinion, but others will be very threatened. Some will punish you by treating you more roughly or rudely if they find out you were considering switching. You have to use your own best judgment as to the best approach in your case.

Some women have found luck with continuing their prenatal care with their original OB until they have found a suitable provider to switch to permanently. Then they simply fill out a form with their new provider to request their old medical records, and call the receptionist at their old provider and quickly and calmly inform them that they are switching to a new provider and that the doctor will be receiving the request for records soon. There is no need to offer explanations or talk to the doctor about the decision, but you should notify the old office that you are switching once you have found someone new. It would be a point of courtesy to write a letter to the old provider and tell them why you are switching, but it is not required (or you can do it after your pregnancy is over).

Again, you do NOT have to talk to the old doctor and tell him yourself; you can simply tell the receptionist and leave a message or you can write it in a letter. Most people find it too intimidating to do in person, but don't let that keep you from switching if you feel it's important. Your doctor may simply take it in his stride (patients switch care all the time) or he may feel quite threatened by it. Some even strike out by being insulting, rude, or telling you that you are "endangering yourself and your baby". This type of doctor has a tremendous ego that cannot take being less than 'dictator-for-life', and they frequently resort to temper tantrums or doomsday predictions despite plenty of evidence of good care outcomes with different protocols. It's best simply to avoid this last type of doctor completely; you owe them no professional courtesy. However, don't anticipate the worst. Many doctors simply take a patient changing provider in their stride and don't take it personally at all. Don't let your anxiety over this issue keep you from getting the best possible care for you.

Finally, since this website overall is aimed at larger women, Kmom urges large gd moms whose providers are size-phobic to SWITCH CARE PROVIDERS TO A NON-SIZIST PROVIDER. There is a real tendency among large women pregnant women (who often feel they should apologize for even daring to have a child at their size) to meekly accept abusive comments and condescending 'care' from their providers, and to never question or dare to think about switching to a different provider. Kmom strongly urges all large pregnant women to DEMAND excellent, respectful, dignified, and non-phobic care from their providers and to use their economic clout and SWITCH if their care is anything less than respectful and fair.

The problem is even more complex for large moms with gd. Many diabetes health professionals are wonderfully supportive, but there IS a strong streak of size prejudice among many in diabetology. Many large gd moms face what could be considered excessive treatment based on their size, though of course, just what is excessive is subject to debate. Discussion in detail on this issue is too complex for this section but will be found in great detail in the websection on GD: Special Issues for Large Women. However, it is Kmom's opinion that many large gd moms are being overtreated and possibly discriminated against on the issues of hypocaloric diets, early induction, elective induction and c-sections for suspected macrosomia, and liberal use of 'prophylactic' insulin especially in obese women. They are also commonly subject to emotional battering to diet stringently post-partum without adequately considering the accompanying risks of this as well.

GD treatment is a very complex and still unclear area even in women of average size. Add to these controversies the issues and assumptions about obesity and pregnancy and you have a recipe for a great disparity of treatment and abuse of large patients. However, this same complexity makes it impossible to also clearly decide what treatment protocols are size-phobic and what are merely sensible precautions. It is an evolving issue and one in which the best protocols have yet to be decided for women of ANY size, but carries particular concern for women of large size. Kmom simply cautions women of size to be very well-informed about gd issues and especially those listed above and then to decide whether their provider's approach is reasonable or not, based on the evidence. If you are not sure about the treatment protocol recommended to you, get a second and third opinion from a variety of other providers, just as you would for other major medical concerns. Simply because ONE provider recommends something does NOT mean that this is the way you MUST do it, and you may find that some providers DO overtreat based on size. Find out your choices, educate yourself carefully, consult providers thoroughly, and then participate in your care decisions. If that means switching to a new provider, then that IS a legitimate option. It is not one to be taken lightly or in denial of the provider's concerns, but in full recognition of the fact that there is not just ONE accepted treatment regimen. Empower yourself and take responsibility. Don't be a victim!

 

Kmom's story: I had to switch care providers in my first pregnancy due to a job transfer, as noted above. My first OB was very nice, but I was beginning to feel reservations when the staff implied that I would need an amnio at 38 weeks to see if the baby's lungs were ready, would induce before term, and post-partum the priority would be to 'get that weight off of you'. They were very put off by my assertion that dieting had only harmed my health in the past and I was not about to start it again and end up even fatter. About this time, my husband was suddenly transferred so I received an abbreviated crash course in gd management from their diabetes center, and had to call in my results long-distance while I interviewed new providers in my new town.

My new OB was extremely nice and personable, and though he was not as flexible as I'd wished, he was the most flexible and personable of the ones I interviewed and I felt I had no other choices because of the gd. While the other OBs wanted to induce me at 38-39 weeks, this doctor would 'let' me go to 40 weeks, but he was rigid that we could go no further. I was a bit disconcerted that he totally dismissed ketones as a concern while my diabetes educators in my old town were very concerned via phone that I'd been having them a lot. (They had me drink milk in the middle of the night which fixed the problem, but my new OB wouldn't have done anything and the ketones would have continued, possibly harming the baby.) These were my first clues that gd is managed very differently by different providers, but I didn't really dwell on it much. I had too many other things to think about and emotionally needed to have my providers think for me.

I was very pleased with my new OB at first...he was so nice! And I was relieved that he was going to 'let' me go to term, unlike my previous OB. But as time went on I was more and more unsettled by the fact that he insisted on inducing right at 40 weeks, even though my cervix was unripe and all my other prenatal tests showed that the baby was fine. He insisted on no eating or drinking during labor, even though I knew from research that the supposed 'dangers' of this were basically bogus. He stripped the membranes around my bag of waters without even asking permission, and was quite rough in some exams at the end (trying to get my labor going), but he didn't tell me what he was doing or why or ask permission. Early into my induction, he broke my bag of waters (without asking--so much for informed consent!), thus increasing my risk for infection and making the baby's posterior positioning set in stone. By this, he virtually assured my c-section. Furthermore, during the c-section, he refused to believe that I was still feeling some sensations and began cutting anyhow, and then told me that he could not give me any more medication until the baby was born. So I passed in and out of consciousness from the pain and horror until my baby was born, then was put under completely and did not get to be with her until many hours after she was born, by which time she had been given formula automatically, against my specified wishes and in spite of normal bG results. We had a terrible time starting up breastfeeding, and my doctors all did things to interfere with this process. All this from my 'nice' physician!

After time and research, I began to discover that not everything I was told was required for gd cases WAS required. I felt betrayed...they told me I had to do it that way or I would endanger my baby! When I became pregnant with my second child, you better believe I chose a NEW doctor! This doctor would 'let' me go till 41 weeks, at least, and she was fine with me hiring a doula, asking permission before performing procedures, etc. She was also very young and very nice, and she was part of an all-woman practice, which I mistakenly assumed would be more progressive. But as time went on, I began having reservations again. She began to treat me as if my blood pressure was bound to go up, simply because I was a large person, even though I have superb blood pressure overall, had no history of high bp in the first pregnancy, and was doing great in the second pregnancy. She was extremely non-commital about what her delivery protocols would be once we got near the end, and it shortly became very clear to me that she planned to induce early simply because she feared a large baby, mostly due to my size (my bG was under excellent control and I was extremely proactive in my nutrition and exercise). Although it was very difficult emotionally, I began exploring other OBs as options, simply because I didn't want to be forced into another induction. My last induction was a horror and I felt it was really unnecessary; I was determined to try to go into labor naturally.

When I finally officially tested negative for gd, I felt able to switch to a nurse-midwife, only to find that I could have switched earlier (as noted above). We discussed the likelihood that I would have another 9 lb. baby, and the risks and benefits of inducing early vs. waiting for natural labor. As long as I understood that either decision presented advantages and disadvantages but was secure in my choices, she was OK with going along with my informed choice. I got my desire---I went into labor naturally, and non-pitocin labor was SO much better!!!!!!!! And I got to labor in a tub of water, walk as desired, switch positions some, etc. It was a great labor. My main reservation was that we only discovered the baby was arrested posterior when it was too late to do anything to change its position and it was too stuck to turn, so we did end with a c-section. However, my midwife went with me, and was my advocate, making sure that my OB took me seriously and gave extra meds to make me completely numb before beginning the surgery.

I was so pleased that I switched care providers----it was very scary to consider doing so at the time, but I was able to labor according to my own wishes and in a much more humane way. It was a much better experience than the first time, MUCH. I still wish my midwife knew more about correcting a posterior presentation proactively, and I wish their practice was smaller, but even so the outcome was far superior than submitting to another induction and all kinds of labor restrictions from the OB. For me, switching care providers to a less interventive approach was the right decision.

There are sometimes women who switch care providers the other way too. Some women with gd go to midwives but want a higher level of prenatal testing and early induction of labor. Some women simply prefer a c-section. I know of some who have switched from midwives to OBs in order to get the level of care they wanted, as well as many more who have switched from interventive providers to less interventive providers. Again, women need to choose the kind of care they are comfortable with, and they need to choose the provider that will help them towards the birth they want and need. This is extremely important, and women need to honor their intuition about these matters.

