Managing Diabetes During Labour
Your own blood glucose levels in the time leading up to the birth have an important effect on your babys blood glucose levels. The higher your blood glucose, the greater risk of hypoglycaemia in your newborn baby. Keeping blood glucose levels close to the target range during labour helps reduce the risk of your baby having low blood glucose levels at birth.
When you are in labour, you will be under the care of your diabetes in pregnancy team including your midwife, obstetrician and endocrinologist/diabetes specialist. Your blood glucose levels will usually be monitored frequently and there will be regular contact with your diabetes team.
If you need insulin during labour, the dose will be adjusted to keep your blood glucose levels in the target range. You may be given the insulin as injections or via an intravenous insulin infusion along with IV glucose . Some women with type 2 diabetes may not need insulin during labour, discuss the management of your diabetes during labour with your diabetes in pregnancy team.
Testing For Gestational Diabetes
Its important to be tested for gestational diabetes so you can begin treatment to protect your health and your babys health.
Gestational diabetes usually develops around the 24th week of pregnancy, so youll probably be tested between 24 and 28 weeks.
If youre at higher risk for gestational diabetes, your doctor may test you earlier. Blood sugar thats higher than normal early in your pregnancy may indicate you have type 1 or type 2 diabetes rather than gestational diabetes.
How Will It Affect My Baby
Your higher blood sugar affects your baby, too, since they gets nutrients from your blood. Your baby stores that extra sugar as fat, which can make them grow larger than normal. They’re more likely to have certain complications:
- Injuries during delivery because of their size
- High blood pressure or preeclampsia
- Pre-term birth
Your blood sugar will probably return to normal after you give birth. But you’ll have a higher risk of developing type 2 diabetes later or gestational diabetes again with another pregnancy. A healthy lifestyle can lower the odds of that happening. Just as you can help your child, you can lower your own chances of obesity and diabetes.
Although you may need a C-section, many women with gestational diabetes have regular vaginal births. Talk to your doctor or midwife about your delivery options:
- Does my baby need to be delivered by C-section?
- How accurate are birth-weight estimates? Could my baby be smaller than you think?
- What are the risks to my baby and I if I donât have a C-section?
- What are the risks to us if I do?
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Considerations Regarding Timing Of Delivery
The recommendations on timing of delivery, and thus induction, are informed primarily by cohort studies examining the risk of a particular outcome, such as caesarean section or stillbirth, occurring in a population of women with diabetes at each week of gestation, compared to women without any pregnancy complication.
Induction Of Labour In Insulin
The need for glucose-lowering medication such as insulin during gestational diabetes pregnancy may often be given as a reason for advising early induction of labour. However, if blood glucose levels remain controlled with insulin, is early induction of labour warranted?
The poorly controlled GDM with a PGDM phenotype should likely be managed more conservatively with consideration towards earlier induction. Conversely, the low risk well-controlled primiparous GDM patient with an unfavourable cervix is likely to benefit from expectant management. Although commonly used by practitioners, the distinction between insulin-treated and diet-treated GDM pregnancies should not necessarily be the sole criterion used when deciding on timing of delivery2
Berger H, Melamed N.
A study between 2010 2012 in Vienna comparing maternal and fetal outcomes in 100 insulin-controlled gestational diabetes patients found that induction of labour at 38 weeks did not significantly reduce the rate of large for gestational age babies compared to induction at 40 weeks. Still, they found a higher rate of neonatal hypoglycemia. It, therefore, questions the benefit of earlier induction of labour in insulin-controlled women with gestational diabetes who have good glycaemic control.
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Its important to maintain a healthy body weight. You should also make sure that you drink plenty of water, and limit your intake of sugary drinks. In addition, make sure that you get regular exercise. You should also avoid alcoholic beverages. Lastly, you should avoid alcohol. These beverages contain high amounts of sugar. If you dont drink enough, youre not doing anything to prevent diabetes. Besides, drinking alcohol can be harmful to your health.
