Gestational Diabetes: Basic Treatment Protocols

by KMom

Copyright 1998-2002 KMom@Vireday.Com. All rights reserved.

This FAQ last updated July 2002


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

 

Purpose of This Web Section

If you are diagnosed with gd, what kind of treatment course can you probably expect? What kind of special testing will be done? At what point is insulin needed? Will you need to be hospitalized for treatment? Will you have to be induced early? 

Will the baby be born diabetic? What special care will the baby of a gd pregnancy need at birth? What kind of post-partum testing will you require? How likely is it that you will remain diabetic after pregnancy? 

All of these are important questions, and this section is an introduction to some of the main issues that surround the treatment and care of gd pregnancies. However, it must be noted that some of this is especially controversial, and the authorities themselves are currently involved in trying to determine the most beneficial level of care and intervention in gd pregnancies. The way YOUR provider decides to handle your gd could differ immensely from the way another provider might handle the same case.

The top priority of this section of the gd FAQ is ONLY to give basic information on the most basic treatment issues and mention some of the controversies; another section will outline the different controversies in more detail and present arguments, pro and con (this section is under development). Kmom urges readers to do their own research, consult their providers and to become a PARTNER in their own care. Remember, NONE of this is medical advice, just a summary of the most common treatment courses and a brief mention of some of the controversies in treatment choices.

 

Prenatal Treatment

Most providers will want you to keep your blood glucose (bG) levels within the norms that non-diabetic pregnant women usually achieve. Basically, in most cases, this means keeping your numbers between 60-120 mg/dl (for a brief overview of common number recommendations, see the discussion at the bottom of this websection. For a more detailed discussion of all the confusion regarding numbers, see the websection called GD: The Numbers Game). Remember that exact recommendations differ between providers, but the most optimum levels seem to be below 95-105 fasting and below 120 after meals.

Dietary Control

In order to keep bG under control, the first step for most women is dietary measures. The goal of a gd food plan (it's not a diet) is to achieve EUGLYCEMIA (keeping the blood sugars as even as possible during the day and night). A series of smaller meals and frequent snacks is the heart of the plan, and careful attention is paid to the timing and combinations of foods

Since proteins help slow down the rise of blood sugar after carbohydrates are eaten, they play an important part of the plan. A careful balance of foods is extremely important, and the ratio of Protein to Carbohydrates to Fats is carefully chosen. Since excellent nutrition is so important to pregnant women, the design of the program can be tricky. Keeping all the considerations in balance and yet flexible enough for the mother to use can be quite a challenge for the registered dietitian.

If the plan has too many calories or carbohydrates, the mother may have higher bG readings or gain too much weight, which can make gd harder to control. If it has too few calories or carbs, the mother may not get enough nutrients for baby or have to start accessing fat stores for energy, which produce a by-product called ketones (which may cause problems for the baby). Although research has been mixed, some research has pointed to large amounts of ketones over time leading to mental or neurological problems for the children of diabetic pregnancies. Although some providers ignore the problem of ketones and don't have their patients test for it at all, most providers feel it is better to err on the safe side and have the mother test her urine every morning for ketones. 

Ketones are usually caused by women skipping meals, not getting enough carbohydrate in their diet, or not consuming enough overall calories. Large amounts of ketones are a cause for significant concern; moderate amounts are a cause for some concern and probably indicate a need to either be more careful in diet or to readjust the carb/calorie totals. Occasional small amounts of ketones are not currently thought to be a big concern unless they happen consistently, but any amount of ketones should be discussed with your provider. (More information on ketones can be found in the websection on GD: Ketone Testing.)

For the larger woman, food plan design is more controversial. Many researchers contend that obese women should be given significantly fewer calories in order to hopefully reduce their potential need for insulin and supposedly keep weight gain to a minimum (based on the erroneous assumption that most large women gain too much in pregnancy). A few advocate reducing intake by half, while the majority advocate cutting by around one-third, basically giving women just enough to keep them slightly above the level of ketonuria. This results in recommendations of caloric intake ranging from 1200-1800 (usually around 1600) calories.  A number of providers have even been documented to recommend only 1800 calories for TWINS.

In Kmom's opinion, it is highly questionable whether this caloric level is enough to provide enough nutrients and energy for pregnancy, and little or no research has been done on this question---researchers simply assume that it is appropriate. They have also completely failed to study the long-term impact on the children of women given such restricted fare. Although the researchers commonly support cutting calories by 1/3, most dietitians have deep reservations about such strong restrictions, and most obese women with gd are actually given food plans ranging between 2000-2200 calories. This seems to be adequate for most large women's needs, although women on insulin or who experience persistent troubles with ketones may sometimes need more, up to 2400-2500 or sometimes even more.

Another option to potentially reduce the need for insulin without compromising nutrition is to reduce the carbohydrate content of the food plan, while slightly increasing the protein and fat categories to provide more energy. This option seems to show some promise in preliminary research. Older gd food plans usually recommended 50-60% carbohydrate levels; new preliminary research seems to show that 40-45% carbohydrate content is better and prevents some women from needing insulin. However, the mothers need to be carefully monitored to be sure ketones do not occur during this process, and no mother should try this on her own without consulting a dietitian first. (See the website section on GD: Nutrition Questions for further information.)

Exercise Therapy

Exercise is often recommended as another therapy for bG control in conjunction with dietary therapy and other measures, since exercise tends to improve glucose uptake and lessen insulin resistance, permitting your body to improve the use of its own energy. Most research shows that ongoing, regular mild exercise is beneficial to most gd mothers (although not all studies agree). Studies showed the most benefit for middle-class obese women who had been previously sedentary, so exercise should be strongly considered by larger women. 

Talk with your provider about the appropriate use of exercise for YOU; most women are able to walk about 30 minutes per day without a problem. Timing your walk for right after breakfast is often recommended, since many gd mothers experience their highest numbers of the day in the morning due to an extra-strong hormonal surge in the morning. However, each mother must find the plan that works best for her (Kmom finds an evening walk most beneficial and convenient as she does not usually have troubles with her breakfast numbers).

For a few women, exercise is contraindicated, such as women with bleeding in pregnancy, pre-term labor, difficult-to-control hypertension, etc. Some sources list obesity as a contraindication for exercise, but this is probably only a concern for those with very extreme obesity. Ask your doctor if you are unsure. For those who cannot participate in regular exercise, sometimes exercise of only the upper body is helpful (see Troubleshooting High Numbers for specific ideas), while other women cannot participate in exercise at all; again, consult your provider for specific guidance. Women who are experiencing high levels of ketones should probably cut back on or cut out exercise until the ketones are brought under control.

The most important items to keep in mind while exercising are usually to keep your core body temperature fairly low, and to not raise your heart rate too high (you should be able to converse comfortably).  Swimming and water aerobics is ideal exercise for pregnant women because the water helps keep you cool and it is more difficult to raise your heart rate in the water.  

You should stop and rest at any sign of contractions or discomfort.  Some women, like Kmom, experience lots of Braxton-Hicks contractions during exercise, but can rest and restart without problems in a few minutes.  Other women experience too many recurrent BH contractions--or those that do not respond to rest--and should not exercise. Once again, consult your provider for guidelines. 

For most gd women, daily walking or swimming is the most appropriate exercise, but it's important to do it regularly, since skipping more than a day or two lessens the effect. Those who have no contraindication against exercise should strongly consider adding it to their daily treatment regimen; it could make a real difference in your treatment!

Blood Sugar Testing

Women with gd used to have to go to their doctor for weekly testing of their blood sugars. This was an expensive, cumbersome, and very error-prone process (some women in studies admitted that they ate differently on the day of the test). The advent of the home blood glucose monitor was a tremendous leap forward; these made it possible to measure your own levels at home and get instant feedback.

Some studies show that Self Blood Glucose Monitoring (SBGM) improves control over weekly testing. It enables you to trace more easily the foods that are your particular triggers, and to take more responsibility for your own care. You and your provider should strongly consider a home monitor as part of your gd program. Most insurance companies will cover its rental as part of pregnancy if it is prescribed by your doctor, but if you can afford it, it would be a good idea to purchase the monitor for yourself permanently (see the section on GD: Blood Glucose Meters and Self-Testing). If your insurance will not cover a glucometer for home testing, you should strongly consider finding a way to get one anyway--it is an extremely valuable tool in your care.

However, it should be noted that bG results from home glucometers naturally have an error range of at least plus or minus 10 mg/dl, and sometimes more. A decision to go to insulin treatment based on a few occasionally borderline readings from the glucometer is questionable, given the error range and possible factors that can affect glucometer readings. Providers will have their own individual guidelines as to how many and what readings necessitate insulin, but be aware of the error margin when considering such decisions. Most providers do not consider an occasional borderline reading on a home glucometer a reason for going to insulin, but a consistent pattern or very high readings probably indicate the need for insulin. If in doubt, request more official lab documentation of your bG levels before going to insulin.

Different providers will require different amounts and timing of bG testing. The most common scenario in a diet-only program is to measure the blood glucose 4 times a day--- Fasting, Post-Breakfast, Post-Lunch, and Post-Dinner. A few providers will consent to one fasting and one post-meal reading per day instead of four, but it's not common. Post-meal readings are now recommended over pre-meal readings because studies have shown that they improve results, but a few providers will have you take both pre-meal and post-meal readings, especially if you need insulin. 

If insulin is needed, you will probably measure more than 4x a day, depending on the severity of the problem and the philosophy of the provider. Some will have you continue with testing as before, while others will add tests before each meal and before bedtime too. Some women will end up testing 7-12 times per day---but only if they are on insulin, and only with more stringent providers. The most stringent testing protocol Kmom has seen has women testing fasting, before each meal, 1 hour after each meal, 2 hours after each meal, before bedtime, and in the middle of the night. However, this represents a very extreme protocol. The most common scenario is to measure about 4x a day for mild cases, and 4-7x a day for cases needing insulin. Some providers will approve less-stringent testing routines.

Measuring often is a nuisance, but it offers the clearest measure of how you are doing, the outlook for your baby, and clear feedback on how certain foods and activities affect your blood sugar. It is a powerful tool for self-management, and with the advice of a health professional, may allow you to catch and fix a pattern of readings that might otherwise put you on insulin or otherwise cause problems. In some cases, you can negotiate for fewer 'fingersticks', but in most cases, 4-7x a day is appropriate. 

Do not avoid testing if you think you might have a high reading, or otherwise try to change or misrepresent the results of your testing. Some studies have shown that a certain percentage of women lied on their self-reported results, probably a result of the 'denial' reaction after a disease diagnosis. Women with eating disorders may be especially prone to this type of data manipulation. Remember that glucometers now have memory chips and your results may be checked, and besides, you should obviously report results accurately for the safety of your child! Accurate results are extremely important in making delicate care decisions.

You will notice that you may occasionally have borderline or slightly high readings. This happens to nearly everyone, even those in great control, and no one really understands why. Many experts generally feel that an occasional borderline or slightly high number is not a huge concern; it is a pattern of recurring highs, consecutive highs, or any very high results that indicate a need for a change in treatment. So if you get a somewhat borderline reading, don't panic, but don't shrug it off either. Try to determine if there was anything that could have caused the problem (such as illness or a trigger food---see the section on Troubleshooting High Readings) and take extra care to be proactive in food, exercise, and reducing stress. Write down in a journal all that you can remember of factors that might have influenced that high reading, so that later you can see if there is a clear pattern or trigger. 

If you have several high readings in a row, call your provider at once. If you have one high-ish reading and then your numbers return to normal, take note and discuss it with your provider, but most providers recognize that an occasional high reading happens and won't make a decision to use insulin based solely on that. Some providers will place you on insulin based simply on 2 high readings in a week or two; others will have more flexibility and will wait to see if the pattern goes away first or is explainable by stress/illness/food errors, etc.. Consult your provider for their guidelines.

The fasting number, obtained upon waking, is the most important number of the day. Fasting hyperglycemia is the least responsive to other measures of control, and if it cannot be controlled, insulin will become necessary. If you have problems with your fasting numbers, see the trouble-shooting ideas in the websection on Troubleshooting High Numbers. The post-meal number (referred to in the research literature as "post-prandial" or 'pp') is obtained a set amount of time after eating. In some cases of gd, the mother becomes very 'resistant' to the effects of her own insulin and so her post-meal bG is way too high, even though her fasting numbers may be normal. This post-prandial spike causes baby to get too much fuel, possibly causing it to grow too big or in asymmetric patterns (shoulders/trunk too big, etc.). It seems clear that post-meal numbers also need to be kept under control as well, though just how tightly is a source for strong debate.

A few providers will also order periodic glycosylated hemoglobin tests as well (abbreviated as HbA1c), especially if you need insulin or developed gd especially early. These lab tests are done from a venous blood draw, and basically confirm your overall level of blood sugar control over the last month or two. These tests are not sensitive enough to detect gd, but they can help assure your provider that all is well once you are diagnosed, particularly if the gd is found early in pregnancy when birth defects from high blood sugars are more possible. Although generally speaking <6% is considered normal, each lab's 'norm' for HbA1c tests is different, and you must consult the norms for YOUR lab in order to determine how well your gd is being controlled. In addition, numbers for PREGNANT women may differ from norms for non-pregnant people; consult your lab and your provider for exact details.

 

Insulin Use

The majority of gd moms will be able to control their bG levels sufficiently with diet and exercise alone, but some women will go on to need insulin at some point. Traditional oral diabetes medications are not appropriate during pregnancy due to possible harm to the baby; for example, tolbutamide has been shown to cause severe hypoglycemia in infants born prematurely.  As a result, insulin has historically been the only option for pregnancy since it does not cross the placenta.

However, researchers continue to search for meds that can be used safely during pregnancy, and there may be some that show promise. For example, a recent study showed that glyburide was effective in women with gd.  As a result, many doctors are jumping on the bandwagon prematurely and prescribing it during pregnancy.  However, other doctors are taking a more conservative route and waiting for more research on its safety and efficacy before utilizing it more widely.  

Metformin (Glucophage) is another drug that has been used, although most often in women with either pre-existing type II diabetes or PolyCystic Ovarian Syndrome.  It has been found to significantly lower the miscarriage rate among women with PCOS and to improve glucose tolerance as well.  Many preliminary reports show that metformin's safety in pregnancy looks promising, but there is not enough data at this time to know if it truly is safe in pregnancy.  Therefore, many doctors choose not to use it (or discontinue it as soon as pregnancy is confirmed). In addition, one recent mainstream study found that the rate of pre-eclampsia and infant mortality was increased in the group of women who took Metformin during pregnancy (although there were other factors that could also have caused the increased risk of problems).   Therefore, the use of Metformin in pregnancy is controversial. 

At this time, most authorities feel that it is probably best to take the most conservative stance and avoid experimenting with diabetes meds in pregnancy, but a few women at especially high risk may wish to consider discussing the possible risk/benefit ratio with their doctors.  Further information can be found at Dr. Glueck's website, http://blues.fd1.uc.edu/~gartsips/polycyst.htm

The number of gd mothers that end up needing insulin varies from study to study. Officially, the American Diabetes Association cites figures that only about 15% of women with gd will need to use insulin, but in practice, the levels are often much higher. A great deal depends on the philosophy and treatment protocols the provider uses. 

For example, the official cutoff for needing insulin is a fasting level of 105 mg/dl, but many providers are using insulin at fasting levels of 95 now, as per the recommendation of the ADA. A few providers are putting women on insulin at 90, or even 80. In some studies, the number of women 'needing' insulin approached 90%! However, in most studies, the number is actually more like 25-50% or so. Again, there are many variables that come into play here; see the websection on What If I Need Insulin for more information.