 

 

Other Possible Health Professionals

Besides your primary care provider (OB, midwife, or family doctor), there are a number of other health professionals you might end up seeing in the course of a gd pregnancy. Exactly who and how many will vary greatly depending on your insurance, the philosophy of your primary provider, the availability of other personnel in your area, and the severity of your gd.

Registered Dietician - Almost certainly, you should be referred to see a registered dietician, one who can design a diabetic food plan (NOT a diet!) to suit your special needs (a few doctors handle this themselves, though sometimes quality instruction is lacking, since few providers are well-trained in nutrition issues). One size does not fit all when it comes to food plans, and so it is important that you see someone who is adept at designing a program that is suitable to your caloric and nutritional needs, yet sensitive to your own personal lifestyle and issues. Also, this person should be available for continued consultation at various points, so you can ask questions or have your plan adjusted as needed later. This can be very important!

Many larger women (including Kmom) are initially strongly dubious about seeing yet another dietician, fearing yet another lecture about losing weight and 'tsk-tsking' over food. (This should not happen, and if it does, you need to tell them off! Do not accept patronizing treatment just because you are large or have gd.) A food plan of about 2100 calories (more or less) will probably be given you (depending on your weight, activity level, and other factors--see the websection on GD: Nutrition Questions). The RD will go over the plan and explain serving sizes, how to count carbohydrates, read labels, and how to adjust your intake if needed (for sick days, etc.). Some dieticians will indeed require that you fill out a food intake diary so that they can analyze it; it is up to you whether you are comfortable with this. It can be useful to do this if you are having troubles with your numbers, or for the RD to see if there's a problem in timing or combination of foods. However, for many large women, this brings up too many negative associations of the 'Food Police', and they have very strong feelings against participating in this. You do NOT have to do this, if you feel strongly about it. Remember that YOU are the consumer, and you can refuse any part of medical treatment that you wish, at any time. It may not always be the best choice, but they cannot force you to participate. Or you can put them off by saying that you will be happy to do a food diary if a problem occurs and you cannot figure out what caused it. It is often possible to negotiate a compromise like this if you are assertive and share your concerns with the staff. On the other hand, don't let previous negative associations with dieticians keep you from getting any help you do need; use your judgment. Pointing out the negative associations many of us have with dieticians and food diaries and such and asking the RD's understanding and flexibility will often enable them to give you better and more empathetic care.

 

(Kmom's story: I was also required to fill out a food diary when first diagnosed with gd. I refused, and do not regret it for a moment, although they might have been able to catch a few misunderstandings I'd had at first about food combinations which caused a few high readings in the beginning. But it was more important to me to not be 'reporting' to the Food Police, and to be trusted to manage my own care. It worked, and I found and worked out the kinks by myself, although others may want to consider utilizing the RD's expertise more quickly. Eventually, I was able to see the RD in both pregnancies as more of an ally, and use her knowledge to answer gd questions my OB did not have time for and to adjust my food plan a bit. With the RD's help, I was also able to work in an occasional treat and more flexibility in the plan for the second pregnancy. If you can develop a good relationship with a RD who is flexible and not judgmental, they can be a great asset to you in your pregnancy, and Kmom strongly attests to their usefulness under these conditions.)

 

Diabetes Educator/Nurse - When you are first diagnosed with gd, many treatment plans call for sending you to a certified diabetes educator, often an RN. She is usually the one to teach you about meters, how to measure your bG, what numbers to aim for, how to measure for ketones, etc. Oftentimes, some programs even require you to call in your bG results weekly for monitoring by an RN or MD, while other programs have you self-report your numbers to your OB or midwife. It's very important to keep an accurate written record of your numbers over the course of the whole pregnancy. Also, be sure to be absolutely truthful in your readings; your provider needs accurate data on which to make treatment decisions. It's very important for your baby's health. Also know that some programs utilize a memory chip in the bG meter and double-check your reported readings against what is stored in your meter's memory. Be honest in your readings--no fudging, regardless of whether your provider double-checks your numbers!

Your diabetes educator is often a valuable ally to your primary provider, and can take time to answer your questions and concerns, or direct you to further research materials. Take advantage of the services they have to offer. Sizist attitudes do tend to run rampant in the diabetes/endocrinology field, but any patronizing treatment should be challenged (YOU are the consumer!). However, these days, more and more diabetes educators are becoming sensitive to treating all people with respect, and mistreatment is less common than it used to be. But if you get a 'lemon', be sure to demand a different educator, one that is more compatible with you and is willing to help you deal with your gd issues without patronization or judgment.

Endocrinologist - If you end up needing insulin, you may need to be referred to an endocrinologist too. Assessing and adjusting insulin dosage is extremely tricky, especially during pregnancy as hormones change and levels need constant adjusting. Insulin dosage is a fine art, and needs a well-trained and knowledgeable hand. Many OBs will manage their patients' insuln dosage themselves, but others prefer to call in the experience of a specialist.

Endocrinologists, as a group, tend to be a bit more conservative and restrictive in their requirements, and many can be quite size-phobic. You may need to be assertive about dignified and respectful treatment, and you may need to speak up about any treatment you perceive to be prejudiced or rude. It may help to bring along an advocate to your appointments who can help bolster you and reinforce your desire for respectful, non-prejudiced care. On the other hand, some women find wonderful endocrinologists who are completely size-friendly, so don't pre-judge! But, regardless, respect your endocrinologist's knowledge and ability to help you determine and adjust your insulin dosages; it is a very tricky process and often benefits from an expert's hand.

High-Risk OB - The course and severity of your gd plus any complications can also dictate whether your care needs to be switched to a specialist. It usually is not necessary to transfer to the care of a high-risk OB when diagnosed with gd, but a few mothers will need this at some point due to the severity of their gd. If your gd develops very early in the pregnancy, proves difficult to control, or if you have threatened pre-term labor/other complications, you may well need a high-risk specialist. This does NOT mean that you will have any complications or a poor outcome; it only means that it would be smart to have someone specially trained in these issues. If you need a high-risk OB, then you will probably also want to deliver in a hospital that has a level III tertiary care Neonatal Intensive Care Unit (NICU). You are not likely to need it, but it's good to have it there, just in case.

Pediatrician - After the baby is born, its care will become the responsibility of the pediatrician (the exception is the family doctor, who usually continues to care for both the baby and the mother after delivery, as noted above). It is important to carefully interview pediatricians well before delivery in gd pregnancies, in case pre-term labor/delivery becomes an issue. It is also important to find a pediatrician who is in tune with your views about postpartum tests and care issues, and who will help and support your breastfeeding efforts knowledgeably and ardently if you plan to nurse.

For example, hypoglycemia is the most common complication in babies of gd pregnancies. All gd babies should have their bG tested after delivery, though it is vital that plasma readings from a lab are used; portable meters and reagent strips are notoriously inaccurate for babies' low levels. Some doctors define hypoglycemia as starting at levels of 40 mg/dl in full-term babies, some use a cutoff of 35 mg/dl, and some use 30 mg/dl (note: numbers are different for pre-term or ill babies). Some doctors are willing to use frequent nursing in borderline hypoglycemia cases before using supplementation or IV treatments, while others mandate supplementation for all gd babies, even normoglycemic ones! So disagreement on proper gd protocols is not limited simply to OBs; there is a huge variation of preferred treatment for issues such as neonatal hypoglycemia, even among pediatricians. Some doctors mandate incredibly huge lists of tests for the gd newborn (Hod et al., Diabetes Reviews, 1995), while others merely use a few simple tests and careful observation. So selecting a pediatrician and agreeing upon the number and types of tests, etc. will be quite important.

Mothers who intend to breastfeed should strongly consider finding a pediatrician who is actively supportive of breastfeeding since gd protocols can interfere with establishment of breastfeeding if allowed to. A pediatrician who has a lactation consultant on staff or available for referrals is often a good choice; also check their training and experience in breastfeeding issues. A recent survey of experienced pediatrians and pediatric residents found that a distressingly high number of them were ignorant of several basic-knowledge breastfeeding issues, and many cited concern over their lack of adequate training in troubleshooting breastfeeding problems (Freed et al., Pediatrics, 1995). In addition, check if they have personal experience with breastfeeding too. A pediatrician who gave up breastfeeding after a month or less (or whose wife did) may only pay lip service to the concept; the 1995 Freed study found that successful personal or family experience in breastfeeding increased their knowledge of and commitment to breastfeeding significantly.

Another factor Kmom considered important was the pediatrician's attitude about larger children. From sheer genetics alone, she knew that her children had a greater chance of being on the heavy side, and she was determined not to have them increase their size artificially through dieting and restriction. She knew she needed a pediatrician who understood that children naturally come in all sizes and that interfering with this can make things worse. She wanted a pediatrician who did not believe in dieting but who did emphasize good nutrition and health prevention for children of all sizes, one who would not nag or berate or make a big deal out of a larger child as long as good nutrition and exercise was present. (Fortunately, she found one!)