The most important thing to do is to follow the recommended diet. Eat more healthy foods that have low amounts of fat and high amounts of fiber. The best way to lose weight is to lose 7 percent of your body weight. If youre overweight, you should try to lose 14 pounds to reduce your risk of developing type 2 diabetes. However, you should not attempt to lose weight while pregnant. Talk to your doctor about what kind of weight is safe for you.
Besides high blood glucose, diabetes can also affect the nerves and skin. It may affect your sexual response and your nervous system. It can also affect your fertility. Women with diabetes are more likely to miscarry or have a baby with a birth defect. It can cause a person to have difficulty hearing and sleep. If the condition is left untreated, it can lead to type 1 diabetes and can even lead to amputation.
National Guidelines For Gestational Diabetes Birth
Below are the National Guidelines for people diagnosed with diabetes in pregnancy. It should be noted that whilst these are the current national guidelines, they are only recommendations and each hospital Trust will have its own local guidelines that they may choose to use.
NICE Guidelines1 for England, Wales and Northern Ireland
Timing of gestational diabetes birth
1.4.4 Advise women with gestational diabetes to give birth no later than 40 weeks plus 6 days. Offer elective birth by induced labour or by caesarean section to women who have not given birth by this time.
1.4.5 Consider elective birth before 40 weeks plus 6 days for women with gestational diabetes who have maternal or fetal complications.
Mode of gestational diabetes birth
1.4.6 Diabetes should not be considered a contraindication to vaginal birth after a previous caesarean section.
1.4.7 For pregnant women with diabetes who have an ultrasounddiagnosed macrosomic fetus, explain the risks and benefits of vaginal birth, induction of labour and caesarean section.
1.4.10 Monitor capillary plasma glucose every hour during labour and birth for women with diabetes, and maintain it between 4 mmol/litre and 7 mmol/litre.
1.4.12 Use intravenous dextrose and insulin infusion during labour and birth for women with diabetes whose capillary plasma glucose is not maintained between 4 mmol/litre and 7 mmol/litre.
SIGN Guidelines2 for Scotland
Timing of gestational diabetes birth
Mode of gestational diabetes birth
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Why Is Labour Induction Important In Case Of Gestational Diabetes
What used to be once a relatively rare condition is now becoming more and more common. Having GD can negatively impact the health of both, mother and unborn child but it does not affect the way you give birth. You can still give birth vaginally and can also have an uncomplicated delivery. Here are some reasons why inducing labor is a good option.
Monogenic Diabetes In Pregnancy
Since pregnancy may be the first time in their lives that women undergo glucose screening, monogenic diabetes may be picked up for the first time in pregnancy. Monogenic diabetes first diagnosed in pregnancy should be suspected in the women with GDM who lack risk factors for GDM and type 1 diabetes and have no autoantibodies . A detailed family history can be very helpful in determining the likely type of monogenic diabetes. This is important because the type of monogenic diabetes influences fetal risks and management considerations. The most common forms of monogenic diabetes in Canada are maturity onset diabetes of the young 2 or MODY 3 . A history of family members with longstanding isolated elevated FBG with mild A1C elevations that do not progress to frank diabetes over a long duration is suggestive of MODY 2. During pregnancy, the usual phenotype for MODY 2 of isolated elevated FBG is not always seen, even though this phenotype may be present outside of pregnancy in the same woman . Fetal carriers of GCK mutations do not usually have macrosomia. Fetuses without the GCK mutation of mothers with GCK mutation are at increased risk of macrosomia. The best way to manage women with GCK mutation during pregnancy has yet to be established, but regular fetal growth assessment can aid in the establishment of appropriate glucose targets during pregnancy for women with documented or strongly suspected GCK mutations.
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Will Gestational Diabetes Hurt My Baby
If not treated, gestational diabetes can lead to health problems. The best way to promote a healthy pregnancy if you have gestational diabetes is to follow the treatment plan outlined by your health care provider.
