What are the risks after a positive Glucose Tolerance Test (GTT)? Is home birth still an option?
What about insulin-dependent diabetes?
This page contains comments and links on diabetes and birth options. I have compiled it, but I personally know little about the topic and therefore have not been able to add much in the way of informed comment. Better, I think, to focus on the women who have experience of diabetes, and sources of more info. A woman with pre-existing insulin-dependent diabetes may face more complex issues than those with 'just' gestational diabetes, but both are included on this page as there are some issues common to both.
Read an intro to gestational diabetes from Diabetes UK, and then go on to 'All About Gestational Diabetes' by KMom. This is an extremely detailed collection of articles put together by a very well-informed birth supporter.
For women with gestational diabetes there is an increased risk of shoulder dystocia; babies born to diabetic mothers tend to lay down more fat on the body than average, if glucose levels are not well controlled, and this means they are proportionately more likely to have trouble with the birth of the shoulders than other babies of the same weight.
Home birth is unusual but is still an option, with careful monitoring of yours and the baby's condition - see for instance Debbie Dooley's comments below. Victoria is a Type 1 Diabetic who explains why she chose a home birth for her second child, how she arranged it, and her personal recommendations and conditions for attempting homebirth with diabetes. For one insulin-dependent diabetic mother's story, see Diabetic Birth Without the Drip, on the AIMS website. Diabetic mother Debbie Dooley gave a talk at a midwifery conference on Diabetes and Home Birth and has also written her birth story. For more on diabetes and pregnancy generally, see the Diabetes UK website
This is a real bugbear of mine. I went through GD issues with pregnancies 2 and 3. With number 2 I endured those long tests which came up slightly high, and stuck to my guns, ignored their advice and gave birth at home without complications (baby weighed 11lb). With baby number 3 I refused the GTT as I did not see the point of taking the test when I knew I would do absolutely nothing should the result be high (their only fear was a large baby, I had already delivered an 11lb baby alone in 40mins so I knew I was capable). I got a lot of hassle from the midwife about this, one even said "do you not want us to provide any maternity care to you?". I discussed it at length with a midwife friend who agreed that there seemed little reason to have the test unless I was putting out *a lot* of glucose in my urine (I wasn't). As it turned out baby only weighed 8lb7oz and again, everything was fine.
Dating scans are notoriously inaccurate, my argument for refusing them both times. I am only 5'3 and managed to birth an 11lb baby in less than 40 minutes with just my husband present, therefore even if they did tell me the baby was large I knew it wouldn't change my plans. My body wasn't going to grow a baby I couldn't birth, I was confident of that.
My advice would be that if your sugars are well controlled that you should stick to your guns. Midwives are trained to monitor blood sugars in labour if necessary, so this shouldn't impact on where you give birth.
If you don't believe there will be a problem, don't let them bully you into something you are not happy with. It's your body, have faith in it.
Kelly
Kelly has written the birth story of Amelia, her third baby.
Bel's second pregnancy was not straightforward, and then it got worse:
15 Feb
So I'm trying not to cry right now cause I really don't think I'm gonna get my homebirth. I just can't believe how many problems I've had. My last pregnancy was SO uneventful and this one is just a nightmare.
Some of you may remember I'm anemic. Then baby was measuring small, but she's caught up now apparently. Then she was breech, but I found out today she's turned head down so that's good. Then last week my glucose came out high so now I'm diabetic, but I'm controlling it really well just by basically not having sugar in my coffee. And now they've had to send off a urine sample cause something showed up that made them think I might have a kidney problem of some kind. I really don't know what.
But at my appt today she asked me to come in next week so they could decide on whether my H/B would be "allowed" to go ahead so they could sort out the kit. Then she went off to speak to the other m/w and came back and said that as far as they were both concerned once you are labelled diabetic that's it. You HAVE to go to hospital and won't be "allowed" a home birth. I said, "you won't ALLOW me to have a HB?" and she said no, but if I chose not to come in that would be up to me. Then she made me an appt with the consultant so I can try and get him to over rule their decision.
What I don't understand is why 2 midwives at my last appt said I would be allowed if I controlled it with diet. Who is the boss? Who gets to decide? How can 4 midwives on the same caseload tell me different things?
So basically, what should I be asking or saying at this consultant appt? What are the risks involved if I had a HB? I know she's not big. They said something about my sugar rising in labour, but didn't explain why this would create any kind of emergency, just that they wouldn't be able to tell if I was at home, but thinking about this just now, I've realised that's balls cause I have a monitor.
Does anyone think I SHOULD go to hospital bearing in mind all the problems I'm having? I just feel so positive about having a HB and was not prepared to be flat out denied. I'm just so upset right now. Another reason I really wanted a HB this time was because I'm moving to the USA in the summer and I wanted to have one under my belt so I'd be in a better position to demand one there. (I'm moving somewhere where it's fairly common). ANY advice will be greatly appreciated. Thanks guys.