But again, these are just a few of many factors to consider in your decision. The important thing is not to leave the decision too late. You want to have enough time to interview several different possibilities so you can select a peditrician who is truly breastfeeding-friendly and not overly interventive simply because of gd, as well as size-friendly. You also want one in place should premature labor become a problem. It's important to realize that most gd moms do NOT experience premature labor and delivery (so don't panic), but that it is a possibility to be prepared for. Choosing a pediatrician well in advance and with great deliberation can be especially important for gd moms.

Perinatologist - If your pregnancy becomes very complicated or pre-term labor becomes a strong threat, you may need a perinatologist too. This is a doctor who specializes in the care of premature or high-risk newborns. It is important to remember that the VAST majority of gd moms do not have any problems, and their babies are usually extremely healthy and normal, or have very minor, transient problems like jaundice or mild hypoglycemia that are usually easy to fix. But it's foolish to pretend that serious complications NEVER happen in gd. Once in a while they do, and if so, a perinatologist can become a tremendous asset to the team.

HINT: Again, if you plan to breastfeed your baby, it is extremely important to emphasize this fact over and over again to your care team, especially your perinatologist. Many of the procedures surrounding a high-risk birth can interfere with breastfeeding, yet no infant needs the protective properties of breastmilk more than a premature or at-risk baby! The milk of the mother of a premature baby has been found to be especially adapted to the particular needs of a premature baby, and preemies fed primarily breastmilk tend to have far less problems in the long run. Yet the difficulties of nursing a preemie, pumping milk, avoiding bottlefeedings and pacifier use, etc. often combine to interfere with the establishment of breastfeeding in the very population that needs it most.

If your baby is born early or if there are complications, you will want to demand the services of a professional lactation consultant (IBCLC) as soon as possible, and you will want to have a hospital-grade double electric pump as soon as possible as well. You will want to discuss your strong desire for alternative feeding options (i.e., finger-feeding, syringes, etc.) instead of bottles should supplementation become necessary, and you will want to have the perinatologist strongly on your side for this. Many hospitals today are much more friendly to preserving the breastfeeding relationship, but many are still significantly behind the times on this issue and routinely use bottles and unnecessary supplementation. Perinatologists, like pediatricians, often pay lip service to the benefits of breastfeeding, but may lack commitment to it under difficult circumstances or knowledge of how to help it. A lactation consultant or a La Leche League leader can help you by providing research to support your position, advice on improving latch-on with preemies, suck training for babies who have been given bottles or who have difficulty latching on properly, or equipment to assist you in alternative feeding methods until baby can nurse successfully. See the FAQ on this website on Nursing When Well-Endowed, and the section of the gd FAQ on Gestational Diabetes and Breastfeeding: A Special Relationship. Nursing offers extremely important benefits to both the mother and baby of a gd pregnancy, and especially so if the baby has special needs; it should be strongly considered if at all possible.

Doulas - One other health professional a gd mother might want to consider is a doula. A 'doula' (doo-la) is a professional labor support person, and functions to help both you and your partner through labor. An OB does not stay with you during labor, and usually checks in for a few minutes periodically until just before the baby is delivered. A midwife often stays with the patient much more, but they are also balancing office calls with laboring mothers and may need to divide their time. Labor and Delivery Nurses can be wonderful help during labor, but they have many charting and paperwork duties, and often have more than one laboring patient to attend to. Also, their quality varies greatly from person to person; some nurses are Attila the Hun in disguise, while others are a godsend and truly embody the best of the profession (Kmom has had both kinds!). Since there is no way to predict which kind you will get ahead of time, and because labor nurses come and go as their shifts change, many women elect to hire a doula who will be with them throughout the entire labor no matter what, and who can enhance the mother's partner in labor care.

Many fathers, rather than being threatened by a doula, are grateful to have an expert's assitance and suggestions, feeling it takes the pressure off of them to be their wife's sole support. Although the father's support can never be replaced, they are often inexperienced in labor and unsure what to do, and it is unrealistic to expect that a few childbirth preparation classes is going to adequately prepare a dad to be able to handle any situation that may challenge the mother's ability to give birth easily. In addition, the father often has his own emotional issues to deal with in labor, and this can make it harder to be objective yet still supportive. A doula has been through childbirth before many times, both personally and professionally, and knows the most effective ways to help laboring women in all kinds of different situations. Their role is not to replace the father but to assist him in any way possible, and to provide additional expert support for both mother and father. A doula can also offer breastfeeding expertise and support after the birth, and if contracted to, can even offer post-partum help as needed (cleaning, cooking, baby care, etc.). Hiring a doula is one of the smartest things a woman can do to help her have as normal a birth as possible.

A meta-analysis of six doula studies showed that doula support lowered the overall c-section rate by 50%, requests for epidurals by 60% and use of other pain meds by 30%, oxytocin use by 40%, and labor length by 25% (Mothering the Mother, Klaus, Kennel, and Klaus, 1995). No study has ever been done on the use of doulas in a gd labor (at least to Kmom's knowledge), so it is only speculative, but it seems reasonable that professional labor support might aid in lowering the already high c-section rate for gd moms and make their labors easier. One recent unpublished study showed that when doulas were used with induced labors, the c-section rate was one-third that of those whose labors were induced without a doula (20% vs. 63%), although the sample size (44) was too small to make any permanent conclusions, and of course, the results need to be confirmed by other such studies (source: Yahoo News, Health Stories, Wednesday May 6, 1998). However, since many gd moms will face induced labors and a high statistical likelihood of a c-section, the hiring of a doula to assist in labor may be a smart, low-tech way to improve your chances for a normal delivery, if possible. For more information on doulas, see the reference section below and also read the general plus-size websection on Choosing Size-Friendly Providers.

 

Facilities: Where to Deliver?

If you have gd, must you deliver at a hospital? What about Home Birth or Birthing Centers? Should you deliver at a hospital with a Level III Neonatal Intensive Care Unit? Again, the answer is.......it varies. A lot depends on your condition, the baby's condition, the philosophy of your provider, and the degree of your glycemic control.

Home Birth - The official booklet on gd from the American Diabetes Association says that "because of the care needed to perform a successful delivery, home births are not recommended for women who have gestational diabetes." And of course, ACOG (American College of Obstetricians and Gynecologists) does not really recommend home birth for anyone, though many critics definitely take issue with this. Certainly, for women with moderate or severe gd, home birth is absolutely inappropriate. These women and their babies need far more monitoring than can realistically and safely be done at home, and emergency back-up equipment needs to be close at hand, just in case. For women with mild gd, however, there are some proponents who feel that home birth is not out of the question, depending of course on the degree of control, medical history, etc. of the patients. Kmom does not express an opinion either way; she only notes that some gd mothers have indeed had successful gd labors (and even gd vbacs) at home without any complications whatsoever, but that the medical authorities are pretty much unanimous against recommending homebirth, especially when gd is present.

Hospitals - The vast majority of women in the United States and most First World countries have their babies in hospitals; it is statistically going to be the most likely choice of most women reading this FAQ as well. Having gd does not necessitate having to be cared for at a regional level III tertiary care facility, however, unless there are also complications like pre-term labor, severe gd, severe pre-eclampsia, etc. If your pregnancy has progressed normally and your blood sugar control has been good, your local facility is probably adequate for a gd pregnancy. However, you will still want to ask a lot of hard questions about the c-section rate at your hospital, standard care requirements, and other such questions. Try to avoid facilities that require all babies (gd or not) to have a mandatory observation time in the nursery, do not allow rooming in, do not allow doulas or extra family members in the delivery room, etc. Notice how many women are walking around in labor, ask what the nurse:patient care ratio is for women in labor, and inquire about whether showers or jacuzzis are available to laboring women. In addition, ask whether gd babies are routinely supplemented, what special tests are routinely performed on gd babies, what kind of support is available for breastfeeding (lactation consultants on staff), etc. Many hospitals are more progressive and no longer mandate separation of a gd baby from its mother at birth or routinely supplement them with glucose water, but there ARE still some hospitals that do this, despite the fact that the routine use of these procedures is dubious at best. You may need to have a hospital birth (especially if you need insulin) but you still have choices. There are tremendous procedural differences between various hospitals; try to pick the one that is least intrusive if at all possible. This is especially important if you plan to breastfeed your baby.

Birthing Center - An excellent alternative for many women is a Birthing Center birth. This is a compromise between the peace and non-intervention of a home birth environment and the safety of having more high-tech support available if needed. Some Birthing Centers are physically part of or next to hospitals (loosely affiliated yet mostly separate) while others are separate but have cooperative agreements with local hospitals, should a transfer become necessary. They are usually staffed primarily by Certified Nurse-Midwives (CNMs) but may also use Direct Entry Midwives (DEMs), Family Doctors, or even OBs as their primary care providers, with OBs always on-call for consultation and back-up care should it become necessary.