'Prophylactic' Insulin

A very strong debate in the gd field is over the issue of 'prophylactic insulin', that is, use of insulin in mothers that technically do not have the official numbers indicating a need for insulin. The most common cutoff for instituting insulin is a fasting of 105, but many providers are now using it at even lower numbers, as noted above. Some researchers would consider this 'prophylactic use' and some would simply consider that the official policy is inadequate; the ADA has now recommended universal use of insulin at fasting levels of >95. 

In the 1970s, a few physicians experimented with giving 'prophylactic' insulin doses to all gd women regardless of their bG levels, and some even experimented with giving 'maximum tolerated doses' in hopes of preventing problems. This practice has largely been abandoned.

A more recent example of 'prophylactic' use would be to utilize insulin strongly in the cases where babies are showing larger-than-average growth even in the face of normal bG numbers with dietary treatment, even though such growth may simply be genetic. Some physicians also advocate giving 'prophylactic' insulin to gd women (with normal numbers through treatment) who have had large neonates in the past in order to reduce the recurrence of macrosomia,  Still other physicians are advocating giving insulin automatically to ALL obese gd mothers, regardless of normal numbers with other treatment. 

Anecdotally, at least one obese mother without any gd has been strongly pressured to go on insulin simply on the basis of her own size and a previous infant of large size--even though she tested very low negative for gd on both occasions and had her babies vaginally.  This trend towards 'prophylactic insulin use' in obese mothers is very strong. Whether ANY of this is justified or even safe is a matter for strong debate and has not been adequately studied AT ALL. In fact, long-term follow-up of gd infants based on treatment modes is nearly non-existent.

A number of studies have shown that more liberal use of insulin lowers the rates of macrosomia (big babies). However, the amount by which birth weights have been reduced on average is marginal in many studies, and the clinical significance of this reduction is questioned. In addition, the lower rate of macrosomia should theoretically result in lower c-section rates, less neonatal hypoglycemia etc., and less shoulder dystocia, but the vast majority have not shown such improvements. Furthermore, in a number of studies the incidence of c-section was actually INCREASED in the prophylactic insulin groups, despite a decrease in macrosomia rates. Since being on insulin puts the mother in a higher-risk category and also virtually mandates early induction between 38-40 weeks, this could certainly increase the amount of c-sections and offset whatever gains (if any) might be had from reducing neonatal birth weight.

Finally, the success of 'prophylactic insulin' in the subcategory of obese women is extremely mixed. Some studies have shown some benefit while others have shown little effect on birthweight among obese women. At this time, the general consensus from 'official' publications is that while using insulin at fasting levels >95 mg/dl MAY be justified (further confirmation is needed but some data supports this), "Prophylactic insulin treatment in patients whose fasting and postprandial values remain within the recommended range is not advised." (Carr and Gabbe, 1998). [More debate over prophylactic insulin use will be found in the sections on GD: The Numbers Game, GD: What If I Need Insulin?, and GD Controversies.]

If You Need Insulin

If your numbers are high and you need insulin, you will have to learn to inject insulin into your body daily. Although many women cringe at the thought of giving themselves shots every day, women who have used insulin say that it's usually not that bad. The needles are extremely small and fine, and if you use proper technique, usually don't hurt. In fact, many women have said that the daily finger-pricking for the bG meter is far worse than the daily insulin shots! New, less painful methods for getting insulin are being developed, including a method for inhaling the insulin (like with asthma medicine) instead of injecting it, but these are several years away from common use. Until then, injecting insulin is your only choice.

In order to learn how to inject and control your bG levels through insulin, you may need to be hospitalized for a day or two. Most providers are getting away from this requirement now, but it still is standard in some places. Advocates of hospitalization contend that it allows your providers to teach you all about using insulin and managing hypoglycemia (low blood sugar), to supervise your injection technique, to monitor you in case you have an allergic reaction to the insulin or a hypoglycemic incident, and to slowly transition your dosages to get your bG into control. Usually you will not be allowed to leave the hospital until you can demonstrate proper technique and knowledge of using insulin. Advocates of outpatient treatment contend that these tasks can usually be handled without overnight hospitalization, and nowadays, most doctors do not require it. 

Two types of insulin, Regular (R) and NPH are usually used. One is longer-acting and the other is short-acting. Your particular dosage may entail only one of these or a combination of the two, and will probably change as the pregnancy progresses. Four of the five highly diabetogenic hormones peak around week 26-28; this is why gd testing is standard then. However the 5th diabetogenic hormone (progesterone) does not peak until week 32 or just after, plus many women find that their insulin resistance increases as the pregnancy progresses. So many women will need their insulin dosage adjusted and tinkered with as they master their food plan and as their hormones increase, and an endocrinologist can be very helpful in this process. If you need insulin, don't be surprised to have the dosage tinkered with fairly often as the pregnancy progresses.

It should be noted that many type I diabetic women and some gd women also experience a marked dropoff in bG (and therefore insulin requirements) at the very end of pregnancy, usually in the last week or two. Caution must be taken that this occurrence does not cause any hypoglycemic incidents. Though hypoglycemia in gestational diabetics is not life-threatening like it is in type I diabetics, neither is it good for mother or baby. Extra care must be taken in monitoring blood sugar and resulting insulin dosage at that time and you should plan to consult with your diabetes educator or endocrinologist closely.

 

Risks in GD: A Summary

In order to better understand the reasoning behind many of the typical treatment protocols for gd, an understanding of the potential risks of gd is helpful. However, it is important to keep these risks in perspective; MOST gd moms and babies come through pregnancy and delivery just FINE. Many gd books and websites tend to emphasize the worst-case scenario so women will understand the potential risks, and (according to some critics) in order to scare women into complying with aggressive protocols or not questioning their treatment, especially since the critics of gd have been very vocal in some childbirth publications. This section is designed to briefly examine the theoretical risks of gd to mother and baby in order to understand their influence in treatment protocols; much more complete details about gd risks can be found in the websection on GD: The Risks. Again, some of these risks (or their significance) are disputed, but it is important for all gd mothers to understand the potential problems possible.

Risks for the Mother

Infections

Women with gd may be prone to other infections, such as Urinary Tract Infections (UTIs) or vaginal infections. If you have gd, you should be careful to report any problems such as this to your provider immediately. In addition, some women are more prone to colds, other illnesses, mood swings etc., until their blood sugars are brought more under control. However, pregnant women in general are more subject to these; having one doesn't necessarily mean you have poor control. But a consistent pattern tends to indicate problems and should be investigated.

Cranberry juice is often promoted as a way to prevent or stop UTIs, but of course for gd moms, juice is not a good option. However, there IS an alternative that may be helpful. Many health food stories carry cranberry capsules; these contain no sugar but reportedly still have the positive effect of cranberry juice in avoiding or minimizing UTIs (drink with plenty of water). If you can stand it, unsweetened cranberry concentrate is also available at health food stores, and is reputed to be the most effective form of cranberry products against UTIs. Ask your provider about trying these if UTIs are a concern for you. In addition, plain (unsweetened) yogurt that contains active acidophilus cultures can also be helpful in women who are prone to yeast infections; if you don't like yogurt, acidophilus capsules can be obtained from many health food stores. Again, consult your provider.

One side effect sometimes missed or dismissed by providers can be skin infections; the same yeast/bacterial imbalance that can make gd moms prone to UTIs or vaginal infections can sometimes cause yeast infections of the skin. Some (not all) large women may be especially prone to this, particularly in the skin folds under the belly or breasts or even inside the belly button. You will need to take extra care with keeping your skin clean and DRY; don't use baby powders or cornstarch (they add to the problem). Use a cool blow-dryer on the area, change bras and towels etc. daily, and use some Cetaphil cleanser periodically to keep the area clean (this reportedly does not strip away the good bacteria, a problem with antibacterial soaps). If you have a strong yeast infection on the skin, your provider may have you use yogurt, Gyne-Lotrimin, or other medicine on your skin to help clear it up, but be sure to consult your provider before using any of these.

Pre-Eclampsia

Another problem that a gd mom may be more prone to is pre-eclampsia, also known as Pregnancy Induced Hypertension (PIH) or Toxemia. (Although technically there are differences between these terms, the tremendous inconsistency with which they are used, even in the medical community, means that they are often used interchangeably.) GD moms who have PolyCystic Ovarian syndrome (PCO) may be particularly prone to PIH and should be watched carefully. PIH is a substantial rise in blood pressure that occurs in pregnancy. It is often accompanied by swelling/edema and protein in the urine (pre-eclampsia). If it is not controlled, it may progress to Eclampsia, a truly serious pregnancy complication, one that can even be life-threatening. Another variation involves other organs (HELLP syndrome) and is also potentially extremely serious.

Most women with gd will NOT get PIH, but the rate is increased somewhat over normoglycemic pregnancies. Pregnancies with gd and PIH often end up being induced fairly early (depending on how well your blood-pressure does) since high blood pressure can mean that fetal nutrition and growth may become compromised. It is important to be extremely careful if blood pressure is a concern for you, and you should be sure to be extra careful to be getting adequate nutrition. Most pregnancies with pre-eclampsia do turn out fine, but there certainly is reason for concern.

However, it's important to note that many obese women are falsely diagnosed with pre-eclampsia/high bp because the wrong-sized blood pressure cuff is being used--a cuff that is too small will often erroneously register higher numbers. There are generally 3 sizes of blood pressure cuff: average-sized, which the majority of the public use; large-sized, which most mid-sized obese people should use; and a so-called 'thigh' cuff, which supersized people should use. Within these 3 sizes, not everything is standardized; sometimes a woman who normally uses a mid-sized cuff will need a thigh cuff, or vice-versa. If you have any doubt about your blood pressure reading, you should have it retaken with the next larger cuff to be sure the reading is accurate. NEVER take for granted that they are using the correct-sized cuff for you; ASK for a large cuff or thigh cuff EVERY time without fail. Sometimes medical personnel will tell you that it's not necessary, that their large cuff is 'broken', or refuse to get a large cuff, but it is VITAL that you insist on one anyhow. It's extremely important that your treatment decisions be based on VALID data. [Kmom knows from personal experience that a correctly-sized cuff makes a world of difference.]

Other Possible Problems

Other problems that can sometimes occur include polyhydramnios and pre-term labor. These are unusual; most gd moms will not get them, but they happen enough that your provider will be alert for the possibility. Polyhydramnios refers to an excess of amniotic fluid around the baby, which can potentially cause problems. If your provider is concerned, you can have an ultrasound to determine the level of amniotic fluid present. Pre-term labor is labor that occurs before the baby is mature enough to be born; medications are available that may be able to help stop labor, and bedrest is usually ordered as well. Although the incidence of both of these is higher in gd, the rate of occurrence is not very high, and gd moms shouldn't spend a lot of time worrying over them. It's something to be aware of as a possibility, but most gd moms won't experience these.

A problem more worthy of concern is the high rate of c-sections that seem to occur in gd pregnancies. C-section rates for NON-gd pregnancies around the USA tend to average about 20-22% currently. Choice of provider seems to be a factor; midwives and family doctors tend to have much lower c-section rates, but they also mostly see lower-risk cases. Generally speaking, the gd c-section rate tends to be higher than the national average, but as with normoglycemic pregnancies, the rate varies greatly. Most research studies have found gd c-section rates to be between 20-40%, probably averaging about 25-30%. Some studies have found c-section rates for gd as low as 9-11% (usually with midwives and family practice doctors) and others as high as 40+%. It is highly questionable just how much of this high c-section rate is truly necessary due to unavoidable risks, and how much is due to physician protocols, questionable delivery practices, etc. A number of studies have found that even when c-section risk factors such as macrosomia etc. were reduced to 'normal' ranges, the c-section rate in most studies remained quite high anyway, strongly indicating that physician perception of gd as 'high-risk' and a resulting lower threshold for intervention were probably partly to blame for the very high levels of c-section in gd.

The majority of gd moms still deliver vaginally, please note. GD moms should mentally and emotionally prepare for a normal delivery but also be aware of the possibility of a c-section and have a portion of their birth plan deal with their wishes in case of a c-section, should it become necessary. Even if you don't think it will happen to you, your birth plan should deal with the possibility. A great deal can be done to make c-sections better birth experiences, even under difficult circumstances, but unless you have discussed these possibilities ahead of time with your OB, you will probably have limited options. Hopefully, you will not need to use this part of your birth plan, but it is better to be over-prepared.

Risks for the Baby

Generally speaking, the baby of a gd pregnancy is not at significant risk for major problems unless the gd is severe and/or uncontrolled, if it occurred in very early pregnancy, or if the diabetes was pre-existing before pregnancy but only discovered during pregnancy. If the gd is discovered in a timely manner and blood glucose is kept in control, the vast majority of babies of gd pregnancies do fine. This is important to stress when listing the possible risks, because the research summaries of risks tend to focus on the worst-case scenarios, and do not generally factor out the influence of co-existing morbidities that may have had as much or more influence on outcome as the gd. So when reading about fetal risk, keep in mind that although these conditions are possible, that doesn't mean that they will happen or even happen very often. Keep the concern in perspective.

Macrosomia

The most commonly emphasized risk for gd pregnancies is macrosomia, or a baby that is extra-large. It is true that macrosomia (babies above 8 lbs., 13 oz.) does occur more often in gd pregnancies on average. This has been thought to be because extra amounts of maternal glucose cause the baby to produce too much insulin, and the combination of fetal hyperinsulinemia and maternal hyperglycemia causes the baby to grow 'too large'. Certainly, many truly diabetic pregnancies of the past have had extreme problems with this, sometimes resulting in 12 and 13 lb. babies that had many physical problems. However, gd pregnancies do not usually result in this kind of extreme overgrowth, and most truly diabetic pregnancies today have such improved ways to control and monitor that this is extremely uncommon today in them as well.

However, the rate of babies above 9 lbs. or so DOES tend to be higher in gd pregnancies. However, the way the risks are often stated, it makes it seem like ALL or VIRTUALLY all babies of gd pregnancies will be huge, when in reality, only about 20-30% of gd babies are macrosomic (average in the general population is about 10%). In fact, the majority of gd babies will be born of average weight. Although many providers emphasize the worst-case scenario of 'huge' babies causing birth trauma in order to scare their patients into compliance, in actuality the chances of you having an extra-large baby are not a sure thing by any means. However, it is correct that your chances of having a bigger baby are greater with gd, about 2-3x greater. The question that critics raise is how clinically significant that is.

GD studies have also found that the majority of the large gd babies born are born to heavy mothers. Despite extremely strict treatment protocols, this number has almost never been able to be normalized to the ~10% that would be expected in the average-weight, normoglycemic population, and critics charge that the higher rates of macrosomia in gd are more related to the size of many of these gd mothers than to glucose tolerance per se. Several studies have found that maternal body weight was more strongly related to baby birth weight than any other factor, including glucose tolerance. GD researchers have attempted to explain this by speculating that other maternal fuels (such as those derived from fatty acids, triglycerides, etc.) are higher in heavier women and thus add to 'fetal overgrowth' even when glucose tolerance is controlled or normal. Critics, on the other hand, point to the influence of genetics as the primary source of larger infants in larger women.

Whatever the cause, larger women do tend to have larger babies on average, with gd or without it. It's important to point out that this is a group tendency only; it does not apply to individuals. Many individual gd moms who are large do not have large babies; some of them even have smaller-than-average babies. It is individual family history that is the best predictor of birth size among individuals. If you are large and have gd, your baby certainly may be of average size anyhow. But if it is not, the question is how much of that size is due to 'maternal fuel abnormalities' or simply to genetics, and also how relevant baby's larger size really is in most cases.