Most women who have gestational diabetes give birth to healthy babies, especially when they keep their blood sugar under control, eat a healthy diet, get regular, moderate physical activity, and gain the right amount of weight. In some cases, though, the condition can affect the pregnancy.
Keeping glucose levels under control may prevent certain problems related to gestational diabetes.
Below are some conditions that can result from your having gestational diabetes. Keep in mind that just because you have gestational diabetes does not mean that these problems will occur.
Macrosomia Babys body is larger than normal. Large-bodied babies can have difficulty by natural delivery through the vagina the baby may need to be delivered through cesarean section. The most common complication for these babies is shoulder dystocia .
Hypoglycemia Babys blood sugar is too low. You may need to start breastfeeding right away to get more glucose into the babys system. If it is not possible for you to start feedings, the baby may need to get glucose through a thin, plastic tube in his or her arm that puts glucose directly into the blood.
Respiratory Distress Syndrome Baby has trouble breathing. The baby might need oxygen or other help breathing if he or she has RDS.
Treatments For Gestational Diabetes
If you have gestational diabetes, the chances of having problems with your pregnancy can be reduced by controlling your blood sugar levels.
You’ll be given a blood sugar testing kit so you can monitor the effects of treatment.
Blood sugar levels may be reduced by changing your diet and exercise routine. However, if these changes don’t lower your blood sugar levels enough, you will need to take medicine as well. This may be tablets or insulin injections.
You’ll also be more closely monitored during your pregnancy and birth to check for any potential problems.
If you have gestational diabetes, it’s best to give birth before 41 weeks. Induction of labour or a caesarean section may be recommended if labour does not start naturally by this time.
Earlier delivery may be recommended if there are concerns about your or your baby’s health or if your blood sugar levels have not been well controlled.
Find out more about how gestational diabetes is treated.
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What Is The Optimal Method Of Diagnosis
Since there is no clear glucose threshold above which pregnancy outcomes responsive to glycemic management occur , controversy persists as to the best diagnostic thresholds to define GDM. The International Association of the Diabetes and Pregnancy Study Groups Consensus Panel decided to create new diagnostic thresholds for GDM based on data from the Hyperglycemia and Adverse pregnancy Outcome study. IADPSG thresholds are the maternal glucose values from HAPO associated with a 1.75-fold increase of LGA, elevated C-peptide, high neonatal body fat or a combination of these factors, compared with the mean maternal BG values of women studied in HAPO. These arbitrary thresholds, when applied to the HAPO cohort, led to a GDM incidence of 17.8%. The National Institute of Health 2013 Consensus Conference summary statement stated that at present, the panel believes that there is not sufficient evidence to adopt a 1-step approach, such as that proposed by the IADPSG . However, since this publication, national organizations have published guidelines that are divergent in their approach to screening and diagnosis of GDM , thus perpetuating the international lack of consensus on the criteria for diagnosis of GDM.
Figure 1Preferred approach for the screening and diagnosis of gestational diabetes.
Figure 2Alternative approach for the screening and diagnosis of gestational diabetes.
Prevention And Risk Factors
The incidence of GDM is increasing worldwide. The global prevalence of hyperglycemia during pregnancy has been estimated at 16.9% using the World Health Organization criteria . A higher proportion of women entering pregnancy at an older age and/or with obesity contribute to this increase in prevalence, along with changes in screening strategies and diagnostic criteria. There is a need for an effective and acceptable intervention that will prevent the development of GDM. Such an approach has the potential to improve maternal and child health, with significant savings to the health-care system.
Understanding the pathophysiology of GDM and its risk factors is important for the development of preventive strategies. The GDM population includes a heterogeneous group of women with different metabolic profiles when exposed to pregnancy hormones. Various presentations include:
- Hyperglycemia that likely preceded the pregnancy , elevated first trimester fasting glucose, overt diabetes in pregnancy, monogenic diabetes)
- Reduced and/or falling insulin secretory capacity
- Significant insulin resistance from early pregnancy
- A combination of factors ).