Labor and Delivery usually take place in one room and emphasizes quiet, non-interventive birth as much as possible. Labor amenities such as labor pools, walking areas, mini-kitchens, and birthing stools are often available but back-up equipment is around should problems arise. However, in Birthing Centers, the emphasis is placed on BIRTH as an important life experience and spiritual act, instead of on technology and intervention. Birth is treated as a normal physiological process, not a dangerous condition ready to explode at any second. Proponents like to say that in a hospital, a doctor delivers a baby but in a Birthing Center, the mother gives birth. Individual care and support are emphasized and rigid rules and regulations are de-emphasized. A loving, caring, private, and gentle approach to birth is the priority.

Although it is unusual to have major problems arise, a Birthing Center should be close enough to a major hospital that an emergency transfer could be made within about 15 minutes if it were to become necessary (your health provider can give you more specific details about optimal transfer times and transportation information). The Birthing Center usually has cooperative treatment agreements with local hospitals and OBs should transfer become necessary. If you are interested in using a Birthing Center, be sure to inquire about these transfer protocols. A good Birthing Center is a combination of low-tech, supportive, non-interventive approach combined with allowances for intervention should they become medically necessary.

Some Birthing Centers do not accept women with gd (they 'risk' them out to the hospital) but some do. GD moms who need insulin are not generally accepted by Birthing Centers; they pretty much need a hospital birth. GD moms with very mild gd and excellent control are accepted by many Birthing Centers but definitely not all. Don't assume that you will be turned down at a Birthing Center based on your gd alone; call and ask for an interview. Many do accept mild gd patients. For gd patients who strongly desire to avoid a c-section if at all possible, a Birthing Center birth may give the best chance to avoid unnecessary surgery, but the providers should be aware of the special needs of a gd mom and baby (i.e., testing carefully for neonatal hypoglycemia) and have quick access to hospital care should it be needed.

Most Birthing Centers are very supportive of larger women, but a few large pregnant women have reported being turned down or discouraged based mostly on their size, a ridiculous limitation unless the woman is demonstrably high-risk from other factors. Birthing Centers are great choices for many large women and may represent the best way for them to have as natural and low-risk a birth as possible; don't let the rare prejudice of a few providers deter you from pursuing birth in a Birthing Center if that is what you want. Go and tour the facility and ask questions, even if you are unsure if this is the birth for you. Explore all the options open to you.

Some Centers do not accept VBAC (Vaginal Birth After Cesarean) candidates, though this is unusual now since VBAC has become so much more widely accepted. Be sure to ask their VBAC success rate and how much experience they have had with VBAC moms. Again, don't make assumptions about your risk level; call and ask for an interview so they can assess your case specifically. Even if under a worst-case scenario they wouldn't take your case, they can usually recommend an excellent local OB who is less-interventive and more pro-natural childbirth than most, and that puts you many steps ahead of the game! Finding an excellent, low-intervention provider is one of the most important choices you make during pregnancy, and some OBs pay mere lip service to non-intervention ideals. But a referral from a Birthing Center is an excellent recommendation and may save you a lot of search time and questions. There are good OBs out there, but sometimes it's hard to find one that matches with your own philosophy, especially if you have any risk factors. Getting a referral from a birthing center to a really good OB may be an great compromise for those who do need to be 'risked out' from a Birthing Center.

An evaluation of each woman's risk factors and case history will be made by the staff of a Birthing Center to determine whether they will accept her as a client, and each woman should also carefully consider whether this facility and staff is for her. If you are interested in a Birthing Center birth, visit and tour the facility and ask a lot of questions about what risks are and are not acceptable. A list of possible questions to ask can be found at www.BirthCenters.org/customizedguides/. Your birthing center staff will likely be quite up front with you about whether or not your gd or other factors will disqualify you from using their facility; if so, be sure to ask for those important OB referrals instead. (For more information and contact numbers for Birthing Centers, midwives, doulas, etc., see the Support Organizations and Contact Info section below.)

 

Childbirth Education Classes

There are many different childbirth education classes that you can attend. Which one is best for you depends, again, on your personal birth philosophy and desires. An excellent site that compares and discusses various childbirth education approaches can be found at www.geocities.com/HotSprings/9947/cbetable1.html. A basic overview of several types of classes is presented in this FAQ, but will reflect a lot of Kmom's personal opinions about each type; feel free to disagree or try a different approach if you want.

A word about Kmom's biases for the sake of fairness---after taking several different types of birthing classes, going through two very different births (one highly medicalized and one not), and a great deal of reading about childbirth issues, Kmom has developed strong opinions about the importance of respecting the natural process of birth as much as possible. She strongly believes in proactive prevention of problems in pregnancy through early and scrupulous attention to nutrition, exercise, and the emotional aspects of pregnancy and delivery. She strongly favors natural childbirth but knows that, though unusual, there are times when certain interventions become necessary, but she strongly believes that parents must make informed choices about these interventions and that fully informed consent is often not practiced by many providers. She strongly encourages using alternative methods of coping with labor instead of drugs but feels that few childbirth classes adequately educate and prepare parents for this challenge and much more must be done. However, while she feels that pain meds are vastly overused today, she is not completely against pain medications, knowing that they have advantages in certain situations as long as the parents are well-informed about their risks. She also strongly believes in the importance of breastfeeding for the health of both the mother and baby, and believes that not enough is done in most childbirth education classes to promote and adequately prepare for either natural childbirth or breastfeeding.

Those are Kmom's main beliefs about childbirth, developed over time through lots of reading and varied personal experience. However, she fully supports the importance of individual choice. Each person's situation and needs are different, and birthing choices must be individual, not one-size-fits-all (large women know how well that works!). Kmom encourages readers to carefully research all options, to fully explore their own personal feelings about birth, to become an informed consumer, and then choose the situation that's best for them. All of these factors are going to influence which type of class will be most effective for YOU.

Important questions include how much you want to be involved in your prenatal care, how involved you want to be in decisions about the birth, how important it is to you to avoid an episiotomy or c-section, how you feel about the use of pain medications, what kind of experience you hope birth will be, etc. For example, some women strongly desire an epidural "as soon as I get to the parking lot"; women who are adamant about this would be best served by an Obstetrician and a traditional hospital childbirth education class. Some women do not want any intervention at all and feel strongly that natural childbirth is the healthiest possible option for most laboring women. These women would probably best be served by a midwife and a Bradley childbirth class. Many women, however, fall somewhere in-between. The degree of their feelings about birth will dictate the best course for them.

Some excellent books for exploring your feelings about birth include Creating a Joyful Birth Experience by Lucia Capacchione and Sandra Bardsley, Pregnant Feelings by Rahima Baldwin, or An Easier Childbirth by Gayle Peterson. Kmom's favorite and most highly recommended book on the subject is Transformation Through Birth by Claudia Panuthos (available only from Cascade Press/Birth and Life bookstore). If you have had a previous birth (especially one that was difficult or less than you desired), read Rebounding from Childbirth: Toward Emotional Recovery by Lynn Madsen. If you have a history of miscarriage or infertility, Ended Beginnings by Claudia Panuthos and Cathy Romeo can be very healing (and is also appropriate for resolving issues from previous childbirth experiences as well as issues of pregnancy loss). In addition, there are many other fine books available that can help you explore your emotional issues surrounding birthing, pregnancy, and laboring. These include Birthing Normally by Gayle Peterson and Pregnancy as Healing by Lewis Mehl M.D. and Gayle Peterson. Some of these books can be found at www.amazon.com, but other sources may include the Birth and Life Bookstore (Cascade Press) or the ICEA bookstore (contact info listed below). Some of these books are older and may be difficult to find; some public libraries can find some of these books if you ask them to run a detailed search on interlibrary loan, or many La Leche League chapters have lending libraries that may include some of these books or similar titles. Kmom strongly recommends reading up on emotional preparation for childbirth.

A word about GD and childbirth education classes---just because you have gd does not mean that you must have a high-tech birth or cannot pursue natural childbirth. A lot depends on the specifics of your medical situation, your desires and level of assertiveness, and of course on your medical provider (and remember, you can always switch this too). Some gd cases are best-served by a high-tech birth with all the accoutrements and plenty of neonatal observation and care. However, many gd cases CAN be born through natural childbirth or nearly-natural childbirth. Many critics contend that gd births have been vastly over-medicalized and overtreated in many cases, resulting in unconscionably high intervention and c-section rates (and Kmom would tend to agree with this). However, it IS still possible to find providers who believe that natural childbirth is still the best choice in most circumstances and that gd does not have to be treated as 'high-risk' but instead as a 'nearly normal' pregnancy. But you may have to search long and hard for one, and you may have to be willing to switch care providers even late into pregnancy if you are really committed to the idea of having as natural a birth as possible. Listen to your intuition about your provider and respect your birthing desires too. Get additional input from other types of birth providers, and then see if your path becomes more clear.