Doctors tend to be particularly uptight about baby size with a mom that is large and has gd, and tend to induce early for 'suspected macrosomia' very often in this group.  Larger women tend to 'measure' larger in fundal height (distance from pubic bone to top of the uterus), and doctors tend to panic when they see this larger number.  It is not surprising that larger women would measure larger, since they have 'more there' in the first place.  But somehow doctors expect the fundal measurement to be the same despite pre-pregnancy size differences, and assume that a bigger number must mean a huge baby.  MANY large moms have been induced early for 'a huge baby', only to find that baby was only 7 lbs. after all. 

How significant macrosomia is to the labor and birth is a critical issue. Simply because more gd infants fall above the 9 lb. cutoff than average does not necessarily create dire predictions for the baby or the birth. GD researchers point out that these babies have higher rates of c-sections and shoulder dystocia/birth trauma, and that in some cases, preferential growth occurs in the shoulders/trunk area, making baby possibly more likely to get 'stuck'. GD babies of large size do have higher rates of shoulder dystocia, injuries, and c-sections, but the question remains just how much of this is caused by interventions from the doctor versus true problems caused by the baby's size. Likely, both contribute to the higher rates of problems, and it's likely that some of the problems could be avoided both through less-interventive treatment protocols and also more careful control of blood sugar. But this is a question that is still being studied and data is limited at this point.

GD proponents also contend that a baby's macrosomia puts it at much higher risk of higher blood pressure, early glucose intolerance, obesity, etc. as it grows up, but research is contradictory on this point. Some studies have indicated more problems among macrosomic gd babies, and some studies have not found more problems. At this point, it is interesting but mostly speculative on the part of researchers to contend that 'normalizing' baby birthweight will help prevent health problems for the baby in the future. The truth is that the research is contradictory, extremely limited, and mostly represents researchers' aspirations rather than proven conclusions. Much more information is needed.

Metabolic Problems in the Newborn

Researchers are rightly concerned about higher rates of hypoglycemia and jaundice in the gd newborn, regardless of size, although it's important to note that most of the time these are mild and can be resolved without major intervention. Some researchers contend that about 50% of gd neonates will experience hypoglycemia (low blood sugar) at birth, but most studies show lower rates than this. A great deal also depends on the glycemic control of the mother in the last weeks before the birth, and also on the intervention protocols of the doctors. There is a strong case to be made that some of the routine interventions and protocols associated with gd actually increase the rate of hypoglycemia and jaundice to be found in gd babies. For more details, see below under 'Postpartum Treatment' or in the websection on GD Risks.

Neonatal hypoglycemia is caused by the higher levels of insulin thought to be produced by baby in response to its mother's hyperglycemia or other fuel abnormalities. When this extra glucose etc. is cut off after birth, the baby's higher insulin levels can cause its blood sugar to plummet. This usually can be treated simply by early and frequent nursing (see the websection GD and Breastfeeding: A Special Relationship). However, occasionally, additional treatment is needed, such as formula supplements or in more severe cases, IV glucose. Although in the past these were routinely done to ALL gd babies, these have been found to be unnecessary in most cases, and routine use has been discontinued in many hospitals. In fact, breastfed gd babies, if allowed to nurse early and frequently, do better on average than formula-fed gd babies, and routine admittance to the Special Care Unit is not needed in most cases when baby is breastfed early and frequently. But occasionally, there are some gd babies do need supplements or IV glucose, and extra careful monitoring. This is more common with babies of insulin-dependent gd moms, but can certainly happen sometimes to babies of diet-controlled gd moms too.

Jaundice (hyperbilirubinemia) tends to occur more frequently in babies of diabetic pregnancies as well. This is thought to be primarily because the gd baby's high levels of insulin production tend to also produce extra red blood cells to help normalize a potentially compromised fetal oxygen supply. After birth, however, these extra red blood cells must be broken down and processed by the infant's liver, and that is a heavy load to handle. However, here again the strongly interventive protocols of the doctors may also iatrogenically increase the jaundice rate as well. More gd mothers face induction of labor, and pitocin is well-known to raise the rates of jaundice in newborns. Also, many gd babies have had delayed access to nursing and liberal use of glucose water supplements, and this can also significantly add to jaundice levels. The best prevention for jaundice is again early and frequent nursing, which tends to encourage the faster excretion of baby's first stool (meconium), which eliminates bilirubin from the body. If stooling is delayed because nursing is delayed or infrequent, the bilirubin present in the infant's intestines gets reabsorbed by the body and jaundice is increased. Glucose water supplements, once thought to 'help flush out the jaundice,' have actually been found to increase bilirubin levels and make jaundice worse.

In all likelihood, routine past practices of automatic separation of the gd baby from its mother, delayed and infrequent access to breastfeeding, and routine use of glucose water supplements probably increased the rates of hypoglycemia and jaundice in gd studies, but even when early and frequent nursing is the norm, the rate of hypoglycemia and jaundice is still elevated somewhat in gd babies. Therefore, newborn observation and/or  testing can be important, particularly for hypoglycemia. (Bilirubin testing varies; in some hospitals it is routine, and in others it is only done in the presence of symptoms.)  Most of the time, gd babies do NOT need to go to the special care nursery; any observation or testing can usually be done from the mother's arms or bedside.  

There are other, more rare metabolic problems that can occur with gd; just how common these are and how clinically significant is debatable. These can include low calcium levels (hypocalcemia), too many red blood cells (polycythemia), low platelets (thrombocytopenia), damage to the kidney veins, etc. Because of doubts about their clinical significance at borderline levels, most providers do not generally routinely check for these unless the baby is ill/shows symptoms, or the mother had very poor blood glucose control or other risk factors.

Other Possible Problems

Prematurity and Respiratory Distress Syndrome are also theoretical risks of gd, but again these may be influenced by the past practice of early elective delivery. In the past, diabetic infants were more at-risk for late-developing lung maturity, but recent research seems to show that this is usually related to glycemic control. For mothers with excellent bG control that are not delivered early, lung maturity is generally not thought to be such an issue anymore. However, regardless of bG control, elective c-section without labor is always a potential risk factor for respiratory distress, and so is prematurity. If there is any doubt about the baby's lung maturity, an amniocentesis will be performed late in pregnancy (see below). If the lungs are immature, steroids can increase lung maturity quickly in many cases.

In some hospitals, careful attention will also be paid to the baby's heart to be sure it developed normally. If gd existed early in pregnancy or there was pre-existing diabetes, heart problems and other birth defects are a possibility, but since most gd develops late in pregnancy (around 26-28 weeks), it is not usually an issue. However, if your gd was insulin-dependent, severe or difficult to control, began early in pregnancy, or may have existed before pregnancy, careful prenatal and postnatal monitoring for these conditions will probably occur, even though the rate of problems is still relatively low.

Long-Term Effects on the Baby

Babies of diabetic pregnancies of any type are almost never born diabetic themselves. You do not have to worry that your baby will be born diabetic simply because you had gd. They do have a somewhat higher risk of developing type II diabetes later, and there is some thought that daughters of gd pregnancies in particular are more at-risk for gd when they enter their own childbearing years, but this research is still fairly new since gd as a diagnosis has only really been extensively researched since the 1980s.

As noted above, there is a new emphasis on investigating the long-term effects on babies of diabetic pregnancies, who may tend to be more obese, have higher blood pressure, and have higher rates of glucose intolerance at earlier ages. However, it is difficult to distinguish inheritance risks, genetics, and environmental factors from the influence of having been in a diabetic pregnancy, and the risks of gd pregnancies vs. other diabetic pregnancies is also difficult to discern. In addition, since the pool of gd mothers has a significant number of obese women in it, it makes sense that genetically their children may also tend to be more obese, but simple genetics is a factor that most researchers refuse to consider. Many gd moms also have PolyCystic Ovarian Syndrome, and it may be this that passes on risk, rather than the gd itself, or a combination of the two.  Similarly, some research shows that babies given formula tend to be more obese, more insulin-resistant, and perhaps develop type II diabetes at a higher rate, so since breastfeeding rates tend to be lower after diabetic pregnancies, this may also be a factor--only time and more research will tell for sure.

Still, some research does seem to indicate that there may be some influence from diabetic pregnancies, especially more severe cases. Researchers have eagerly claimed this as a reason to justify ever more aggressive gd treatment, although little research as yet shows treatment improves long-term outcome for children. It's an interesting avenue of research, but one still largely speculative at this point, and unfortunately, one likely to instill a lot of guilt in gd moms. It will be an important area of investigation in the future, but in the meantime, beware extravagant claims justifying stringent interventions for the future health of gd children without proof of benefit.

 

Delivery Timing and Protocols

Extra Testing

Most women with gd will face some additional prenatal testing, although the debate continues over when to institute testing and how much is appropriate (see the websection on GD: Delivery Protocols for more details). Women with diet-controlled, mild gd will probably start testing very late, perhaps only at or near term (36-40 weeks). Women who need insulin are basically treated the same as most type I or II pregnant diabetics, and testing will probably be instituted at around 32-34 weeks. The goals of testing are basically to ensure normal growth patterns for baby, adequate development of the baby, and adequate nutrition, blood supply, and oxygen to baby. Tests used usually include extra ultrasounds, non-stress tests, sometimes biophysical profiles, and possibly an amniocentesis if early delivery is contemplated. Again, the amount and type of testing will vary greatly from one provider to the next, and the value of it in well-controlled diet-only gd pregnancies is debated, but nearly all researchers agree that gd moms with extra risk factors (high blood pressure, insulin-dependent, or history of stillbirth) should receive early and frequent prenatal testing. Mothers with well-controlled, diet-only gd and no other risk factors will probably undergo much less testing, started much later.

Another test that some doctors have considered adding is for Group B Strep colonization. This is an area of emerging research, so it is difficult for experts to make recommendations yet. Some studies have found that diabetic women as a group have about twice the rate of group B colonization as non-diabetic women; it is difficult to separate out the risk of gd moms vs. pre-diabetic moms in these studies. Of the studies on strictly gd moms, some have found increased rates while more recent ones have found no increase at all. Since obesity is also a small but significant risk factor in some studies, a few doctors consider testing more important for obese moms, though it's important to note that MOST obese women do not have group B strep colonization. At this point, it is unknown how important Group B Strep testing is in gd moms, obese or not. Some doctors do it routinely, and some only do it in the presence of risk factors such as pre-term rupture of membranes, etc. Presently, there is no universal guideline.

Although most babies of women with group B strep colonization are fine, those few that do get infected have a high mortality rate, so it makes sense to use an IV antibiotic prophylactically during labor in women who have tested positive shortly before labor. All gd women do not need IV antibiotics since most are negative for Group B Strep, but it may make sense to test them for Group B Strep shortly before term, although research and care protocols are still emerging in this area and may need to be re-evaluated over time. More on Group B Strep issues can be found at the following URLS: www.babycenter.com/refcap/1647.html#0 or at www.modimes.org/pub/groupb.htm.

The Debate Over Delivery Protocols: A Summary

The timing and mode of delivery for gd women is a matter of strong debate, and is complicated by any number of factors. ACOG states that "in most cases, women with GDM may be managed expectantly as long as fasting and postprandial glucose values remain normal," though in practice, most gd women (especially large women) are pressured into an early induction at 39-40 weeks or so. This may be part of the reason that the c-section rate for gd pregnancies is so high, although macrosomia and other factors also play a role. It should be noted strongly that there is a appalling lack of good research on the question of delivery in gd pregnancies; what little there is often has methodological or other problems. This is an area where tradition and fear has dictated the majority of present protocols instead of evidence-based medicine; it will likely be an area of rapidly expanding research in the next 5-10 years, so be sure to search out all the latest research for yourself. It remains to be seen whether early elective delivery (early induction or elective c-section) really improves outcome, or whether allowing a more 'liberal' policy of expectant management is better.

Generally speaking, there is a significant gap between theory and actual practice in delivery timing with gd, and this is a very important point to understand. Although the books and research SAY that delivery can vary quite a bit, the most commonly found practice in real-world obstetrics generally is to deliver earlier. This is because type I and II diabetic pregnancies in the past often had high rates of stillbirth at term, and even though blood glucose control and monitoring has improved this rate tremendously, doctors still are generally in a very conservative mode about delivery timing in diabetic pregnancies. Whether this risk really carries over into well-controlled gd pregnancies is highly debatable, but the 'default' position of most doctors is "earlier is better" when the diabetes label is present in any form at all. So although the following paragraph lists what is considered appropriate by books and research, it also notes when this differs from common clinical practice. It's important to remember that one is not proven better than the other, just that there's a difference between theory and practice. What research that has been done into which timing is better is still largely inconclusive at this time; much more is needed.

Basically, women who have excellent control by diet alone and who have an average-sized fetus can go to 41-42 weeks before induction, but often are induced at 40 weeks in practice. Women with excellent control by diet alone but whose babies look 'large' are often induced between 38-40 weeks; this practice has not been adequately studied and may or may not be beneficial, but it is extremely common. Women who need insulin can technically go to term (40 weeks) though usually they are not permitted to go beyond 40 or so weeks (a few studies have gone beyond 40 weeks but this is unusual). However, in practice they are usually induced at 38-39 weeks after establishing that fetal lungs are mature enough to breathe on their own after delivery. Again, it is not known conclusively whether it is better to induce at 38-39 weeks or to go to term, but the most common practice is to induce one to two weeks early when insulin has been used.

Women whose babies are estimated to be 'very large' (macrosomic) are often delivered by elective cesarean sections; this is because fetuses of diabetic pregnancies often exhibit exaggerated growth in the trunk/shoulders area and tend to have much higher rates of shoulder dystocia (shoulders getting stuck) and birth injuries. Although these rarely result in permanent injury to the infant, it is a potential emergency and occasionally does result in very poor outcome, even death. So extra caution is warranted with very large babies of diabetic pregnancies. However, experts vary on the definition of 'very large' and just what level of caution is needed.

In theory, nearly all experts recommend an elective c-section in diabetic women if the baby is estimated to be >4500g (9 lbs., 14 oz.); some recommend an elective section in diabetic women with fetuses at weights of 4250g (9 lbs., 6 oz.) or even 4000g (8 lbs., 13 oz.). In practice, most doctors strongly err on the side of conservatism and choose an elective c-section at estimated weights of about 4000g or so. However, since the accuracy of fetal weight estimation is generally poor, especially at higher weights, this policy will result in a number of unnecessary c-sections being done on women whose babies were not actually macrosomic. Furthermore, since the majority of marginally macrosomic babies, even in diabetic pregnancies, are actually delivered without shoulder dystocia or injury when given a vaginal trial of labor, many more of those 'elective' c-sections will have been unnecessary. At what level the tradeoff (potential injury in a population at high risk for such injury vs. the very real morbidity associated with major abdominal surgery) is justified is highly debatable and will also undergo a great deal of research in the near future.

Thus the recommendations for timing of delivery, liberal use of inductions, and use of early induction or elective section with suspected macrosomia is the subject of a significant amount of debate, as noted below. The current standard of practice at this time on delivery issues is mostly based on custom, not research. Much more work remains to be done before optimal, evidence-based recommendations for timing and mode of delivery can be made.

Issues of Concern When Contemplating Early Elective Delivery

A real concern in early delivery is the possibility of Respiratory Distress Syndrome (RDS) in the baby, so unless the baby's health is compromised, establishing fetal lung maturity before any consideration of early delivery has been a must in the past. An amniocentesis to establish lung maturity is usually done if delivery is contemplated at or before 38 weeks; after 39 weeks it is not usually seen as needed anymore if the mother has had excellent control. 