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Maternal Outcomes With Elective Induction Vs Expectant Management
The largest study to look at maternal outcomes included over 8,000 pregnant people with GDM. They found that inducing labor at 38 or 39 weeks for GDM is linked to a lower rate of Cesareans, less pre-eclampsia/hypertension, and more epidural use compared to expectant management at those times . When they looked exclusively at first-time mothers, there was no benefit to inducing labor at 38 weeks only 39-week induction was linked to a lower rate of Cesareans compared to following expectant management to 40+ weeks .
In another study, researchers also reported cervical ripeness and whether the mother had given birth before . These researchers found that people with GDM who had had a previous vaginal birth significantly increased their risk of Cesarean by attempting induction before 39 weeks, especially with an unripe cervix. Therefore, based on this and the Melamed et al. study, it appears that 38-week elective induction for gestational diabetes should not be routinely recommended to first-time or experienced mothers. In the Feghali et al. study, induction at 39 weeks gestation resulted in a similar Cesarean rate compared to expectant management at that time. After 40 weeks gestation, everyone experienced an increase in Cesareans, regardless of whether their labors were induced or spontaneous.
Why might Cesareans go up after 40 weeks?
The Difference Between Diabetes And Gestational Diabetes
Only pregnant women get gestational diabetes. When you are pregnant, your body goes through many changes that can make it difficult for your insulin to work properly. Your body cannot get the sugar out of your blood and into your cells to use for energy as well as it did before.
The placenta, a system of vessels that passes nutrients, blood, and water from mother to fetus, makes certain hormones that prevent insulin from working correctly. This is insulin resistance. Your body has to make three times its normal amount of insulin or more to overcome the hormones made by the placenta.
For most women, the bodys extra insulin is enough to keep their blood sugar levels in the healthy range. For about 5 percent of pregnant women, even the extra insulin is not enough to keep their blood sugar level normal. Testing for gestational diabetes is done between the 24th and 28th week of pregnancy.
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Induction More Painful Than Spontaneous Labour
Some people may find that labour and contractions are brought on much faster with induction and, therefore, it may be more intense than if the body was to spontaneously labour at its own pace.
Pain relief should be discussed with your health care professionals and detailed in your birth plan.
Many mothers have used birthing pools and baths for pain relief, even during inductions. The diagnosis of gestational diabetes does not necessarily mean that waterbirth is off the cards. For more information on waterbirths with gestational diabetes, read more here.
Screening For Gestational Diabetes
During your first antenatal appointment at around week 8 to 12 of your pregnancy, your midwife or doctor will ask you some questions to determine whether you’re at an increased risk of gestational diabetes.
If you have 1 or more risk factors for gestational diabetes you should be offered a screening test.
The screening test is called an oral glucose tolerance test , which takes about 2 hours.
It involves having a blood test in the morning, when you have not had any food or drink for 8 to 10 hours . You’re then given a glucose drink.
After resting for 2 hours, another blood sample is taken to see how your body is dealing with the glucose.
The OGTT is done when you’re between 24 and 28 weeks pregnant. If you’ve had gestational diabetes before, you’ll be offered an OGTT earlier in your pregnancy, soon after your booking appointment, then another OGTT at 24 to 28 weeks if the first test is normal.
Find out more about an OGTT.
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Is Induction Of Labour Necessary When You Have Gestational Diabetes
Some women have symptoms of GD whereas others dont. Some can also fix it just by managing diet and some exercise whereas others need shots of insulin. A lot of health care providers recommend around 3940 weeks for inducing childbirth. The WHO says not before 41 weeks, albeit backed up by weak evidence. Guidelines for GD according to the American Congress of Obstetricians and Gynecologists recommends induced labor not before 39 weeks of gestation with controlled GD.
Each case is treated individually based on the patients medical analysis and requirement. For many women, if the diabetes labor through the course of the pregnancy, they can most likely have labor deliveries. However, inducing labor becomes important when diabetes is not controlled to maintain the health and safety of both the baby and the mother.