Some gd women will feel more comfortable with extremely high levels of monitoring and intervention, but others will feel that 'high-risk' creates a self-fulfilling prophecy. There is room for both approaches in gd pregnancies, though again, a great deal depends on the specifics of your case. But it is not true that once you have gd, you must give up having a natural birth or a VBAC or even a waterbirth. GD does present more concerns to be careful of, but it does NOT have to preclude natural birth or a good birthing experience. But it does generally mean that you will need to be very well-educated and very proactive in pursuing the type of birth that you want, and that you must choose your birth providers very wisely. Choose one that believes in the type of birth you want----in other words, if you want as natural a birth as possible, don't choose one that puts a lot of conditions on gd labors or routinely insists on early inductions, etc. Conversely, if you want every monitoring test there is and could care less if you have a c-section, go to a high-risk OB, not a direct-entry midwife who believes in natural birth. In other words, as many childbirth educators say, don't try to order sushi at a McDonald's. It's almost certain you won't get what you wanted. Go somewhere where what you want is likely to be on the menu and the staff will be able and likely to accomodate your tastes!

Of course, most women don't enter pregnancy and birth knowing clearly what they want, and usually are not informed health consumers in the beginning. They often need to take time out to clarify their value systems so that they can choose care that is most appropriate for them. The first step in this is reading up on childbirth issues (try Transformation Through Birth and A Good Birth, A Safe Birth) then carefully discussing your thoughts and concerns with your partner. Taking an excellent childbirth education class is also a good (though later) step in this direction. Here are descriptions of a few of the many you can choose from.

Hospital Childbirth Education Classes - These classes tend to be very traditional but the quality does vary significantly from one hospital to another. Some classes are excellent and very fair-minded while others are little more than instructions in how to be a compliant and unquestioning patient. They generally use Lamaze techniques of distraction and patterned breathing during labor; also contains lots of simplified information about childbirth, including very basic anatomy, stages of labor, etc. Will usually contain quite a bit of information about pain medications and availability; ostensibly is not supposed to be pro-meds but the vast majority of women who take hospital classes end up using pain medications. Classes usually begin late in pregnancy and continue until just before birth, but sign up early since they fill up quickly. Hospital classes are also usually quite cheap and many HMOs will pick up a big percentage of their cost, a big advantage for many couples.

Some of these classes really are well-done but the majority are superficial and do not adequately prepare you for the demands of childbirth. Critics contend that most hospital classes are so controlled by OB politics that they are little more than classes in how to be a compliant patient and prepare for intervention; this criticism is often a legitimate one. The problem is there is no real way to tell ahead of time which hospitals have the good classes and which do not. These classes are well-suited to the mother who strongly desires pain medications/epidurals during labor or who feels better with lots of monitoring. They are NOT for the mother who prefers a more natural birth or who strongly wishes to avoid a c-section if at all possible. It is Kmom's admittedly biased opinion that most childbirth classes given through hospitals are not worth taking unless you are a mom strongly determined to use pain medications. For all others, Kmom believes that another childbirth education option is preferable.

She does make a few exceptions, however. Some hospitals do have excellent supplementary classes on Baby Care, Breastfeeding, Infant CPR, etc. These are often VERY well-worth taking, and Kmom strongly recommends taking a quality class on breastfeeding in order to increase your chances of breastfeeding success, and also becoming proficient in infant first-aid and CPR. These are hospital classes well worth taking if available. (Be sure the breastfeeding class is taught by a board-certified lactation consultant---IBCLC---if possible. Another alternative is to attend La Leche League Meetings for 4 weeks prior to the birth.)

Bradley Childbirth Education Classes (American Academy of Husband-Coached Childbirth) - These classes are independent of OBs and take place out-of-hospital, so they are not likely to be controlled by local OB politics and present a more complete point of view. Bradley Method classes strongly emphasize excellent nutrition and proactive prevention of problems in pregnancy. Their classes promote natural childbirth whenever possible, active participation of the husband as coach, avoidance of drugs during pregnancy, birth, and breastfeeding unless absolutely necessary, relaxation and NATURAL breathing, "tuning-in" to your own body, immediate and continuous contact with your new baby, breastfeeding beginning right at birth, consumerism and positive communications, parents taking responsibility for the circumstances of their births, and preparing patients for unexpected situations such as emergency childbirth and cesarean sections. Their stated goal is for "you and your baby to have the best, safest, and most rewarding birth experience possible."

Some parents are afraid that commiting to a Bradley birth will not prepare them should complications arise, or that they must commit to having a birth without any pain medication whatsoever. Many women would like to have a more natural birth, but do not want to have to commit to forgoing any form of drugs. They are frankly afraid they cannot handle the pain of labor and will need an epidural to cope; they want fair and unbiased information so that they can choose for themselves instead of having to follow rigid dogmatic rules. Other women are afraid that if they do end up using pain meds or having interventions, they will be looked down on or derided. Couples with these reservations sometimes unnecessarily elect not to take a Bradley class, fearing that they will not be given complete information on all their birthing options or will be looked down on if they end up using pain meds.

These parents needn't worry---this kind of rigidity is not what the Bradley method is all about. It is about making informed choices, not about judging other people's choices. Bradley does not mandate that all women labor without drugs, nor does it label pain medications as evil. It does present information about pain medications during its classes, and it does so fairly and without condemnation. It leaves the choices up to each couple. Its position is that in the vast majority of cases, natural childbirth IS best for both mother and baby, but that each situation must be judged on its own merit and needs. It does present information about the risks of pain medications, information that is often de-emphasized or completely left out of many hospital classes, and it does take the position that medications can be a very slippery slope on the way to intervention and c-section, but it also recognizes that in some situations, pain medications can be beneficial and appropriate. It is not unfair or biased in its presentation of information on pain medications, but it does carefully examine all the risks so parents can make a truly informed choice, something that is lacking in many OB offices. It also carefully prepares you in alternative methods of dealing with contractions so that you are less likely to use pain meds. Reportedly, over 90% of Bradley couples do not use pain meds in their births, a tremendous success rate and one that speaks tellingly of the preparation you receive. However, if you end up in the ~10% who has pain meds or other intervention, no one will look down on you or judge you.

One caveat is that some Bradley teachers believe that there is 'no such thing' as gestational diabetes. While Kmom believes the jury is still out on whether mild cases of 'gd' are serious enough to treat aggressively, she feels that there is no question that severe gd needs to be treated, and that the potential dangers of mild gd are sufficient enough to justify extra caution while we wait for further data. Even so, most gd treatment does not have to be incompatible with Bradley classes. The strong emphasis placed on nutrition by the Bradley method meshes quite well with the gd approach, and the nutrition recommendations from Dr. Brewer used by the Bradley method are compatible with gd food plans (except the hypocaloric gd plans, which still have not been proven safe). The overall intake is usually not much different, though your plan may utilize a bit less dairy, due to its influence on blood sugar levels (so you just substitute non-dairy calcium choices, something Dr. Brewer allows for). The main difference is that Brewer/Bradley does not really address the combination and timing of foods so critical to managing blood sugar levels (i.e., not having heavy carb loads at breakfast, balancing protein and carbs at each meal/snack, eating frequent small meals/snacks every 3-4 hours, checking for ketones, etc.) but this can easily be done and still follow both plans. In fact, one advantage of the Brewer/Bradley approach is its strong emphasis on getting enough vegetables, something some gd plans tend to de-emphasize in their concentration on carb-counting and food combo concerns. As long as your doctor has not prescribed a restrictive, hypocaloric diet, you should be able to follow both a Bradley plan and your gd plan just fine.

A few Bradley teachers do have earlybird Bradley classes available, but most parents take Bradley classes at about the same time they would hospital classes---in the last several months of pregnancy. If there are earlybird classes available to you locally, you really should consider taking them if at all possible, but later classes are still quite valuable even if that's all that is available. Classes are usually 12 weeks long and are limited to a few couples at a time in order to assure lots of individual attention (sign up early to get a spot!). If you are having reservations about your present provider or wish to find a doula for extra labor support, many Bradley teachers can recommend the best OBs and midwives in the area to you, potentially saving you a lot of time and effort searching for one. The main disadvantage of Bradley classes, though, is the cost. Classes generally run $150-200 and are held in private homes; the price deters many couples from taking the class. However, those couples who have scraped together the money to take Bradley classes rarely regret it and are generally very positive about the experience.

To summarize, Bradley Method childbirth classes are overall quite good, and Kmom does recommend considering them. Their strong emphasis on being a well-informed health consumer, their insistence on excellent nutrition and other proactive health measures, their use of natural relaxed breathing techniques instead of gimmmicky breathing patterns, their focus on preparing both the mother AND her partner for handling the birth process, and especially their frequent rehearsal of a variety of labor coping techniques makes it one of the strongest childbirth education programs available. Further information about Bradley classes can be found at www.bradleybirth.com or by calling 1-(800)-4-A-BIRTH for a list of classes local to your area. [Kmom is not associated with the Bradley program.]

 

Birth Works Childbirth Education Classes - This is a fairly new entry into the childbirth education area and a very promising one. This is one of the only childbirth education classes to really address the emotional preparation as well as the physical preparation needed for birth. It also is one of the few classes available that is appropriate for parents who have given birth before, either vaginally or by cesarean. It is an excellent preparation for VBAC birth as well as for first-time birth.