The amnio measures the Lecithin/Sphingomyelin ratio (L/S ratio); a ratio of 2.0 or more is generally thought to indicate a low risk of RDS. However, the presence of the acidic phospholipid phosphatidyglycerol (PG) is considered to be the final marker of fetal lung maturation. There are reports of RDS occurring in women with a mature L/S ratio but absent PG. So if early delivery (before 39 weeks) is deemed necessary, documenting lung maturity with both an L/S ratio and the PG marker is important. 

Some doctors are challenging the need for this test at a fetal age of 38 weeks. Before 38 weeks, it IS necessary, and after 39 weeks it probably is not necessary in women with excellent control. However, in women right at 38 weeks, it is still unclear whether documenting lung maturity is truly needed. If you are at 38 weeks, you can either choose to wait another week to induce or discuss with your provider whether an amnio is really needed in your case. If in doubt and if early delivery at 38 weeks is really that important, most providers feel it is probably better to err on the side of testing, just in case. Research has shown that the majority of cases of RDS are in babies at 37 and 38 weeks without documentation of lung maturity, and research has urged doctors to be more careful to test lung maturity before elective delivery.

An issue which must be balanced against the maturity of the fetal lungs is the sufficiency of the placenta in diabetic pregnancies. In 'true' diabetic pregnancies, placentas do tend to age faster and may be insufficient for the fetus beyond term. It is unclear whether this a real concern for a well-controlled gd pregnancy, especially one that doesn't need insulin. 

At this time, insulin-dependent gd pregnancies are generally treated as if placental sufficiency is a vital concern, and are rarely 'allowed' to go past term (most are induced before term). It is difficult to discern whether concern over placental condition in NON-insulin-dependent gd pregnancies with excellent control is that vital. In practice, most are induced at 39-41 weeks, though some providers do 'allow' diet-controlled gd moms to go to 42 weeks if all tests are reassuring and the baby seems of average size. Certainly careful testing to assure the well-being of the baby and the placenta near term and beyond is justified, but it is also clear that more study and clarification of this important issue is urgently needed.

Another issue in early delivery is whether the estimated fetal age is actually correct. Quite a number of cases of elective induction or delivery of "39-40" week fetuses have actually been found to have involved 37-38 week fetuses. If the mother has irregular menstrual cycles or longer-than-average cycles, the Estimated Due Date (EDD) may well be incorrect and the fetus is probably younger than previously thought. To proceed with delivery of a baby younger than predicted probably strongly increases the c-section rate due to failed inductions, and certainly raises the rate of Respiratory Distress Syndrome. Any gd mom who has had irregular cycles or longer-than-average cycles should be very careful to weigh all the issues of possible prematurity before considering early delivery.

For women with extremely irregular cycles, an ultrasound very early in pregnancy can help confirm fetal age pretty accurately, but ultrasounds in late pregnancy are notoriously inaccurate for estimating due dates, size, etc. It is best not to use late ultrasounds to adjust the expected due date unless it was impossible to date the pregnancy earlier. 

For women whose cycles are pretty regular but significantly longer than average (averaging 33 days or more), the due date should generally be adjusted one day for each day exceeding a 28 day cycle; i.e., if your cycle is 35 days on average, you should add a week to the usual due date given. Many doctors, however, are reluctant to adjust the due date and refuse to use anything but the Last Menstrual Period (LMP) to calculate the due date. This leads to many women with longer cycles being induced unnecessarily, and perhaps having unnecessary c-sections due to 'failure to progress' when their bodies simply weren't ready yet for labor.

In women with gd, having scrupulously accurate due dates is a particularly critical issue, since they often face pressure for early induction anyhow. Inducing a mom at 38-39 weeks would actually mean inducing a mom with long cycles at a true gestational age of potentially 36-38 weeks, and the risks of c-sections and Respiratory Distress Syndrome increases strongly. An extra week may seem like nothing, but it can mean a great deal in terms of lung maturity and the body's 'ripeness' for labor. If your cycles are 33 or more days, you should lobby to have your due date adjusted accordingly.

Kmom's Story: Based on Last Menstrual Period, my due date in my second pregnancy should have been the end of the month, but because my cycles average 35+ days, my provider and I agreed that my due date was a week later. My actual due date would have been called '41 weeks' by LMP and it is unlikely that I would have been 'allowed' to go to 41 weeks if I'd had gd, since my babies run 'big'. However, in actuality, I went into labor 2 days before my adjusted due date and dilated efficiently and completely naturally.

Had this pregnancy been strictly dated by LMP, this would have been called 'overdue' by a week and I probably would have been induced (in fact, the hospital refused to use the adjusted date and listed me as 41+ weeks in the records). But with accurate dating, my body was able to go into labor naturally just before my REAL due date, without my provider hyperventilating over being 'overdue'. I did not have gd in that pregnancy after all, but had it occurred, accurate dating would have become even more important because of the pressure for even earlier induction. In all likelihood they would have tried to induce me at 38 weeks (due to gd and a history of 9 lb. babies), which would have been not quite 37 weeks in actuality for the baby. One week does not seem like a lot, but those final weeks are not 'disposable' and unimportant, and should not be discarded lightly. The risk for RDS goes up significantly even a week or two earlier.

It is VITAL for women with long (but regular) cycles to have adjusted due dates, but had I not had charted documentation of my 'late' ovulation, my doctor would not have adjusted my due date, and some doctors would not have adjusted it even with documentation (as the hospital did not). Women with long cycles MUST be assertive about correct due dates, and especially if they have gd.

The Debate Over Delivery Protocols: Inductions

At this time, in the face of concerns over macrosomia and placental function, early induction remains extremely common among most gd providers, particularly OBs; family practice doctors and nurse-midwives tend to induce less. From the research, it is unclear which approach is more favorable. Many critics strongly object to the fact that timing for induced labors for the same presenting symptoms can vary HUGELY from one provider to the next. A diet-controlled gd mom may face mandatory induction at 38 weeks with one doctor, mandatory induction at 39 weeks with another, mandatory induction at 40 weeks with another, or expectant management up to 41-42 weeks with another. Obviously, this lack of standardization is a source of much controversy.

Many critics also object to the high rate of inductions with gd pregnancies in general. They contend that the medical evidence that inductions are necessary in most gd cases is mixed at BEST, and that providers are simply relying on a tradition of extremely conservative care rather than real evidence of benefit. In addition, critics are concerned about the level of suffering, since induced labors are often difficult, complicated labors, have fairly high rates of fetal distress and c-sections, and are generally very hard on the mother. Finally, the possible issue of fetal lung maturity and prematurity caused by improper due dates raise significant concerns with the routine use of induction in gd pregnancies.

Proponents of liberal use of inductions in gd cases feel that they can reduce the c-section rate by allowing the baby to be born when it is smaller and theoretically 'easier' to deliver and theoretically less likely to have birth trauma or shoulder dystocia. They point to a few small studies that seem to show that early induction can help the c-section rate or reduce the macrosomia rate without strongly increasing the c-section rate. They also feel that earlier induction is safer because of concerns about placental sufficiency and stillbirth at term, and note that the danger of fetal hypoxia (low oxygen) may be greater with fetal hyperinsulinism. They generally do not make a significant distinction between the risks of a gd pregnancy and the risks of pregnancy in women with pre-existing diabetes. Indeed, in more severe gd cases, the risks of a gd pregnancy may be comparable to those of a woman with true diabetes, but it is difficult to quantify the risk in borderline gd pregnancies.

Again, there is a significant lack of clear evidence on this subject, and what evidence there is is open to interpretation. Significantly more research is needed, done with more careful and thorough methodology.

The Debate Over Delivery Protocols: Elective C-Sections for Macrosomia

Another area of great controversy, as noted above, is the recommendation for 'elective c-sections' when macrosomia is suspected. This (and/or early induction) is usually recommended for larger babies in order to avoid the possible problem of shoulder dystocia (where the head is delivered but the shoulders are stuck), injury to shoulder/arms and nerves (Brachial Plexus injury/Erb's Palsy), or other birth trauma such as clavicular fracture, etc.

This tradeoff of many more c-sections in return for possibly preventing a few cases of shoulder dystocia or injury is a matter of significant debate. Although very few cases of shoulder dystocia end up in permanent injury to the child, the few injuries that do occur can be serious. In extremely rare cases, a few deaths have been recorded. Doctors are especially concerned about shoulder dystocia in diabetic pregnancies due to possible asymmetric growth in the trunk of the baby. Research confirms the higher rate of shoulder dystocia in diabetic pregnancies compared to non-diabetic pregnancies with infants of the same birthweight. Although some of this can probably be attributed to iatrogenic (doctor-caused) problems due to the extreme amount of intervention typical in diabetic pregnancies, not all of the higher rate of problems can be thus attributed. Doctors ARE correct that more caution is justified in macrosomic babies of diabetic pregnancies due to potential injuries; the question is just WHAT the best treatment is and where the line should be drawn.

Using an arbitrary cutoff of 4000g (8 lbs., 13 oz.) to automatically select elective c-section means that many women who would NOT have experienced shoulder dystocia or fetal injury will be 'sectioned' as a precaution. They will thus be subject to the considerable risks and problems of a c-section, such as wound infection, traumatic surgery, excessive blood loss, anesthesia problems, fetal respiratory distress syndrome, poorer initial fetal response, increased placental problems in future pregnancies, etc. In addition, all of her future pregnancies will be considered 'high-risk' and subject to many more interventions and restrictions, simply because of her previous cesarean surgery, a serious long-term implication not taken seriously enough by the obstetric community. Furthermore, estimating fetal weight by ultrasound, even a series of ultrasounds over time, is subject to a strong margin of error, especially at higher birthweights. Thus, a woman may be electively 'sectioned' (with all its attendant risks) for a suspected large baby that in actuality is not even >4000g. [This has happened many times.]

Finding a balance between preventing the real risks of the occurrence of shoulder dystocia versus the real risks of major abdominal surgery is a very difficult balancing act, presenting a real dilemma for the gd provider. Currently, almost all providers recommend considering elective sections in gd if the fetal weight is estimated to be 4500g (9 lbs., 14 oz.) or more. Although some babies of diabetic pregnancies have been delivered safely vaginally over this weight, the rate of shoulder dystocia and problems is high enough that most providers agree that the risk of trying vaginal delivery outweighs the risk of major surgery. Again, the weakness of this policy is that estimated fetal weight can be highly inaccurate, but at this point most providers currently feel that this cutoff is justified.

In actuality, most providers generally 'default' to the lowest possible guidelines due to the extreme conservatism typical of most doctors dealing with 'diabetic' pregnancies and their grave concern over potential injuries. Most use a threshold of a fetal weight estimation of 4000g (8 lbs., 13 oz.) to determine the 'need' for an elective c-section. As noted above, that means that a significant number of the resulting c-sections will be 'unnecessary', but these providers feel that this is preferable to even a small risk of shoulder dystocia and birth trauma (please read below for a further discussion of shoulder dystocia and birth trauma). More providers today are actually beginning to consider raising this threshold to 4250g (9 lbs., 6 oz.) instead, in order to lower the rate of unnecessary c-sections resulting from the 4000g cutoff, and some research on this looks promising. However, it is also difficult to dismiss the real concern for potential injuries. At this time, the standard of care among most care providers is to consider elective c-section when fetal weight is estimated to be 4000g; whether this is justified is a matter of significant debate.

The Debate Over Delivery Protocols: Early Induction for Macrosomia

In order to try and reduce the high rate of elective c-section at term for macrosomia, many providers favor early induction in a pregnancy where it looks like baby might end up between 4000-4500g. This is a debate that is likely to be widely examined in the next few years; little satisfactory research has been done on it. What little research there is has mostly been done on the babies of insulin-dependent gd pregnancies, not diet-controlled pregnancies, which may distort the results towards more intervention. Very little research of sound methodological design has been done, particularly in non-insulin-dependent gd moms. So at this time, it is difficult to know if the typical recommendation to induce early in the case of suspected macrosomia is really justified or not.

Complicating all of this is the high rate of inaccurate estimates of fetal weight by third-trimester ultrasound (the prediction for the size of Kmom's gd baby was off by *2 pounds*!). Different studies show differing levels of accuracy for fetal weight estimation, but it seems to be most accurate in babies of average size, and least accurate at extremes of size, either large or small. Critics are strongly dubious about whether early induction or elective c-section really prevent enough problems to justify their routine use, but they continue to be standard procedure in many practices.

In looking at the issues, it is important to make the distinction between diabetic and non-diabetic pregnancies with suspected macrosomia. In NON-DIABETIC pregnancies, recent research has repeatedly found that routine induction for suspected macrosomia was unjustified because it did not improve outcome (did not prevent injury, and either did not lower c-section rates or actually significantly increased them--see references). Similarly, these studies do not support elective c-sections until the baby gets very big indeed (around 5000g/11 pounds) and points out that while macrosomic babies do have higher c-section or injury rates, the vast majority CAN be delivered vaginally and usually without injury to the baby. The research tide in *non*-diabetic pregnancies with suspected macrosomia is expectant management (waiting until labor starts on its own, up to 42 weeks), though clinical practice lags behind.

However, the higher rate of shoulder dystocia in DIABETIC pregnancies (even when the infant is in the same weight class) means that these are justifiably treated with more caution. Routine use of early induction and elective c-section at lower weights (see above) is generally accepted among many gd researchers, though relatively few trials have adequately examined the question fairly. Certainly, more caution is appropriate, though some feel the guidelines may have become too stringent. The research on this issue is comparatively sparse, and often applies standards of 'true' diabetic pregnancies to gd pregnancies (and the standards of insulin-dependent gd pregnancies to mild gd pregnancies) without really examining whether this is justified. It's possible that these standards are universal, but it has not been proven or addressed fairly.

Of the few gd trials conducted fairly, no clear answers have emerged when the research is examined closely. Some have shown definite benefits to inducing early or by term (mostly in insulin-dependent pregnancies, but not always) while others have shown that some non-insulin-dependent pregnancies with mild macrosomia can go past term and be managed expectantly. Some people speculate that these cases may benefit from a trial induction (but perhaps not as early as before), or several 'serial' inductions where there is the option to stop and try again in a few days. The most optimal management for gd pregnancies with mild macrosomia has yet to be determined, especially where control is excellent and insulin not needed. This will be an area of emerging research in the next few years.

Obscuring the true risk in this situation is how much shoulder dystocia is actually created or exacerbated by common obstetric practices (restricting women to bed, using stirrups during pushing, lack of flexibility in pushing positioning, inattention to fetal presentation, overuse of pitocin, rushing the delivery of the shoulders, etc.) and how much is endemic to diabetic pregnancies. This is a critical issue for determining risk and reasonable standards of practice for diabetic pregnancies, but it is a topic strongly neglected by the obstetric community. Much more research needs to be done on this topic in the near future before the issue of the best management of the gd patient with suspected mild macrosomia can be determined. This is an extremely important but vastly neglected area of investigation.

More Voices of the Critics

Many gd critics charge that few gd mothers are being given truly informed consent about her choices in this situation; most OBs are choosing the most conservative course of treatment possible without informing mothers adequately of the concurrent risks of induction and c-sections (uterine rupture, infection, mortality or serious morbidity risk, higher rates of infertility/ectopic pregnancies/placental problems in future pregnancies, lower rates of breastfeeding,etc.). They charge strongly that most gd women (especially those that do not need insulin) do not need to be treated with such high-risk protocols, and many gd mothers are being sectioned unnecessarily. They strongly question the need for early induction, even in the face of mild macrosomia, and are particularly critical of the automatic policy of 'elective' section at 4000g. Again, this is likely to be an area of lively debate in the near future.