Bel
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21 Feb
So I had my appointment with the consultant today to discuss my HB because I have diabetes. I had already sent a letter to the midwifery manager, but I took a copy in my notes. I saw the midwife first and while she was feeling the baby she asked me hadn't I been hoping for a homebirth. I then told her all that had happened and that if the doctor didn't give me a good reason to come into hospital at this appt. that I would be carrying on planning a homebirth and that I'd written a letter. She read the letter and totally agreed with me. She even said she couldn't see why they couldn't use my glucose monitor to check the baby as this was the only real problem.
The doctor then came in after reading the letter and while he was very interuptive and slightly patronizing, he did only state the facts and explained that the only real risk for me (as my baby is now measuring small again) is that the baby's sugar may drop in the 1st 24 hours and there would be no one to check it at home, but that the risk is very small and even if I wasn't diabetic it would still be a small risk.
I explained to him that my daughter had her blood sugar tested after birth as she wouldn't feed and I am aware of the signs of sugar dropping in a newborn. I told him I would get some formula and I've arranged a session with their breastfeeding counsellor to begin expressing before the birth. As long as I feed her regularly she should be fine. All they would do in hospital is feed her anyway. I said I would be happy to take her to hospital were there a problem after she was born and that should my sugars go crazy in the meantime I would reconsider my decision.
He said fine and just wrote in my notes that he'd made me aware of the risks and my homebirth kit is being delivered on friday! So proud of myself. Just have to hope the diabetes appt goes ok tomorrow. I think my monitor is broken. It keeps giving me really weird readings. Like saying my sugar is 16.1 an hour after eating a plain bagel when it came out fine the 2 previous days from eating the exact same thing.
I just have to say thanks to the list members for helping me write the letter as I think that had a lot to do with my success today. I think it showed that I already knew what was what and was willing to listen to their advice, but that I was capable of making my own decision.
Followup from diabetes appointment:
My diabetes appt today was fine and she didn't want to put me on insulin so everything APPEARS to be working out at the moment
Bel went on to have a great birth at home, and to breastfeed her daughter exclusively - read Persephone's Birth Story.
Rachel McGrath went through '8 weeks of hell' after she was diagnosed with GD. After fighting her corner with obstetricians and having a healthy homebirth, she found out that her diagnosis had not been so clear-cut after all.
Bel was told that she had gestational diabetes after a GTT test in her second pregnancy.
Debbie Dooley had gestational diabetes in several pregnancies, and then developed insulin-dependent diabetes.
Kelly had a positive GTT test in her second pregnancy, and declined further testing in her third pregnancy.
Victoria is a Type 1 Diabetic who explains why she chose a home birth for her second child, how she arranged it, and her personal recommendations and conditions for attempting homebirth with diabetes.
From Debbie Dooley:
I am Type II Diabetic (Having been Gestational in 3 of my previous pregnancies first) and had a HB last July with no problems at all. I had all the usual 'advice' from my Diabetic Consultant and the Obs Consultant, but after I researched everything and presented my findings they backed me all the way. If your Glucose levels are well controlled and baby is doing well, there really isn't any reason for you to be treated any differently to a non-gestational Mum.
I drew up a comprehensive Birth Plan to show I knew exactly what I was doing. I suggest doing your BS levels every 15-30 mins in labour and if they are high then you'll need to administer a fast acting insulin like Actrapid. If your levels go to low, then Orange Juice is fab at bringing them up gently and it's easy to digest whilst in labour. I also drew up a back-up Hospital Birth Plan, just in case we needed to be transferred.
The main problem is that baby 'could' be hypoglycaemic at birth, however, the chance of this with good glucose control in Mum is very low. However, I did try to cover all eventualities and had harvested my colostrum so that it could be given to the baby in conjunction with frequent breast feeds, if he/she showed signs of going hypo.
I found that the main thing to do was to be totally open minded about what 'could' happen and reassure the medics that if a problem occurred I would be more than happy to transfer immediately.
As long as you are confident that you can control your levels during the labour and you are well clued up on the signs of hypoglycaemia in the newborn, then I say go for it.
Do blood sugar levels need to be checked this often?
It was entirely my choice to check them so often. I am an Insulin Dependant Diabetic and my levels can fluctuate within a half hour period depending upon my activity. It was important that I didn't go Hypo myself and pass out, but also by keeping such a close check I was researching how Diabetic Mums perform under labour conditions. I got a comprehensive 12 hour period of blood glucose levels and I am presenting my findings at a meeting next week to Supervisors of Midwives, to try and help change procedure for Diabetic and Gestational Mums.
It is entirely up to the Mother how often she checks, but I 'advised' half hourly so that baby isn't put at risk of being affected by high/low blood sugar levels and therefore, won't have to have any invasive blood tests.
Debbie Dooley
Note:
Debbie has written up her birth story, and also the presentation on GD for midwives which she gave.
Intro to gestational diabetes from Diabetes UK
www.diabetes.org.uk/Guide-to-diabetes/Introduction-to-diabetes/What_is_diabetes/Gestational_diabetes/
'All About Gestational Diabetes' by KMom. Thorough, evidence-based, intelligent discussion.
Gestational diabetes from the UK Midwifery egroup.
CEMACH reports on maternity care for mothers with Diabetes - CEMACH is the Confidential Enquiry into Maternal and Child Health, a UK government body.
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Home Birth Reference Site
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www.homebirth.org.uk