Its flyer states that "Birth Works embodies a philosophy that develops a woman's self-confidence and trust in her innate ability to give birth. The classes are experiential and provide both a physical and emotional preparation for birth. Birth Works classes are taken by new parents, and women with prior cesarean or vaginal births. The program meets the needs of parents planning hospital, birthing center or home births."

The emphasis on emotional preparation, grieving and healing, and discovering belief systems before birth is probably the most unique aspect of this program. It says that "talking about obstetrical drugs, medical procedures and birth plans is straightforward. The challenge is to get today's women to develop trust and faith in their bodies." [their emphasis] However, they also emphasize nutrition, exercise, birth plans, breastfeeding, and postpartum issues as well as traditional topics such as components of labor, pelvic body work, labor positions, comfort measures for labor, etc.

Birth Works classes are about 10 weeks long and they do encourage coming early in pregnancy. The disadvantage of Birth Works classes is that they are probably not subsidized by insurance and cost more than hospital classes, but the information provided is more complete and fair. And unlike many hospital classes, they teach not just cold, abstract facts about anatomy, birth, medications, etc., but also exploring one's belief systems about birth, healing from past emotional issues that might affect your ability to give birth, etc. It does believe in natural childbirth but emphasizes the importance of each woman choosing the right way to birth for her. It is "a unique and innovative approach focusing on the integration of mind, body, and spirit, a process which builds confidence that birth, indeed, works!" [emphasis theirs] Their official statements of belief are:

  1. The knowledge about how to give birth already exists inside every woman. Women's bodies are designed to give birth.
  2. A woman will labor the best wherever she feels the safest and most secure. For some that may be a hospital; for others it may mean at home or in an alternative birthing center.
  3. Birth is one of the greatest challenges life has to offer. It provides an opportunity for personal growth.
  4. While a cesarean section can be necessary at times, the current rate is too high.
  5. In most cases VBAC (vaginal birth after cesarean) is a safer alternative to routine repeat cesareans.
  6. Birth Works is a process, not a method. Birth Works seeks to facilitate a woman's or a couple's personal process in childbearing, not to impart a preconceived method of labor and birth. There is no one right way to give birth. Each birth is unique.
  7. A woman in labor deserves an environment in which her privacy, autonomy, and emotional security are protected, and her mobility is encouraged.
  8. Expectant parents should have access to information they need about obstetrical procedures. They should participate in decisions regarding the judicious use of obstetrical medications and procedures.
  9. A woman's beliefs influence her birth. Exploring her beliefs heightens self-awareness, serving as a catalyst for positive change.
  10. The emotions of a birthing woman have profound effect on the birth outcome. Women must be allowed to express all their birth-related feelings.

(copyright 1995, Birth Works, Inc.)

You can learn more about the Birth Works childbirth education program (and to locate classes in your area) by visiting its website at http://members.aol.com/birthwkscd/bw.html or calling 1-(888)-TO-BIRTH or (609) 953-9380. Their email address is birthwks@aol.com. [Kmom is not associated with Birth Works at this time but is considering joining their training program to become a Birthworks childbirth educator.]

 

Kmom's story: I have been through 2 different programs in my 2 births and am considering a 3rd for my next pregnancy. Each program has had its own strengths and weaknesses. Every person must select the program that best meets their own needs and beliefs. Here are my experiences and opinions of the various classes I've explored.

In my first pregnancy, we took the standard hospital childbirth education class, as most couples do. This was not a total wash-out---I learned many things about anatomy and birthing that I did not really understand before. We also saw some cool videos and audio-visual aids that were inspiring or helpful. The instructor was very knowledgeable and nice, and a cut above most hospital instructors---we did receive pretty fair assessments of the risks of labor drugs and episiotomies, for example. Still, the overall tone was that most of the hospital procedures were appropriate and we should ask questions but not too much. There was little to no information on emotional preparation for birth, only a small amount of information on nutrition, and natural childbirth was de-emphasized. I got the feeling that the instructor was a bit more radical but was carefully walking a line between the giving information she thought was important versus pleasing the doctors who sponsored her program.

We did have time each session to do relaxation exercises and contraction 'rehearsals', but not nearly enough. The techniques taught were the traditional Lamaze techniques of breathing patterns, distraction, and focus on an outside object. Because we moved to a different state during the classes, we did have to miss the last two classes, the ones on cesarean birth (!) and postpartum issues. But even so, we received the most important parts of the class and practiced the relaxing and breathing techniques.

When we got to labor, though, these techniques did NOT help much at all. It should be noted, though, that my first labor was much more difficult than most, and some women do find these techniques enough for them. And these techniques did help some----they got me through the first 6-7 hours of an induced pitocin labor without any meds. However, the combination of a relentlessly increased dose of pit, tetanic and continuous contractions from the pit, an amniotomy (waters broken by the doctor), and a posterior presentation causing serious back labor made it impossible to continue laboring like that. I elected first IV meds, then an epidural, which in that case was a wise decision. However, the end result, not surprisingly, was a c-section. I really felt deserted by my 'preparation' and was unprepared for the emotional aspects of labor, birth, and recovery, though I did at least manage to preserve breastfeeding and escape the post-partum depression so common to c-section mothers.

However, the emotional recovery from the horrible pain of my c-section and overwhelming contractions was difficult to integrate. When I conceived my second child a year later, I became determined to avoid induction and as much of the intervention as possible in order to have a better birth. There was NO way I wanted to repeat THAT experience! I also recognized that I needed better coping techniques if I was going to labor naturally as much as possible. We enrolled in a Bradley class at 6 months or so. It was expensive but well-worth the time.

My husband was a very reluctant participant at first, but was converted to its usefulness by the time the class ended. We both found it somewhat helpful in dealing with what had gone before, though the class was not specifically about that. And we both REALLY appreciated the great amounts of time devoted to relaxation and labor coping techniques, and he really felt that the emphasis on preparing the coach for his role was vital (he'd felt really alone and helpless in trying to help me through my difficult first labor). The Bradley emphasis on natural, deep abdominal breathing was also MUCH more effective for me, and their preparations really helped me in labor. Coping with my second labor (even the difficult back labor) was SO much easier, and my husband felt much better about his role. We also hired a doula to give both of us expert support, which also aided us greatly.

The disadvantages of Bradley classes were that they were mostly for first-time parents, and a lot of the information was a repeat for us. It was still worth doing, but I'd wished for a program specifically with these techniques but aimed at second-time parents and with a strong VBAC component. My instructor knew little about VBACs and while she was great at trying to help anyway, we were both groping around in the dark a bit. I have since found resources and books that could have helped me a lot then, had I only known where to search for them, but I did not have them in time for that labor. Oh well! Still, even though we ended with another c-section (due to malpresentation), it was a MUCH better birth, and the surgery was not a horror this time, partly due to my assertiveness about things important to me as learned in my Bradley class.

But I still wished for a class that addressed past births instead of only new parents, and one that was specifically about VBACs. VBAC classes are offered in the hospitals, but they are often a short-circuit to repeat sections and more interventions instead of looking at the issues carefully and fairly. I knew those were not for me anymore; I'd outgrown them. Now I have begun to look into Birth Works classes, which seem to fit the bill in so many ways! Emotional healing from past births, attention to the needs of second-time parents, emphasis on VBAC issues and avoiding unnecessary cesareans.......sounds great! However, at this time I have not attended any classes because there aren't any in my area and because we are not planning for a new baby quite yet. Readers should know, though, that I am looking into the possibility of certifying as a Birth Works instructor if I like what I see when I do take the classes. The required list of reading is very exciting and refreshing, and it echoes my growing belief that the emotional side of birth and healing from past experiences is an important and overlooked component of birthing.

As large women, I think that this is particularly true; we have been taught to distrust our body and think of it has unhealthy, diseased and dysfunctional. Many of us are actually malnourished from years of dieting and deprivation, and we encounter great negativity from family and friends as we consider or enter pregnancy. All of this negativity leads many of us to a profound distrust of our body, and if you are diagnosed with gd it only gets worse. I think that my next birth is all about reclaiming health and trust in my body, about emotional growth and healing as a person, and about becoming more assertive in my own health care. Birth Works sounds like a great place to work on this process, but we'll see if it's all I hope for it to be. If not, I'll find another way to grow, perhaps through private work with a birth educator or midwife.

My wish for others is that they find a great childbirth education program, one that suits their needs. Don't just accept the easiest or cheapest available, but search for the one that's right for you.

 

What if you would like a Bradley or Birthworks-type class but there are none in your area?

This is a dilemna faced by many women, especially those in more rural areas. There is no clear answer; a lot will depend on your priorities. You need to decide on your priorities, and if you are motivated, then start thinking creatively! Reading lots of labor books is a good start, but doesn't involve actual hands-on training with an expert, and book information tends to fall away when confronted by the realities of labor. You need to have labor coping techniques well-rehearsed so that they become second nature instead of having to try to remember 'what the book said' in the middle of a contraction. Kmom can't emphasize enough the importance of regular, ongoing practice of labor techniques with an expert in the field. It really can't be replaced.