Issues regarding macrosomia are especially pertinent to large women, since large women tend to have larger babies as a group (though not always as individuals) and maternal size is a strong risk factor for 'macrosomia'. A critical question is whether the macrosomia that occurs with large women in gd pregnancies is due to genetic size (simply a variation of normal but not necessarily pathological), abnormal maternal metabolism (pathological), or a combination of the two. If it is due to maternal metabolic abnormalities, then aggressive correction is necessary and early delivery may be beneficial. If it is due simply to genetic size, then aggressive correction could be potentially extremely harmful to the baby and early delivery could be similarly harmful. It seems likely to assume at this time that many cases are actually probably due to a combination of both, and this makes for very gray areas in deciding timing/delivery issues and risk versus benefit scenarios.

Critics are also strongly derisive of the vast differences in delivery protocols and timing between providers. Some providers are extremely aggressive about early elective delivery, especially in women of size, while others would permit the same women with the same presenting situation to go past term and without elective delivery if tests were reassuring. Little study has been done specifically on the best protocols for women of size with gd; much practice is based simply on the assumptions of the providers without actual data to back up their choices. Studies show that women of size are induced at much higher rates than the rest of the population, even when there are NO medical indications for it. Such a predisposal towards induction in women of size may lead to large gd moms being induced at even higher rates without knowing whether this is helpful or not.

All of these delivery issues remain strongly variable in practice and the source of much debate. Women who are being advised to submit to very aggressive delivery practices may well be advised differently by a new provider; similarly, women whose providers favor expectant management might well receive advice in favor of more aggressive early induction/sections from a different doctor. This causes a significant dilemma for gd moms, who must either agree blindly to follow their provider's recommendations (which may or may not turn out to be justified), or try to discern the relative value of different delivery policies herself. Women who are uncomfortable with their providers' recommendations might wish to consider obtaining a second or third opinion before agreeing to anything, though it's important to carefully consider your provider's reasoning since it could well be appropriate in your case. Women should carefully study these issues before making any decisions.

Kmom's story: In the course of interviewing OBs and midwives, Kmom found a HUGE discrepancy between providers. Assuming the same presenting conditions of mild and well-controlled gd with no complications except that the baby was looking 'a little big', one OB wanted to deliver at 38 weeks, another at 39-40 weeks, another at 41 weeks, and the nurse-midwives [backed by OBs] were willing to go until 42 weeks, all of course providing that all prenatal tests were encouraging and no other problems emerged. The difference between 38 and 42 weeks is an entire MONTH-----a HUGE difference for a baby in utero, and one with major potential implications for the baby's health! I was absolutely flabbergasted by the differences in delivery recommendations----how could they justify such differences in protocols? This was my first and biggest clue that treatments for gd weren't really standard at all and the treatment you received TOTALLY depended on the provider you randomly had chosen. Had you chosen a different provider, you might well be managed in a TOTALLY different way.

Labor in the GD Mom

During labor itself, gd delivery protocols should not generally be that different from normal labors. Although some providers maintain a more intense level of monitoring and labor restrictions, this is not based on any official recommendation. A gd mom does not generally need constant fetal monitoring or to be restricted to bed or in certain positions, although sometimes they are told this (or inductions make it necessary). However, it is likely that a higher degree of monitoring will accompany insulin-dependent pregnancies or ones complicated by high blood pressure or previous stillbirth, which seems sensible.

Blood sugar is generally measured during labor every 1-2 hours; some providers prefer that plasma glucose levels should be kept <90-100 mg/dl (up to 15% higher with home monitors) in order to decrease the risk or severity of neonatal hypoglycemia. Some critics have questioned whether these strict protocols actually lead to more hypoglycemia and fetal distress due to lack of energy reserves in the mother, and some providers do allow higher readings (up to 120-140), especially if they are flexible about eating during labor. Consult your provider.

Women needing insulin in pregnancy often do not require it during labor because of the workload of labor, but some women react strongly to the stress of labor (especially induced labor) and do need insulin in labor. Many providers will provide for some administration of insulin but exact bG levels should be monitored closely to be sure this is necessary and does not cause hypoglycemia. Exact protocols will vary; again, consult your provider.

One area of significant concern is keeping up the energy reserves of the gd mom in labor without raising her glucose level unduly. Most hospitals, unfortunately, do not permit eating or many liquids during labor (this is considered outdated by most critics but still exists in many places); a gd mom in a long or induced labor may be without nourishment for a long time. In order to avoid ketones and to help maintain energy, sometimes glucose will be given by IV. However, this raises the mother's risk for a spike in bG, and does not address her need for other nutrients during a period of extended hard work. Most gd moms are not given any nourishment during labor, even by glucose IV, raising her risk of energy depletion and exhaustion. They are being asked to run a marathon while starving, in essence, and this may be particularly difficult with gd. Different providers have different protocols to help with this; ask your doctor. However, negotiating for some food intake during labor if possible (or laboring at home for as long as possible and eating lightly during early labor) may be an option to consider. You'll do your best work if you have adequate nutrients and energy through the process. Keeping well-hydrated is particularly important since dehydration tends to increase fetal distress and maternal exhaustion.

Since you don't know ahead of time when you'll go into labor or how long it will last, it's VERY important to keep excellent and frequent eating patterns during the end of your pregnancy (and into early labor if possible)---you don't know how long it will be before you can eat or drink again! Many women slack off in their eating and fluid intake in the last week or so of pregnancy due to fatigue and 'fullness', but this leaves many women with low energy reserves and near-dehydration at the start of the hardest work of their lives! It is especially VITAL for gd moms to take care of these issues, since she is less likely to be able to have energy foods at the hospital and because the degree of her glycemic control in the week or two before labor greatly influences the rate of hypoglycemia in the baby after birth. It's a nuisance to have to push frequent eating and liquids in the last few days of pregnancy, but it's VERY important to the health of you and your baby, particularly with gd.

Other tips that might aid your chances of a vaginal birth include keeping an upright and mobile position to help labor progress better. Sit in a chair, walk extensively, kneel, labor on hands and knees (especially if you have back labor), rock your hips back and forth, use nipple stimulation, sit leaning forward with your back rounded (like when getting an epidural but without the drugs), have your partner use counterpressure on your back, sit on the toilet, lean over the edge of a chair or bed, lay on your left side when tired, kneel on one knee but keep the other foot up, etc.---all of these are excellent ways to help labor along. The use of water through either showers or getting into jacuzzis tends to really relax you and help dilate you faster and handle pain better (Kmom can attest to that!). Research has also shown that a professional labor assistant (called a 'doula') reduced the risk of c-section by as much as 50%, as well as the length of labor and the need for pain meds. So in addition to trying to vary your labor coping patterns, strongly consider hiring a doula in order to have experienced, professional labor assistance that knows from experience the best coping techniques and will help you stay relaxed in the face of pressure.

Types of Induction

If you are induced, your chances of being able to use these helpful measures (mobility, Jacuzzis) are strongly reduced, although some providers still 'allow' them during some types of induction. You can often 'negotiate' with your provider for some of these options if an induction is a must in your case. It is VERY important to establish as much flexibility and mobility as possible with your doctor ahead of time, so the nursing staff has written orders to that effect in their records. Many of the restrictions on labor that are routine in many hospitals are not strictly necessary and can be negotiated around if your provider is flexible and you establish your desire to utilize them.

Kmom was able to be induced sitting upright in a rocker and taking short walks in her room for the first few hours, and the staff was generally cooperative to this flexibility at first even though it was not standard procedure. However, after the waters were broken by the doctor, she was restricted to bed in one position and the labor pain became truly unbearable. Breaking the waters committed the baby to a poor position for delivery, made the baby have to be delivered within hours no matter what, made the staff require her to stay in bed mostly on her back, and greatly increased the pain factor. It basically made her c-section inevitable. Yet other gd mothers, even those on insulin, have been able to negotiate much more liberal laboring protocols during inductions, including full freedom of movement, use of showers and tubs in labor, unrestricted walking, and movement after the waters have broken (see Dee's gd vbac story in the GD Birth Stories section). So even if you have to be induced, many of the past routine restrictions are not strictly required everywhere, and negotiation with your provider can often help you utilize many of these.

There are many types of medical induction; some are more interventive than others. Much of the following information is taken from "Methods of Cervical Ripening and Labor Induction" (Summers, 1997) and The Thinking Woman's Guide to a Better Birth (Goer, 1999). If an induction is considered, it is important to read up on methods and understand the risks/benefits of each method thoroughly long before any action is taken. Consult your provider for recommendations, and negotiate as much flexibility as possible under the circumstances.

Oftentimes, if the mother's cervix is not yet soft and ripe, an induction has a high chance of failing and needing a c-section, especially in a first-time mom or a VBAC mom (ask what your 'Bishop Score' is and what it means). Studies show that it is extremely important to try to ripen the cervix before resorting to pitocin or other traditional medical inductions, but some providers are more receptive to trying ripening strategies than others (midwives are generally more proactive than OBs). A complete list of suggestions of all types (traditional and alternative) can be found at www.gentlebirth.com, an excellent resource. However, be sure to consult your provider. Even more 'natural' methods of induction can carry some risk.

Things that you can do to increase cervical ripeness are numerous, but your body has to be ready to be receptive to them, so they do not always work (this is why they generally do not affect women earlier in pregnancy). Also, few of these work overnight, so it is important to try these for more than a few days. When to start depends on the method you choose, but a general rule of thumb is not before 37 weeks (so the baby wouldn't be pre-term if you went into labor) but at least 1-2 weeks before the induction is scheduled (preferably 2 weeks). However, be sure to consult your provider as these decisions can be intricate.

Although you may not feel like having sex at that point, the natural oxytocin your body produces in response to orgasm also helps prepare your body for labor, and the prostaglandins in semen help ripen the cervix, so feel free to indulge as often as you feel like it! Evening Primrose Oil can be excellent for helping to ripen the cervix, but generally needs to be used for at least 1-2 weeks, and the evidence for it is mostly anecdotal because the medical community refuses to study it. (Kmom found it extremely helpful in her second pregnancy.) Many other herbal preparations are used by many midwives in the last few weeks of pregnancy (see the Midwife Archives) and anecdotally have good results. However, there is little 'official' study of these methods, and herbal preparations have risks and are contraindicated at times, so be sure to consult your provider.

Nipple stimulation can also help ripen the cervix and even start labor; it can be a VERY helpful tool for inductions, but rarely do OBs consider recommending it and a few even caution against it. Midwives tend to use it (often in combination with frequent sex) much more often, and what studies have been done do tend to show nipple stimulation to be quite effective. It is probably an underutilized tool, and many midwives advocate recommending it more often. However, it has to be done extremely frequently and for long stretches of time to be most effective (typical study regimens included 45 minutes/3x per day, or a total accumulation of 3 hours/day, etc.), so it's not as much fun as it sounds like. You must be careful to watch for uterine hyperstimulation; some sources recommend beginning by stimulating one side only, and stopping during a contraction or if things seem to get going too strongly. If you are prone to premature labor, uterine hyperstimulation, have a complicated pregnancy, or are carrying multiples, nipple stimulation is generally not recommended.

Most OBs are more comfortable with traditional pharmacological options such as the various prostaglandin preparations (Cervidil, Prepidil, etc.). These also help ripen the cervix for induction, but are much more effective if used in multiple doses over time instead of once or twice shortly before pitocin. For some women that are particularly sensitive to it, prostaglandin gels may be all that is needed to go into labor, so they should usually be tried before most other medical forms of induction. There are several types of prostaglandin preparations. Each has advantages and disadvantages; most doctors have a preferred type and dosage protocol.

Sweeping or stripping the membranes (where the provider loosens the membranes inside by sweeping the finger around inside or massaging the cervix) also tends to shorten time to delivery in many women, but it can be quite uncomfortable and should always be done ONLY with the mother's informed consent (unfortunately, many doctors do this without asking). It may slightly increase the risk of infection, cord prolapse, or accidental breaking of the waters, etc., so it should not be used routinely in all women, but for women who are facing a mandatory induction it can be helpful. As with prostaglandin gel, it may be more effective if done frequently over a period of a week or more prior to the induction, rather than one time only at the due date. However, mothers should be fully informed about this procedure before consenting to it, and they should understand that they may experience discomfort, cramping, and bleeding afterwards.

Sometimes automatic breaking of the waters (AROM; artificial rupture of membranes) is used by itself to induce labor, though most often it is used in conjunction with labor drugs like pitocin. This commits you to delivering within a set time limit and if accompanied by lots of vaginal exams, puts the mother and baby at much higher risk of infection. If AROM is used or if the water breaks on its own during labor, it is best to avoid or minimize as many vaginal exams as possible in order to lessen the risk of infection. This is a significant concern with AROM because most hospital protocols require frequent exams and the rate of infection in hospitals is high. Another concern with AROM is that the 'cushion' around the baby is gone, which can sometimes increase the rate of fetal distress and episodes of abnormal fetal heart rate. AROM tends to be most effective as an induction tool when the mother has had vaginal deliveries before, when the cervix is already partially dilated and effaced, and when accompanied by nipple stimulation, pitocin augmentation, etc. Many sources feel it should NOT be done if at all possible if the fetal head is not well-engaged in the pelvis since this can increase the rate of cord prolapse. Also, if the baby is not in a good position for delivery, AROM also tends to commit the baby to a difficult-to-deliver position and prevent it from adjusting its position in many cases.

Pitocin (the trade name for the synthetic version of oxytocin, the hormone that produces contractions in a woman's body) is the MOST commonly used method of induction, but it also tends to be the most painful and most restrictive. In this, a woman is given an IV and pitocin is introduced in small doses. As needed, the dose is increased, hopefully slowly and gradually since it can cause 'tetanic' (super-strong) contractions that hyperstimulate the uterus and can occasionally cause it to rupture, especially if there are previous cesarean scars. Although tetanic contractions and uterine ruptures are rare and usually avoided with careful attention to pitocin dosage, they do sometimes happen if the laboring patterns of the mother are not carefully monitored. Usually, however, pit simply tends to create long contractions with little space in-between to recover, making it harder to cope without drugs, and also tending to restrict oxygen to the fetus in some cases. Therefore, a fetal monitor (external or internal, depending on whether the waters have broken) is necessary at all times to check for fetal distress, which is a real concern. This means that women are usually stuck in bed (nearly motionless) so that the monitor can keep track of the fetal heart rate, which reduces chances of adjusting position and being in the more-favorable upright position. A few hospitals have telemetry monitoring, which allows the woman to be upright and mobile even with pitocin, but this is unfortunately not as common.

Each woman responds differently to pitocin inductions. For some it works very well, and for others it does not. If you've had a vaginal delivery before, you are more likely to respond more easily. If your cervix is ripe and already partially dilated/effaced, you are more likely to respond better. Pitocin induction often does not succeed on a cervix that is closed, long, or hard, so it's important to use the methods to ripen your cervix ahead of time (see above) if possible. Some women find pitocin labors impossible to cope with without labor drugs or an epidural, but there are sometimes women who are able to do it without drugs. A lot has to do with their ripeness for labor, favorable position of the baby, training in coping techniques, labor support personnel, and keeping the waters intact for a longer period. Many women cope with pitocin fine until the waters break (naturally or by AROM); after AROM, many women find it quite difficult to cope for very long, although some women do manage it.