One option that has worked for others in the past was to hire a Bradley instructor for private classes and then drive there for a couple of weekend sessions instead of going for 12 weekly classes. It's not optimal, since regular ongoing practice is so helpful, but it's better than not having the experience at all. Another option is to hire a local midwife or doula to work privately with you for your childbirth education needs, while still going to your original provider for prenatal care. If there is no local midwife or doula to help you, consider hiring one in another city to come to you (or vice-versa) for one-on-one classes. Hiring a midwife for your main care is often an excellent choice in this situation, since the really good ones take the time to do any necessary childbirth education during their prenatal care sessions and will often spend an hour per appointment with you. Many birthing centers or family practice organizations run their own birthing classes in the community; these are often quite good too BUT you need to inquire about their philosophy because some are simply like tame hospital classes in a private setting. Make sure any approach you take is well-rounded and contains lots of practice of labor coping techniques.

Not having access to quality childbirth education programs that emphasize consumer awareness and truly informed decision-making can be a difficult quandry. There are no easy answers in this situation. However, many women have gotten through this challenge by engaging their creativity. You need to see if you can find answers that suit YOUR situation.

 

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Whatever birthing facility and childbirth education class you end up using and whatever type of provider you end up going to, it is most important to find ones that match your birthing philosophy, needs, and personality. You want to find the provider and facility that will treat you with utmost dignity and respect, involve you in your own care decisions, respect your birthplan as much as possible, and commit to giving you the best possible birth experience under your specific circumstances. Remember that no one can guarantee a perfect or non-interventive birth, but you need a provider that you can trust to follow your wishes as much as possible under the circumstances and to treat all involved with great respect. Read, read, read up on gd, childbirth issues, and related topics, ask the tough questions, and then trust your intuition.

Some people spend less time and research on this issue than they do on buying a car or other major purchase, and they often have cause for regret afterwards. If you choose and then have reservations about your choice, don't feel that you are stuck; care can be switched at any time during the pregnancy if necessary, even quite late and even in a gd pregnancy. Honor your intuition. Choice of provider and facility is one of the most VITAL and telling decisions you make in pregnancy! Don't abdicate your responsibility in this area. Choose wisely and well.

 

 

References

Stephenson, M.J. Gestational Diabetes Mellitus. Canadian Family Physician. 39:745-8, April 1993.

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.

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 40%, but in some studies have reached even higher.

Weller, KA. Diagnosis and Management of Gestational Diabetes. American Family Physician. 53(6):2053-7, 2061-2. May 1, 1996.

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.

Jackson, E.A. et al. Management of Gestational Diabetes by Family Physicians and Obstetricians. Journal of Family Practice. 43(4):383-8, October 1996.

The charts of 813 women with gd were retrospectively examined to see if management practices and outcomes differed between family practice doctors and obstetricians. 33% of OB patients were placed on insulin, while only 24% of FP patients were placed on insulin, even though patients exhibited similar demographics of body mass index, weight gain, gestational week at entrance to care, etc. Even more striking was the difference in c-section rates----OB patients had a c-section rate of 33% while family practice patients had a c-section rate of only 11%. There were no significant differences in neonatal outcome (including macrosomia) between the two groups, despite treatment differences.

Avery, MD and Rossi, MA. Gestational Diabetes. Journal of Nurse-Midwifery. March 1994. 39(2 Suppl):9S-19S.

Reviews the treatment of patients with gd and emphasizes the importance of client participation. Recommendations for the management of gd pregnancies are given. "Although medical consultation is necessary in these pregnancies, many nurse-midwives continue to provide care for women with gestation diabetes. Appropriate nurse-midwifery management of women with gestational diabetes is emphasized."

Butler, J et al. Supportive Nurse-Midwife Care is Associated with a Reduced Incidence of Cesarean Section. American Journal of Obstetrics and Gynecology. May 1993. 168(5):1407-1413.

This retrospective study examined the results of 3551 physician-managed patients and compared them with the results of 1056 CNM-managed patients in a university hospital with a mixed socioeconomic and ethnic population. Odds ratio for a cesarean section for women delivered by a CNM vs. those delivered by physicians was 0.71 (in other words, CNMs had lower c-s rates). "This work demonstrates that labor abnormalities and diagnosis of fetal distress are less frequent in patients cared for by nurse-midwives, and there is an association with a lower incidence of cesarean section." [Does not address GD patients, but provides background statistics on the treatment and outcome differences between various provider types. ]

Blanchette, H. Comparison of Obstetric Outcome of a Primary-Care Access Clinic Staffed by Certified Nurse-Midwives and a Private Practice Group of Obstetricians in the Same Community. American Journal of Obstetrics and Gynecology. June 1995. 172(6):1864-1868.

Retrospective study that examined the obstetric outcomes of 496 CNM births (in an economically and socially at-risk group) vs. 611 OB births (private practice patients) in the same community. The c-section rate was 13% for the midwives and 26% for the OBs; neonatal outcome was not compromised by the reduced section rate among the CNMs (i.e., the higher c-section rate among the OBs was presumably to prevent problems but did not improve fetal outcome; the lower c/s rate among the CNMs did not come at a cost of more problems for the babies). Of special note was the fact that the 81% of the private practice OB patients who had had previous c-sections chose elective repeat c-sections instead of trying for a VBAC. [Does not address GD patients, but provides background statistics on the treatment and outcome differences between various provider types.]

Applegate, JA and Walhout, MF. Cesarean Section Rate: A Comparison Between Family Physicians and Obstetricians. Fam Pract Res J. September 1992. 12(3):255-262.

Although the overall c-section rate for this study was quite low (7.5%), obstetricians were still 3x more likely to deliver by c-section than were family physicians (11.3% vs. 3.8%, though both are admirably low). Both populations were low-risk, equal complication rates were noted between the two groups, and fetal outcome was equivalent. [Does not address GD patients, but provides background statistics on the treatment and outcome differences between various provider types.]

MacDonald, SE et al. A Comparison of Family Physicians' and Obstetricians' Intrapartum Management of Low-Risk Pregnancies. Journal of Family Practice. November 1993. 37(5):457-462.

This study compared the rates of intervention in 351 pairs of women, matched for age and parity. Family doctors had lower rates of induction, external and internal fetal monitoring, narcotic analgesia use, and postpartum oxytocin use. "This study supports the hypothesis that at our center, family physicians intervene less than obstetricians in intrapartum management." However, study does note that there are differences between institutions as well as between doctor specialties. [Does not address GD patients, but provides background statistics on the treatment and outcome differences between various provider types.]

Hueston, WJ et al. Practice Variations Between Family Physicians and Obstetricians in the Management of Low-Risk Pregnancies. Journal of Family Practice. April 1995. 40(4):345-351.

Compared the practice patterns and outcomes for maternity care between family doctors and OBs. 4865 women from 5 different sites across the US were compared. Comparing women treated by family doctors to those treated by OBs, the family doctors were only marginally less likely to induce labor or to receive oxytocin augmentation. However, women managed by family doctors were much less likely to have an epidural (5% vs. 17%), an episiotomy (54% vs. 75%), or a c-section (9% vs. 16%). Even after adjusting for possible confounding factors, significant differences between outcome in epidurals, episiotomies and c-sections persisted. Neonatal outcome, however, was the same between groups, showing that the higher rates of intervention among OBs did not result in better outcome for the babies. [Does not address GD patients, but provides background statistics on the treatment and outcome differences between various provider types.]

Hueston, WJ and Rudy, M. A Comparison of Labor and Delivery Management Between Nurse Midwives and Family Physicians. Journal of Family Practice. November 1993. 37(5):449-454.

Compares the practice and management styles of nurse-midwives and family doctors to see if they are compatible and a reasonable way to increase coverage of obstetric care in rural areas. Few differences were noted in management styles, yet the women cared for by midwives had fewer episiotomies (30% vs. 40% in first-time moms, 10% vs. 20% in moms with previous births) and fewer c-sections resulting from a diagnosis of dystocia (labor problems- 8% vs. 14%). Even when parity and multiple risk factors were factored in, women managed by family doctors had 2.79 times the risk of having a c-section as those managed by a midwife. "Family physicians and nurse-midwives managed patients in labor similarly, but nurse-midwives were more likely to achieve a vaginal delivery in primiparous women and do so without an episiotomy."

Klaus, Marshall (M.D.), John H. Kennell (M.D.) and Phyllis H. Klaus (M.Ed, C.S.W.). Mothering The Mother: How a Doula Can Help You Have a Shorter, Easier, and Healtheir Birth. Reading, Massachusetts: Addison-Wesley Publishing Company, 1993.

Highly recommended! Excellent book summarizing the help that a doula (professional labor assistant) can give you in your labor; cites medical studies to support its positions. For example, a meta-analysis of 6 different doula studies showed that the presence of a doula reduced the c-section rate by 50%, length of labor by 25%, oxytocin use by 40%, pain meds by 30%, the need for forceps by 40%, and requests for epidurals by 60%. Also helps you find and choose a doula and gives a number of contact organizations to aid your search.