Although it's best to avoid epidurals if possible, neither should a woman hesitate to take one in this instance if it's truly needed. Pit inductions can be very difficult, and although Kmom is no fan of routine epidural use, they can be a real blessing in this instance when really needed. An epidural can allow a woman finding it difficult to cope with pitocin to get enough relief to finish dilating and get to pushing. 

However, studies show that it is best if the mother tries to cope on her own (without drugs) until at least 5 cm dilation if possible; the c-section rate for epidurals before 5 cm is much higher than for those done after 5 cm in some studies. Before 5 cm, you can go ahead and consider one if it's truly necessary, but if at all possible, try to wait until at least 5 cm. If you are coping well and don't need an epidural, by all means avoid them! Epidurals are associated with a higher c-section rate in a number of studies, so if you can do it without, it's probably to your advantage! But if you find you need one to cope, as many women do, it can actually be helpful to have one. Don't feel 'weak' or that you have 'failed' if you choose one; inductions tend to be much more difficult labors than natural labors (Kmom can attest to that!) and many women find an epidural necessary in order to complete the labor.

Pitocin is still the most commonly used form of labor induction around. It's usually combined with other methods (breaking the waters, prostaglandin gel, etc.), but most women who require an induction end up with pitocin at some point. It has significant risks to the mother and baby, so close monitoring is necessary, but it DOES also work in many cases. It's least likely to work on first-time mothers or VBAC moms, especially if the cervix is not ready, but it certainly HAS worked for these populations in the past. 

The advantage of a pit induction is that until the waters are broken, it is reversible if the drug is having little effect. The doctor can turn off the pitocin drip, the mother can go home and rest, and then come back and try again in a few days. This type of 'serial induction' has anecdotally worked well in a number of cases, and is another induction option to consider. Although pit inductions are generally more painful and difficult than natural labors, the ability to stop and restart later is a distinct advantage. However, once the waters are broken (either naturally or by the doctor), delivery must proceed within a day or so, and labor generally becomes much more painful and difficult to tolerate, particularly with pitocin. So some sources recommend waiting until 5 cm dilation to consider AROM when pit is used in order to minimize the risk of infection and maintain the option of stopping the induction and trying again later.  This should probably be strongly considered.

Pitocin is also notorious for causing fluid retention in the mother, and you may experience significant swelling/edema afterwards, especially if you've had a lot of IV fluids and/or an epidural. Diuretics can help this, but will make impede breastfeeding and also tend to raise your blood sugar, so time is really best to resolve most cases of edema. Pitocin is also noted for strongly increasing the rates of jaundice in the baby, so if you have pitocin in your labor, it's very important to be watchful for jaundice and VERY proactive about nursing early and frequently in order to reduce the occurrence or severity of jaundice (see below).

Another new method of induction is called misoprostol (Cytotec by trade name). This comes in tablet form, is inserted into the vagina, and generally results in shorter labors. Preliminary studies are fairly promising in some ways, and misoprostol has the distinct advantage of ripening the cervix as WELL as inducing labor, and in letting the woman stay mobile, utilize upright positions, and not be tied to bed. It is also generally cheaper as well. The disadvantage is the misoprostol is NOT approved for use in labor; it is actually an ulcer drug and the manufacturer states strongly that it is not to be used for pregnancy. OBs have been studying it anyhow, and can prescribe it 'off-label' without legal problems, but the fact remains that it was never intended for labor use and really careful study of it is limited. Because of this, caution should be used when considering it, but it may provide a good potential alternative to pitocin etc. inductions eventually.

Caution is also indicated because misoprostol tends to have a much higher rate of uterine hyperstimulation and sometimes meconium/fetal distress. This is a serious problem with this drug.  As a result, doctors are currently involved in a lot of study of the 'best' dosage regimens. Some studies seem to indicate less hyperstimulation with doses of 25 micrograms as opposed to 50 micrograms, and dosing less often seems to avoid more hyperstimulation as well. However, each doctor or hospital has their preferred dosing method, and no absolute guidelines are possible at this point. If possible, it's probably best to stick to the lower doses. 

One important note, though, is that misoprostol is CONTRAINDICATED in women who have had a previous c-section or uterine surgery as it tends to have unacceptably high rates of uterine rupture in limited studies on this. In addition, induction in general tends to be more risky for women who have had a prior c-section or uterine surgery.  That doesn't mean elective cesarean is the best choice, however; VBAC is still a very viable choice for gd moms, even if induction is a possibility.  However, any use of induction in a VBAC mom should be approached with caution,  knowledge of possible risks, and consideration of ways to minimize the risks involved.

Several recent studies have found that induction of labor in VBAC moms tends to increase the uterine rupture rate.  This seems particularly true when multiple induction drugs are used, excessive dosages are used, or when an induction is done on a cervix that is not ripe.  That does not mean induction can never be used with a VBAC mother, but that expectant management (waiting for spontaneous labor) is probably best, unless a truly compelling medical indication for induction exists.  If induction MUST take place, it is probably best when done on a ripe cervix.  Less extreme methods of cervical ripening (such as sex, Evening Primrose Oil, or nipple stimulation) may be helpful if started well before an induction is anticipated.  If multiple agents such as prostaglandin gels plus pitocin etc. must be used, it is probably best to space them out over quite a period of days instead of placing them close together.  However, always consult your provider regarding the specifics of your particular case.

Making the Most of an Induction

If your doctor tells you that you should be induced, there are strong reasons to question the necessity or timing of it. It's important to question and study further whether induction really is indicated in your case. However, if an induction does become necessary, there are things that you can do to increase your chances for a vaginal delivery. Some are more controversial than others and none are medical advice, simply options to consider and discuss with your provider.

First, do what you can to ripen your cervix ahead of time. Anything that can be done to increase 'ripeness' (softness and effacement, a prelude to dilation) will greatly improve your chances in induction. However, these methods must usually be used for more than just one or two doses in order to be MOST effective. Evening Primrose Oil should be used for a minimum of one week, and preferably two weeks (some midwives do even more) before traditional inductions like pitocin are used. Also consider lots of sex (with orgasm) ahead of time, and having your doctor sweep the membranes can help increase the prostaglandins present and reduce somewhat the time to delivery in some women. Nipple stimulation is another option to consider, though with caution about hyperstimulation. Anecdotally, prostaglandin gels tend to be most effective when given in at least TWO doses or more, and especially if the doses are given over more time than just before pitocin induction. However, the optimum timing, type of prostaglandin, and dosage are still under heavy debate.

Second, try a variety of induction techniques, starting with the least interventive protocols if possible. Although many doctors are reluctant to try less-traditional methods such as Evening Primrose Oil or herbal methods (like blue or black cohosh), they have been very successful with some women. However, most of the evidence for them is anecdotal because the medical community does not study them, and these methods potentially have risks as well (for example, the cohoshes should not be used if high blood pressure is a concern).  Decisions on herbal options must be made carefully and thoughtfully. Nipple stimulation in particular seems to merit more attention, but women should be aware that this method is not nearly as fun as it sounds!

Third, consider trying serial inductions. In this, ripening techniques are done ahead of time as much as possible, and then labor is started (usually with pitocin). However, rupturing the waters is avoided at all costs, so that if the pitocin is not effective that day, labor can be stopped and returned to on another day. (Occasionally, the waters will break anyhow, which then commits you to delivery.) Oftentimes, this method of pitocin induction will work on the second try when it was ineffective on the first try. Increasing the level of oxytocin in the body from the first try seems to somehow jumpstart the labor process, but it may just take a few days to be most effective. Although little formal study on this option exists, some gd moms have anecdotally had quite a bit of luck with serial induction. Doctors tend to be more conservative about its use, since it does tend to be more costly and take more time, but many midwives and some doctors will consider it.

Fourth, consider hiring a doula (professional labor assistant) for an induced labor. Doulas in general have been found to reduce the c-section rate in the overall general population by nearly 50%; only one small study has been done on doulas specifically for induced labors (so conclusions are limited) but the results were promising in that study. In this study, women without a doula who were induced had a 63% c-section rate, a tremendously high rate. The women who were induced but had the support of a doula, on the other hand, had a c-section rate of only 20% in comparison. While the study is very small and needs duplication, its results ARE impressive.  Hiring a doula is another option that may help improve your chances of a vaginal delivery, and a very low-risk option at that. (For more information on finding doulas, cost, and the reference for this study, see the websection on GD Providers: Who to See?)

Inductions are most successful on women who have given birth vaginally before, but they do work on a surprising number of women, especially those with ripe cervices. However, it is also important to have a birth plan dictating your birthing wishes should a c-section become necessary, since this occurs in approximately 1/4 to 1/3 of gd moms on average. In the c-section portion of a birthplan, you should consider specifying anesthesia preferences, care of the baby, prohibition of unnecessary supplements, whether you wish to see the baby emerge, who you wish in the OR with you if possible, keeping the baby as close as possible, nursing ASAP after birth, etc.). It's important to be prepared for a c-section as a possibility, but keep in mind that the majority of women will deliver vaginally, even with gd. Prepare for any eventuality just in case, but mentally prepare for and EXPECT a normal delivery. Visualize it.

If your medical condition dictates induction as necessary, approach it with the most positive attitude possible (knowing that it does work for many women), with as much protocol flexibility as possible, trying as many different methods as appropriate for your case, and with plenty of labor support to help you through it. Although induction can be a more difficult labor than a spontaneous labor, it CAN be done. A positive mental attitude and good labor support goes a long way in inductions!

 

Post-Partum Treatment

Neonatal Testing

[Note: Much more detail on hypoglycemia, jaundice and prevention through breastfeeding can be found in the websection on GD and Breastfeeding: A Special Relationship. This is simply a summary. Please be sure to consult that FAQ for further information on prevention and treatment, and for study references.]

After birth, the baby of a gd pregnancy is usually subjected to close observation and several tests. The most important problems to watch for in a gd baby include low blood sugar (neonatal hypoglycemia) and jaundice (hyperbilirubinemia). Some hospitals also include monitoring for other problems such as low calcium (hypocalcemia), too many red blood cells (polycythemia), low platelets (thrombocytopenia), etc., but most providers do not generally do so unless the baby is ill, shows symptoms, or the mother had very poor blood glucose control or other risk factors.

Since hypoglycemia is the most common complication of gd pregnancies (see above), gd babies are usually subjected to mandatory bG testing after birth. Testing regimens will differ, but it is important to draw not only levels shortly after birth, but also after several hours have passed in order to be sure that they baby's blood sugar is responding to feeding and is stable. If all of these bG levels are fine, baby is nursing well, and the baby looks and acts healthy, some doctors will forego more testing. However, exact judgments on the best testing routine must be made on a case-by-case basis at the time, and some staff is more rigid about testing protocols than others. Discuss testing protocols with your doctors ahead of time; sometimes more flexibility can be obtained if you have your doctors on your side or if they issue specific written orders for your chart.

Most gd babies will have either no hypoglycemia or a very mild case where early and frequent nursing is the only remedy needed. This should be the FIRST line of treatment in mild cases. Those babies whose cases are more significant should be nursed first and then supplemented with formula; babies with severe hypoglycemia or ill babies are in danger and need IV glucose right away and nursing has to wait. 

The exact levels of what constitutes hypoglycemia varies from one provider to the next and on the gestational age and health of the baby (more aggressive treatment is needed for premature or sick babies), but most hospitals generally use cut-offs of between 30-40 mg/dl in healthy full-term babies. <40 mg/dl used to be the standard (and still is in some places), but many pediatricians believe that healthy full-term babies do not need aggressive treatment at that level, and that treatment is better saved for infants whose blood sugar is <30 mg/dl (or <35 mg/dl in some protocols). Again, exactly what constitutes hypoglycemia differs from one provider to the next, how old and how healthy the baby is, whether it is showing symptoms of hypoglycemia or appears normal, how it responds to feedings, and other medical considerations such as a difficult birth, etc. Defining hypoglycemia is very much a judgment call for providers.

Several sources have noted that it is VITAL that a lab test be used instead of (or in addition to) a chemstrip or glucometer reading, since research shows that many of these notoriously underestimate neonatal blood sugar levels. Because of this, some babies are being supplemented unnecessarily, so it is very important to request confirmation of a problem with a lab test if the readings are borderline (severe readings dictate immediate treatment and later confirmation with a lab test). Be sure to discuss your pediatrician's protocols and procedures AHEAD of the birth, preferably getting them in writing. If you intend to breastfeed your baby, be SURE your pediatrician and obstetrician know it and it is emphasized in your birth plan. You will also want to remind the staff verbally and request their help in establishing breastfeeding fully.

It used to be mandatory to routinely supplement all gd babies with formula or glucose water at birth (even if their bG results were normal) and to whisk them away for a number of hours (or even days) of close observation in the intensive care nursery. These protocols were notorious for interfering with breastfeeding and bonding and are generally thought to be outdated by most providers now (although a few holdouts still exist). Recent studies have shown that most gd babies do just fine with 'routine care' (non intensive-care nursery), especially if they are breastfed early and frequently. Observation is still important, but many hospitals have found a way to do it more humanely and in a manner that is less interruptive of bonding. On those occasions when supplements are needed, hospitals are also finding ways to give them without interfering with breastfeeding and without taking the baby away from the mother as much.

Glucose water supplements in particular can cause more problems for the gd baby, since they contain no protein to help even out the blood sugar rise, and generally causes many infants' bG readings to spike and then plummet later. Since in the past, glucose water supplements were used routinely with gd babies, they may also be part of the high rate of hypoglycemia (especially that needed treatment) in some gd studies. Although glucose water can still be useful occasionally, generally colostrum (nursing) is the best treatment for marginally low blood sugar, since it is extremely high in protein, as well as containing plenty of lactose to raise baby's bG. 

If the baby's bG has problems stabilizing, sometimes a supplement is needed, and formula is generally thought to be better because of its high protein content. However, because formula does contain proteins that are more difficult to digest and because some babies react to these proteins, sometimes glucose water is still chosen. Which to choose is generally a judgment call and should be discussed with the staff.

Anecdotally, many moms who have been induced with pitocin and ended with a cesarean have reported that their milk tends to 'come in' later than usual.  This may be because the hormones for 'jumpstarting' breastfeeding may not have had time to kick in naturally by themselves, plus cesarean babies tend to be nursed later and less often, delaying the mature milk supply (which is based on supply and demand--the less often you nurse, the later it comes in).  Thus, these moms often end up being convinced into using lots of formula supplements, further endangering supply and delaying the mature milk.  

Therefore, the gd mom who has been induced and/or had a cesarean should be particularly proactive about nursing as SOON as physically possible after the birth, and very frequently thereafter.  Remember that the 'first milk' (colostrum), while sparing in supply, is EXTREMELY packed with nutrients and immunities and lots of protein.  Newborns don't need to drink ounces and ounces at birth; they are born with extra fluid to help sustain them until the 'mature' milk comes in.  All they usually need in the meantime is the nutrient-rich colostrum, given through frequent feedings.  However, if you are concerned that your baby is losing too much weight, getting dehydrated, or not getting enough nutrition, be SURE to consult a PROFESSIONAL lactation consultant (IBCLC) who has extensive training in helping mothers nurse and also knowing if supplements are truly needed.

When truly needed, supplements should be given only AFTER the baby nurses if at all possible for a number of reasons. If formula is used, it is helpful to nurse first in order to get colostrum's protection in the baby's intestines against the foreign proteins of formula. If glucose water is used, it is helpful to nurse first in order to get the high levels of protein in colostrum into the baby to better stabilize its blood sugar against the spikes and dips that can happen with glucose water. Furthermore, it is important to nurse first in order to get the immunological protections established quickly, to be sure baby does not fill up on supplements and refuse to nurse later, and to keep up stimulation of the mother's milk supply.