Kennell, John H. (M.D.) and Dr. Susan McGrath, Case Western Reserve University, Unpublished Study (as reported in Yahoo! News, Health Stories, May 6, 1998).

As yet unpublished, this study looked at 555 first-time mothers who were randomly selected to labor with the aid of a doula. The arm of this study mentioned in the Yahoo news article noted that of the women who were induced for medical indications (n=44), those who had doula support during their induction had a c-section rate of 20% vs. a c-section rate of a whopping 63% for those who were induced without a doula. However, it must be noted that the size of this arm of the study was so small (only 44) that distortions of results can occur and the power of the study is too small for permanent conclusions. Obviously, these results are so potentially significant that this question should be replicated again with 'gold-standard' studies of greater size and power. But in the meantime, women who face the likelihood of a possible induction might well consider hiring a doula for help.

Freed, G.L. et al. Pediatrician Involvement in Breast-Feeding Promotion: A National Study of Residents and Practitioners. Pediatrics. Sept. 1995; 96(3 Pt 1):490-494.

Over 1000 pediatric residents and experienced pediatricians were surveyed to assess the adequacy of physicians' breastfeeding-related training, knowledge, and attitudes. Found many respondents remarkably ignorant about breastfeeding and quite deficient in its management (almost 50% of residents did not know that supplementing during the first few weeks of life may cause breastfeeding failure). Those with personal or family experience with breastfeeding knew the most. "Although more than 90% of respondents agreed that pediatricians should be involved in breast-feeding promotion, their clinical knowledge and experience did not suggest a high degree of competency...these results indicate that residency training does not adequately prepare pediatricians for their role in breast-feeding promotion."

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.

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."

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.

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.

McCutcheon, Susan. Natural Childbirth the Bradley Way. (Revised Edition.) New York: Penguin Group, 1996.

Summarizes the Bradley Method approach to labor and birth; generally a good book. Some Bradley writings are a bit patronizing to the mother, but the information in the books is really invaluable and it's a good idea to get past some of the style awkwardness in order to benefit from the great info and ideas. Reading this is a good intro to birth issues, but Kmom cautions against using only the books and not taking the classes. The classes have so much hands-on info and rehearsal of coping strategies that they are MUCH more valuable than simply reading the book. Be sure to do BOTH.

Panuthos, Claudia. Transformation Through Birth: A Woman's Guide. Westport, Connecticut: Bergin & Garvey, 1984.

THE best book on emotional preparation for birth around-----HIGHEST recommendation! Unfortunately, this book is now out-of-print, but the Cascade/Birth and Life Bookstore has a stockpile of some left. Kmom highly recommends getting one-READ THIS BOOK.

Baldwin, Rahima and Terra Palmarini Richardson. Pregnant Feelings: Developing Trust in Birth. Berkeley, California: Celestial Arts, 1986.

Another very good resource for preparing emotionally for birth. This one is in a workbook format and addresses both the mom and her partner. Some of the dialogue exercises are a bit hokey, but there is still much insight to be had from the book.

Madsen, Lynn. Rebounding from Childbirth: Toward Emotional Recovery. Westport, Connecticut: Bergin & Garvey, 1994.

Superb book for addressing the difficulties of a previous birth experience and grieving/healing them. Another HIGHLY recommended title, and fortunately, one still easily found. www.amazon.com has it, as do many other bookstores. If you had a difficult birth or a previous c-section, READ THIS BOOK.

Peterson, Gayle, PhD. An Easier Childbirth: A Mother's Guide for Birthing Normally. Berkeley, California: Shadow and Light Publications, 1993.

Another book on preparing for childbirth emotionally as well as physically, with the advantage of being easy to find. Not as valuable as Transformation Through Birth but still worth reading. The author is a leading authority in this area and has written a number of valuable books.

 

Support Organizations and Contact Info

ALACE (Association of Labor Assistants and Childbirth Educators) - provides training for childbirth educators and labor assistants, consumer referrals, and has publications like "Special Delivery".

DONA (Doulas of North America) - provides referrals to those looking for a doula (labor assistant) to help them through their labor and birth. To find a list of doulas in your geographical area, email askDONA@aol.com and specify your area. Also trains and certifies those wishing to become a birth doula.

NACC (National Association of Childbearing Centers) - collects and disseminates information on birth centers staffed by certified nurse-midwives and physicians. For list of birth centers in your area and guidelines on how to select one, send to the address below. Include $1 for postage and handling.

Other Birthing Centers - may be found in yellow pages locally, through parenting magazines, through midwifery organizations, or through local childbirth educators. www.BirthCenters.org/customizedguides/ is a webpage that has info on how to choose a birth center, questions to ask, basic info, and a list of their affiliated birth centers around the country.

ACNM (American College of Nurse-Midwives) - provides information regarding nurse-midwives around the country. Nurse-midwives are certified as nurses before taking classes and professional hands-on training in midwifery. See the websection on Finding a Size-Friendly Provider for further discussion of the differences between various types of midwives and their training process.

MANA (Midwives Alliance of North America) - organization of mostly Direct-Entry Midwives (DEMs) or licensed midwives. These midwives are usually not RNs before becoming midwives; they usually do their training in hands-on programs. Most are usually well-qualified and well-trained but since the training is not standardized everywhere, lots of questions about training and experience are appropriate. DEMs mostly attend births at home and at birthing centers. This organization promotes midwifery as a 'means of improving health care', encourages cooperation among midwives, and improves quality and availability of educational opportunities for midwives.

Association of Ontario Midwives - provides referrals to midwives in Ontario, Canada

California Association of Midwives - provides information on midwifery and referrals to CA midwives.

Informed Homebirth/Informed Birth and Parenting (IH/IBP) - provides information on alternatives in birth and parenting, plus referrals to midwives, childbirth educators, and birth assistants. Also has books and videos.

Bradley Method Childbirth Classes (formerly American Academy of Husband-Coached Childbirth) - provides referrals to Bradley Method childbirth classes and sends free package of information. One of the best childbirth classes around; concentrates on nutrition, prevention, parent as health consumer involved in decision-making, preparing the partner to help coach childbirth more effectively, etc. Emphasizes relaxation and deep natural breathing over external distraction techniques of other philosophies; uses a LOT of practice of relaxation and labor support techniques. Does not disparage use of pain relief medications or those who use them, but presents realistically the risks and benefits of pain meds so that parents can make a truly informed decision about using them in whatever circumstances their birth presents them.

Birth Works - provides a childbirth education and teacher certification program designed to develop a woman's self-confidence, trust, and faith in her innate ability to give birth. Provides referrals to specific classes and instructors in your area. Call, email, or send a SASE with 55 cents stamp. Excellent program for new moms and prevous moms. Particularly appropriate for those who have had previous birth experience, experienced or saw a difficult previous birth, or had a c-section. One of the few childbirth education programs to address births that are not a woman's first birth, to discuss emotional healing from previous births, or to provide specific emphasis on VBAC (Vaginal Birth After Cesarean) as well as other aspects of birth.

ICEA (International Childbirth Education Association) - provides childbirth education certification programs, publications, audio-visual materials, workshops, and conferences.

Fat-Friendly Health Professionals FAQ - provides a list of size-friendly health providers all around the USA. Recommendations come from on-line people of size all around the country. Of course the list is limited to what has been submitted to it so it is not totally comprehensive, but it's worth checking for leads before finding a provider on your own. Also, the main emphasis has been on doctors other than OBs, midwives, and birth professionals, but there are some birthing professionals on the list and more are being added all the time. Worth checking out to see if there is one listed in your area (if you do not already have a preferred provider).

ICAN (International Cesarean Awareness Network) - provides information on cesarean birth and how to avoid one if possible; provides referrals to VBAC-friendly doctors and midwives, support groups, net access groups, and a quarterly newsletter, The Clarion. Excellent on-line resource and support group.

LLL (La Leche League International, Inc.) - provides mother-to-mother breastfeeding information worldwide; has local support groups nearly everywhere to help provide information, instruction, and emotional support to women during pregnancy and lactation. Has extensive resources available in free lending libraries or low-cost pamphlets and books; many include childbirth books and parenting books as well as breastfeeding books. On-line catalogue of materials, website with some of these articles and information, 900 number to call for counseling and support, materials on tape and in braille for visually impaired women.

Cascade Press/Birth and Life Bookstore - great source for many childbirth education books, especially those that many not be carried by the large-volume bookstores, online or not. If you are looking for a birthing book and have not found it yet, try here! Especially good for hard-to-find or more 'alternative' books. Also carries quite a wide variety (over 5800 products!) of parenting, midwifery, breastfeeding, and health books, as well as videos and teaching kits/visual aids.

ICEA Bookstore (International Childbirth Education Association) - another source for childbirth-oriented books, though perhaps more traditional.

Birth and Bonding Bookstore - a bookstore reputed to have a wide selection of many hard-to-find birthing and parenting books; located in the Bay Area (Albany, CA).

 

 

 

 

 


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