If supplements are contemplated, they should be medically documented as needed and given only through non-bottle methods such as cup, syringe, eyedropper, spoon, finger/tube feeding if at all possible. (A good explanation and illustration of many of these alternative methods can be found in The Baby Book, by Dr. William Sears and his wife, Martha.) Giving a bottle is much easier, but studies show that bottle use significantly lowers the success rate of breastfeeding (as do pacifiers, injudiciously used). 

Although some hospitals still resist using alternative feeding methods for supplements (and the mother may need to be assertive), others are very helpful and have come a long way from the days of routine bottle-feeding. Just in case, the mother should have it written into her records that she wishes to fully breastfeed, and that if supplements should become medically necessary they should be given by alternative methods. Again, a signed order from her pediatrician to this effect may be helpful just in case, even though many staff today are more skilled and open to these alternative feeding methods.

The baby will also be watched closely for jaundice, and may have bilirubin tests if jaundice develops (heel sticks for blood are used--nursing the baby through this can be calming). Jaundice is especially likely with diabetes, use of pitocin, and babies delivered before 40 weeks, a combination all too common in gd. More than half of all newborns (with or without gd) become jaundiced within the first week of life; levels are usually not serious enough for treatment but the gd baby does need careful observation just in case. Since extremely high bilirubin levels have been connected to possible brain damage, the baby who shows symptoms of jaundice will need bilirubin levels taken periodically. 

As with hypoglycemia, exactly what levels are cause for concern depends on the age and health of baby, the pattern of the bilirubin's rise, and the specific protocols of the hospital. Jaundice is usually diagnosed if the bilirubin rises above 12 mg/dl; more aggressive treatment is usually needed somewhere around 20 mg/dl, depending on the circumstances. Some providers in recent years have been less aggressive and will allow the baby's levels to go slightly higher, but it depends on the situation and the provider. Consult your provider.

Again, early and frequent nursing is the best prevention/treatment for mild jaundice. Nursing (especially the first 'milk', colostrum) increases stooling, which eliminates more bilirubin from the system. Babies who don't stool often at first often reabsorb the bilirubin, increasing jaundice severity. The best prevention is to nurse the baby immediately (or as soon as possible) after birth, and about every 2 hours thereafter (every 4 hours at night). 

Babies should be allowed unlimited time on the breast; sleepy babies (and jaundiced babies are often sleepy) should be stimulated to waken them for frequent nursing. Exposure to indirect sunlight also seems to significantly improve mild jaundice. Some studies have found that the number of feedings the first day in particular is critical to preventing normal jaundice from becoming severe; at least nine feedings the first day seemed to help significantly. But the first day or two is when the gd infant is most likely to be kept from his mother or given supplements, so you may have to be assertive about frequent nursing in some hospitals.

If the baby does not respond well enough to frequent nursing and indirect sunlight, phototherapy may be needed, although it's important that nursing continue during this process since it tends to dehydrate babies. Sometimes this can take place at home with a portable unit, at other times it must occur in the hospital, stressing to the staff the desire to keep nursing fully as much as possible. 

In the past, it was felt that glucose water supplements helped 'flush out' jaundice; recent research has indicated that these may actually make it worse and should be avoided. If the mother's milk is delayed coming in or if the baby is not nursing well, formula supplements sometimes are preferred over glucose water. But again, these should take place AFTER the baby nurses, and should be given by alternate methods instead of bottles in order to minimize nipple confusion (see above).

In extremely rare cases, bilirubin can rise to levels where it becomes necessary to give the baby a blood transfusion, which will usually take care of the problem. However, this treatment is rarely needed anymore in cases of normal 'physiological' jaundice, and if normal prevention measures are taken (frequent nursing, no glucose water, phototherapy and/or formula supplements), blood transfusions are almost never needed. (There are other types of jaundice that are more pathological and severe, but these are generally not caused by gd but by other complications.)

Finally, nurses will also be on the watch for any other possible metabolic disturbances or congenital anomalies (birth defects), though these are quite rare with gd. Problems such as hypocalcemia (too little calcium) or polycythemia (too many red blood cells) can develop, though some providers seem to feel that the problem has been overestimated in studies and marginal levels have no real clinical significance. Thus, some providers will test routinely for these conditions (a simple blood draw), but most test only in the face of symptoms, severe/poorly controlled gd, if the diabetes is thought to have pre-existed before pregnancy, or when other health problems exist. As noted previously, careful attention may also be paid to the baby's heart to be sure it developed normally, but this problem is also quite unusual and usually occurs only in the conditions noted above.

Although more observations and tests may be done with gd babies, it is usually possible to conduct them fairly unobtrusively and in a way that does not interfere with breastfeeding or bonding. Parents may have to be a bit assertive about this, but most hospitals are getting better at it. Again, establishing this ahead of time with your pediatrician (and especially emphasizing the importance of early and frequent breastfeeding access) will help smooth the transition. Standing orders to this effect from your providers will carry a lot of weight with the staff and soothe the chafing some may feel at a departure from past routines.

Breastfeeding

Breastfeeding offers many health benefits in general to babies, including increased protection against ear infections, diarrhea and other gastrointestinal illnesses, bacteremia, allergies, bacterial meningitis, urinary tract infection, and lower respiratory tract infections. There is some evidence that breastfeeding may also provide some protection against Crohn's Disease, some childhood cancers, SIDS, ulcerative colitis and other chronic digestive diseases. Because of this, breastfed babies have been shown to have fewer visits to the doctor and less healthcare costs overall in the first year, and of those babies who do become ill, breastfed babies usually become less seriously ill and need less hospitalization. In addition, breastfeeding offers many general health benefits to mothers as well, including less postpartum bleeding, an earlier return to prepregnant weight, less risk of premenopausal and postmenopausal breast cancer and ovarian cancer, and perhaps less osteoporosis.

Nutritionally, breastmilk is species-specific (it exactly matches the unique needs of human beings), whereas formula generally has too much protein, too little lactose, and too many salts because it is derived from cows' milk, which is species-specific for cows' needs. Breastmilk also provides many important substances such as DHA that are not found in most formulas, and the nutrients in breastmilk are generally much more bioavailable to infants than those in formula (in other words, the total amount of a nutrient may be less in breastmilk, but it is generally much more absorbable and usable by the baby than those in formula). 

If breastfeeding is not possible for whatever reason, formula is an adequate substitute, but breastmilk is THE most optimal food. The American Academy of Pediatrics (AAP) "identifies breastfeeding as the ideal method of feeding and nurturing infants and recognizes breastfeeding as primary in achieving optimal infant and child health, growth, and development...human milk is uniquely superior for infant feeding."

For these reasons alone, it is important for mothers to breastfeed their babies if at all possible. However, nursing is even more important for gd moms and their babies, as it offers special benefits to them. As noted above, early and frequent nursing is one of THE most important preventative steps for dealing with the hypoglycemia and jaundice that can occur after a gd pregnancy. A 1998 study found that breastfed babies of diabetic pregnancies of all types required less admittance to the NICU for problems after birth (including hypoglycemia, jaundice, etc.), and did better on average than formula-fed babies. Since these are two of the most common risks for gd babies, breastfeeding is particularly important in the gd context.

Other studies have found that insulin-dependent gd mothers who breastfed returned to normoglycemia faster after birth than those who did not breastfeed. One study found that gd mothers who breastfed had better bG and HDL cholesterol levels 6-8 weeks later, and half the rate of immediate postpartum diabetes as those who did not breastfeed (Kjos, 1993). Kjos further noted that, "Lactation, even for a short duration, has a beneficial effect on glucose and lipid metabolism in women with gestational diabetes. Breastfeeding may offer a practical, low-cost intervention that helps reduce or delay the risk of subsequent diabetes in women with prior gestational diabetes."

Breastfeeding may also play a special role in lessening the baby's chances for type II diabetes later in life, although this research is still also preliminary. Pettit et al., 1997 found that, "Exclusive breastfeeding for the first 2 months of life is associated with a significantly lower rate of NIDDM in Pima Indians" in later life. In fact, after adjustment for possible confounding factors, the relative risk of exclusively breastfed babies developing type II diabetes by age 40 was approximately HALF in this study as those babies who were formula-fed from birth.

A number of studies have found that children that had little or no breastfeeding had higher rates of obesity later in life, though many other factors of course influence rates of obesity, including genetics. However, it is speculated that since obesity is a risk factor for diabetes, preventing it or keeping it to genetically-determined rates may be able to help prevent some cases of diabetes. 

Furthermore, Wallensteen et al., 1991, found that, "In formula-fed infants the insulin response to a meal is enhanced compared to that in breast-fed infants. The finding of similar blood glucose values in the two groups may also indicate an insulin resistance in the formula-fed infants following a meal." In other words, more insulin had to be produced by the formula-fed infants in order to achieve the same bG results, which could be a sign of early insulin-resistance. This may explain the mechanism by which formula-feeding may tend to produce more type II diabetes and/or obesity.

It's important to note that research into breastfeeding, gd, and NIDDM is preliminary; much more needs to be done. Most studies are for a very short time only---mostly 2 months or less, whereas the American Academy of Pediatrics calls for breastfeeding to continue for at least one year, and the World Health Organization recommends at least two years. In addition, some studies do not adequately distinguish between exclusively-breastfed infants versus infants being fed both breastmilk and formula. It may turn out that breastfeeding has less effect than these preliminary studies indicate or it might turn out that extended breastfeeding has even more benefits when done for longer periods of time and focusing on exclusive breastfeeding. Only time will tell. However, the preliminary work has been enough for the Fourth International Workshop-Conference on GD to issue a call to increase research into breastfeeding and gd. This will be an interesting and evolving field of research in the near future. But in the meantime, this preliminary evidence just adds more weight to the argument that mothers who have had gd should consider breastfeeding if at all possible.

It should, however, be noted that a substantial percentage of women with gd also have PolyCystic Ovarian syndrome (PCO), and that in some PCO women, milk supply is lower than normal. Although most women with PCO are able to breastfeed just fine, a few are not able to fully breastfeed, and supplementation may become necessary. Although women with PCO should not despair of or avoid breastfeeding, they should be more vigilant for signs of significant dehydration in their infants, and should work with lactation consultants before and after birth if at all possible in order to optimize their milk production. For those few who will not produce enough milk to fully sustain their infants, supplementation may be needed, but it is important to note that ANY amount of breastfeeding (especially the all-important first 'milk', colostrum) is highly protective to the baby. A lot of immunological agents are packed into the first days and weeks of breastfeeding, and even if your baby must receive supplements, he or she will also be receiving this VITAL nutritional and immunological protection.

It should also be noted that many past hospital policies have routinely sabotaged breastfeeding in diabetic mothers of all types. Therefore, it's especially important for gd moms to be well-informed and prepared for breastfeeding, to fully inform the staff of their strong desire to breastfeed and avoid as many supplements as possible, and to have a truly breastfeeding-friendly pediatrician. The most important steps to avoiding medical interference with breastfeeding include:

Most gd moms are able to breastfeed successfully, and their path is generally easier if they follow these steps, but each individual situation has its own needs, and sometimes adjustments are necessary. Flexibility, preparation, proactive behavior, and knowledgeable help are the keys. [For more information, please read the websection on GD and Breastfeeding: A Special Relationship.]

Postpartum Diabetes Testing for the Mother

The mother will likely return to her normal non-diabetic status once the placenta is delivered. A very few women remain diabetic or in a borderline state called "Impaired Glucose Tolerance" but most return to normal. Again, women with severe gd who breastfeed seem to return to normal more quickly than women who do not breastfeed and fewer remain diabetic, so breastfeeding is to be encouraged in gd mothers if at all possible.

A glucose tolerance test at about 6-8 weeks post-partum should be done in order to establish that all has returned to normal. It is particularly important to establish normoglycemia after pregnancy if you plan on considering another pregnancy in the future. Thereafter, blood glucose testing should be done every year or so to be sure that you have not progressed to true diabetes; women with severe gd and strong family histories of diabetes may want to have testing done more often. If you have your own bG meter, it is an excellent idea to test yourself periodically between yearly tests by the doctor.

Careful monitoring of the woman's blood lipids (cholesterol, triglycerides, etc.) and blood pressure is also important post-partum, since part of the 'Syndrome X' of insulin resistance also includes high blood pressure and problems with blood lipids. According to research, about 50% of all gd women will eventually develop type II diabetes; some within a few years and others within 10-20 years. Since early diabetes is often silent (without many symptoms), it can do a great deal of damage to the mother's system if undetected as it starts to develop. Regular testing (of blood sugar, blood pressure, and blood lipids) and attention to improving lifestyle factors are very important parts of post-partum care of the gd mom.

Considering Another Pregnancy

If you plan to have more children, you need to be very proactive about your health first. Careful attention to a very effective method of birth control is very important, since a few women develop high bG between pregnancies and this is extremely harmful during conception and early pregnancy. Avoid gaining weight between pregnancies, since this appears to strongly increase the rates and severity of subsequent gd. Some experts feel that a small weight loss after a gd pregnancy may prevent subsequent gd or diabetes; for some women this may make sense. However, research proving this is sparse and contradictory, and the advice is mostly based on the assumption that weight loss will help. Anecdotal evidence seems to indicate that in some women it does help, but in others may trigger a return to yo-yo weight patterns and an overall gain in the long run. Each woman needs to determine what the best course of action is for HER.

Try to nurse long-term if you can, since this tends to improve your bG and cholesterol levels, may help you lose pregnancy weight faster or keep your weight more stable, and provides the best start for your child (the American Academy of Pediatrics recommends at least a year if possible, the World Health Organization, two years). Improve your health habits (especially watching the amount of carbohydrates you consume at any one time), keep up the general food guidelines of a gd plan, and strongly consider increasing your exercise routine. Some diabetes books estimate that regular daily exercise decreases your risk of diabetes by as much as 40%! Improvements in diet and exercise may lead to some weight loss in some women, but more stringent attempts at losing weight should never be attempted in the first several months of breastfeeding, and it is important to remember that sometimes weight loss attempts do more harm than good in the long run in some women. Each woman has to decide what is best for her situation.

Proactive health habits are particularly important in preparing for a subsequent pregnancy. Before starting to try to conceive, get tested to be positive your blood sugar is normal, and then start eating on your gd food plan BEFORE you start trying. Get regular exercise and use your bG meter to be sure everything remains normal during conception and early pregnancy. Chart your cycles if at all possible in order to firmly establish when you conceive, since an accurate due date is extremely important in planning delivery protocols in gd. Once you conceive, most authorities suggest being retested for gd in the first trimester or early in the second instead of waiting until the usual 28 weeks, since gd sometimes recurs earlier and more severely (or you can use your home glucometer to monitor your levels on a more frequent basis if your provider agrees). If you test negative, your provider will retest you again at 28 weeks, and possibly again at 32 weeks in some cases.

It is possible that you may not get gd again. Although it is usually quoted that about 2/3 of women do recur, 1/3 therefore do not. Some studies have even smaller rates of recurrence (33-50%), especially if the women pursued proactive health programs of exercise and sensible eating. Anecdotally, some women have found that proactive diet and exercise permit them to avoid gd in subsequent pregnancies (Kmom did!), and others have found that while the gd recurred, their proactive actions allowed them to avoid insulin the next time. Several women who nursed their first children through subsequent pregnancies found that the gd did not recur (again, Kmom was one), and though the sample size is FAR too small to prove anything conclusively, it is an interesting coincidence.

If you had a c-section in a previous pregnancy, you should strongly consider pursuing a Vaginal Birth After Cesarean (VBAC), since overall the risks are less to mother and baby in a vaginal birth than in a repeat cesarean. Of course, each woman must choose what is right for her own situation, and you may choose a repeat c-section instead. But it's important to know that if you would like a VBAC, it is possible to have a VBAC, even if your gd recurs. Although doctors are statistically more likely to push gd moms towards a repeat c-section according to several studies, VBACs in gd moms can and HAVE occurred. For more information about investigating the possibility of a VBAC, get the book, The VBAC Companion by Diana Korte ( www.1cascade.com ), or Natural Childbirth After Cesarean by Crawford and Walters ( www.lalecheleague.org ); also read the websection on GD and VBAC here.

Overall it is likely that your gd will recur. There is certainly a chance that it won't or that it will be less severe (especially if you are very proactive), but it's important not to count on that possibility. In many cases, it returns, earlier and more severely. Therefore, it's extremely important to be VERY proactive when planning a subsequent pregnancy.

(NOTE: Technically, your health provider should strongly stress proactive nutrition and information before conception and in early pregnancy, but many women have found that their providers (especially OBs) did not, even with a past history of gd. It may be up to you and your partner to practice proactive health care instead---excellent nutrition is particularly important. Don't wait to start on a gd food plan until the gd is diagnosed again! 

Prevention and proactive health care just does not seem to be a priority for the majority of doctors; they are more trained to respond to problems instead of working on preventing them. Midwives as a group tend to be more attentive to prevention through methods such as nutrition and exercise, but certainly this emphasis is by no means universal there either. There are no guarantees that prevention will keep gd from recurring or prevent the need for insulin, but careful attention to nutrition and careful monitoring of bG levels can't hurt and might even help. Certainly, it's a good idea no matter WHAT your circumstances are.)

Emotional Recovery After a GD Pregnancy

Emotionally, recovery from a gd pregnancy can be difficult. The stress of all of the treatment regimens some providers insist on, the fear of needing insulin, the anxiety of worrying over the health of your baby, the pressure of disapproving friends and family (who may blame your gd on your size or your lifestyle, etc.), the stress of an early or induced labor (which for many women can be a very difficult experience), the emotional and physical recovery from a possible c-section, the stress of trying to establish breastfeeding under the circumstances, and the mourning of the ideal pregnancy and birth you did not get to have, etc.----all of this can take a significant toll.

Some women shrug it off easily and are fine post-partum. Certainly, simply because you have had gd does not mean that you WILL experience significant post-partum depression, and you should not create a self-fulfilling expectation of problems simply because of the gd! However, some gd moms DO experience postpartum depression, which in part may be related to the stress of the gd pregnancy or a difficult delivery. In addition, mothers who have PCO (PolyCystic Ovarian syndrome) also tend to be more prone to depression which puts them more at risk for postpartum depression. Still other mothers are able to focus all their attention on their new babies and seem to recover well emotionally only to suddenly be ambushed by unresolved feelings later (especially when considering a new pregnancy). 

Very little attention is paid to emotional issues in gd research, or the role the stress of gd may play in post-partum depression. Doctors often tend to ignore gd issues as irrelevant or simply throw drugs at post-partum depression instead of recognizing the importance of counseling and support in recovery from difficult pregnancies or births.  

An excellent book to help in the recovery process is Rebounding From Childbirth: Toward Emotional Recovery by Lynn Madsen (available from www.amazon.com). It doesn't deal specifically with gd, of course, and occasionally some of its imagery is a bit 'New Age' and strange, but overall it is an excellent resource, one of the best Kmom has ever found. 

Kmom also encourages gd moms to find other gd moms online and share experiences, and also to try to communicate to spouses the worries, guilt, and concerns you have had about the gd experience. Keeping it inside or minimizing it to others can make it worse. Find a support system that understands and will listen, and work on your emotional recovery through the use of sharing, journal-writing, bonding with your child, reading about emotional recovery from childbirth, or even sometimes therapy with a counselor that specializes in birth issues. 

Childbirth is one of the defining moments of women's lives; a difficult pregnancy or birth experience can have a long-lasting impact on a woman's emotional life. Don't ignore the issue; be proactive about healing.

 

Summary of Probable Treatment Course

In summary, the typical treatment plan for most gd mothers is to use a registered dietitian and/or a diabetes educator to help the mother institute 'medical nutrition therapy' (a food plan) to help control blood glucose levels. Control will be monitored in most cases through the use of daily self-monitoring using bG meters. Exact treatment goals will vary from provider to provider. Most women can also benefit from regular, mild exercise in addition to nutrition therapy.

If bG levels return to normal and stay well-controlled throughout pregnancy, most gd moms can go into labor on their own, without early induction or extensive extra prenatal testing. However, in practice, extensive prenatal testing, early induction or induction near term is more common, though it is debated how much of this is truly necessary. Mothers who need insulin during their gd pregnancy will undergo more frequent prenatal testing and will probably be induced early, often around 38-39 weeks, perhaps after establishing fetal lung maturity by amniocentesis. Some providers will agree to let insulin-dependent women go to 40 weeks, but most will not permit delaying labor much longer than that. Blood sugar will be tested frequently during labor; insulin-dependent women may or may not receive insulin in an IV during labor since the exertion of labor can obviate the need for it, but sometimes it is still necessary. Keeping the bG within normal limits during labor tends to reduce the incidence of hypoglycemia in the baby postpartum.

Post-partum, gd babies will be tested routinely for hypoglycemia and jaundice, and will be watched closely for other possible (though uncommon) problems. Again, early and frequent nursing is the best prevention/treatment for mild hypoglycemia and jaundice, though the parents may have to be fairly assertive about nursing. The baby of an insulin-dependent gd mom may undergo more tests, routine procedures, and observation than the baby of a diet-controlled gd mom--discuss with your providers exactly what procedures are really necessary and when.

Nursing offers extra benefits for gd mothers and children, but parents would do well to educate themselves thoroughly about it since many providers pay lip service only to its importance and many barriers to breastfeeding are put in the way of gd moms. Be sure to emphasize your desire to nurse to your providers and all staff and avoid use of all bottles and pacifiers at first, as well as any unnecessary supplements. If supplements become necessary, strongly request that they be given through alternative (non-bottle) feeding methods. 

If it becomes necessary to be separated from your baby for any reason, be sure to ask for an electric, hospital-grade breast pump and use it religiously. Also seek help from a professional lactation consultant (IBCLC) as soon as possible if any problems are encountered. GD moms with PolyCystic Ovarian Syndrome (PCO) may want to be particularly proactive about consulting expert help both before and after birth. If possible, nurse your baby for the longest period of time suitable in your situation; breastfeeding has an antidiabetogenic effect in most women.

After the delivery, your gd will almost certainly go away, since the hormones from the placenta will be gone and your insulin sensitivity will improve. However, a few women remain diabetic or in a borderline state after pregnancy, so it is important for your provider to test you for diabetes again at 6-8 weeks post-partum and then again YEARLY after that. 

More than half of all gd mothers will develop type II diabetes within 10-20 years of their gd pregnancy; some will develop it within a few years or even months in a few cases. Risk factors for developing overt diabetes sooner rather than later include diagnosis of gd early in the pregnancy, need for insulin, family history of diabetes, high fasting numbers, and poor or brittle control during the pregnancy (obesity is a risk factor in some studies but not in others). Careful and frequent testing for these women is extremely important. Blood lipid and blood pressure levels are also important to monitor regularly, since they may become problematic a few years after the gd pregnancy.

On the other hand, developing diabetes is not a certainty; it's best to be as proactive as you can about your health. GD indicates that you have the genetic predisposition towards the disease and probably a tendency towards insulin resistance as well, but environmental factors are also generally necessary for the gene to express itself. Don't over-emphasize the possibility of developing diabetes so much that you create a negative self-fulfilling prophecy with your health, but do take common-sense precautions and receive regular yearly testing. Improving lifestyle factors can do a lot towards improving your risk, and testing yearly could catch the disease very early, before it has had a chance to do any damage. This could be very important!

If you plan to have more children, be very proactive ahead of time. Get tested first to ensure normal blood sugar, then start on your gd food and exercise plans before you even conceive. Chart so that you can establish your due date securely, and see a health provider early in the first trimester for monitoring. If you have had a c-section, strongly consider the possibility of a Vaginal Birth After Cesarean; if you decide pursuing it is the right course for you, start researching and preparing for it thoroughly. Although gd usually recurs, it does not always, and careful care may help prevent a repeat of the gd, a difficult pregnancy or birth, or both. Proactive care and action is extremely important in planning subsequent pregnancies.

One area frequently ignored by most health professionals is emotional recovery after a gd pregnancy. Many gd mothers experience significant guilt and/or depression after a gd pregnancy, and if the delivery was difficult, this can be compounded even further. Finding a support system that listens openly and non-judgmentally about your concerns about gd, subsequent health risks, and further pregnancies is very important. Reading about emotional recovery from childbirth is also often helpful. But don't be surprised if your emotional road is a bit bumpy after a gd pregnancy. Don't rush yourself; let yourself grieve for your lost ideal pregnancy as needed. In time, this too will heal.

 

A Brief Overview of Treatment Numbers

One thing that is especially confusing in gd is the various numbers that are tossed around all the time. This is one of the most confusing things for newcomers to gd issues. This section is intended to give a brief overview of the most common numbers used when discussing gd and what they refer to. A much more detailed discussion will be found in the websection, GD: The Numbers Game.

Basically, the crux of the matter is that a woman with gd needs to keep her blood sugar levels equivalent to those found in non-diabetic women. The usual target range is between 60-120 mg/dl. The exact numbers depend on the philosophy of your provider (how strict of control he/she insists on) and the exact requirements of when the measurement is done and what kind of measurement it is (fasting vs. post-meal). You must be extremely careful to understand EXACTLY what your provider requires and why. Be sure to ask lots of questions so that you understand it thoroughly.

The most-preferred fasting number is usually below 95, though providers may be stricter than that or looser than that when it comes to requiring insulin use. Some will put you on insulin if your fastings are only 90 (or even lower!), while others do not resort to insulin until a woman's fasting numbers are 105 on two or more occasions. The official recommendation from ACOG is 105 fasting as the cutoff for needing insulin; it notes that lower numbers may be preferable but that this is not proven yet. So any fasting numbers between 90-105 are in a very gray area; some providers will deem them too high and some will deem them acceptable. Probably it is MOST optimal to have fastings under 95 and preferably under 90, but whether readings between 90-105 justify the assignment of insulin is highly debatable. (See the sections on What If I Need Insulin?, GD: The Numbers Game, and GD: Controversies for further perspectives on this issue.)

The most-preferred post-meal number is usually <120 two hours after a meal, but a great deal depends on how they time the post-prandial (pp) measurement. Some providers prefer measuring one hour after a meal; in this case the most common recommendation is <140 one hour after a meal, although a few providers demand even stricter values of <130 or <120 one hour after the meal, and occasionally even lower. Another important question is whether the measurement is timed from the beginning of the meal or the end of the meal---recommendations vary. With the two-hour measurement, it is usually measured as two hours from the beginning of the meal. With the one-hour measurement, it is usually measured as one hour after the end of the meal, but this is not as uniformly accepted as the other. Again, ask your provider THEIR requirements.

Understanding the Context of readings

Those are the most basic requirements you'll come across in your gd treatment process. However, there are many other numbers you may run across in the process of reading about or dealing with gd. For example, the number 140 mg/dl is used in a number of contexts:

So you see that any one number can mean different things in different contexts. This can quickly become extremely confusing to the novice, and even to those more familiar with the subject! It is especially important to pay attention to WHAT the number refers to. Consider a reading of 105. This could be excellent news, a bit worrisome news, or alarming news, all depending on the situation it occurs in.

So you MUST pay close attention to the CONTEXT of the number.

The critical questions are who is being tested (are they pregnant or not), what type of test is it (fasting, post-meal, glucose challenge, glucose tolerance test, capillary blood, venous plasma), what the purpose of the test is (screening, diagnosis or treatment), and what is the timing of the test (how long since eating/testing). Another important question is whether this a universally accepted protocol or whether recommendations vary from one provider to the next.

Here is a summary of the important questions to ask and why:

  1. Is it for use in pregnancy or outside of pregnancy? - Because there is a fetus involved, the control required in pregnancy is MUCH stricter than for people who are not pregnant.
  2. Are the numbers for the purpose of diagnosis or for the purpose of a treatment plan? - The numbers for diagnosing gd on a test will be different than those used as treatment goals. Also, the numbers used to diagnose the need for insulin in gd will be higher than the treatment goals that your provider will want you to aim for once you start using insulin.
  3. Do the numbers refer to gestational diabetes or to 'regular' diabetes? - For example, target numbers for treatment of type I pregnant diabetics may be lower than the initial numbers given as treatment goals to diet-controlled gestational diabetics, though this will vary between providers.
  4. Are the numbers for insulin-dependent people or those treated by diet alone? - The treatment goals for gestational diabetics who need insulin may be somewhat stricter than for those who do not use insulin, though again this depends a lot on provider philosophy.
  5. What do the terms mean? Do the numbers refer to fasting readings or post-prandial readings and how exactly does your provider measure these? Fasting numbers refer to the first morning reading before eating, while post-prandial results are measured after eating. The exact protocol for taking each measurement, too, will vary between providers---some want fastings only after 12 hours, while others want them after only 8-9 hours. Post-prandial protocols also vary quite markedly; see above for more detail.
  6. How are the readings being measured? What was being tested? Home monitoring uses capillary whole blood. Lab tests usually use plasma. Sometimes venous whole blood is used on a home monitor too. Plasma readings tend to be higher by about 15% as a general rule, but not always. References for diagnostic and screening tests refer to PLASMA levels, not capillary levels.
  7. Are the numbers standard to all providers or are they the recommendation of your own provider, based on his/her personal philosophy of treatment? Some providers require much more stringent control and will put you on insulin at much lower levels than other providers because of a difference in treatment philosophy. Just because one provider requires certain levels of adherence does not mean that all will. In gd, there is significant variance in treatment requirements between providers.

And just to make things MORE confusing, remember that the USA uses different standards of measurement than the rest of the world. This FAQ mostly uses the USA measurement of mg/dl because the readers are mostly from the US, but other parts of the world may use different numbers instead. If you read the actual medical studies, many will use the measurement of mmol/L instead. 

To convert between mg/dl and mmol/L, use a factor of 18----in other words, to go from mmol/L to mg/dl, multiply by 18; to go from mg/dl to mmol/L, divide by 18. In other words, the usual cutoff for the one-hour glucose challenge test is 140 mg/dl, but many medical references will use the worldwide standard of 7.8 mmol/L. (A further discussion of the conversion issue and the reasons for using primarily mg/dl in this FAQ can be found in the section on Glucose Testing.)

Remember, a more complete discussion of the official numbers usually found in gd and diabetes can be found in the websection, GD: The Numbers Game. It is probably a good idea to have a thorough understanding of this subject.

 

References

There are far too many references in this section to be listed on this same file; a separate file had to be created. To see the references for this websection, please go to GD: Treatment References. Kmom strongly urges readers to review these references, particularly the references regarding delivery timing and protocols, since this will be one of the most critical decisions in gd treatment.

To see a summary of more gd references (medical journals, magazine articles, books, websites, etc.), see the websection on GD: General References.

 


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