The latest guidance from NICE, published in 2015, has extended the time by which women with gestational diabetes should give birth to 40 weeks, 6 days – not much less than the general guidance for all pregnant women, which is 42 weeks. If you have not gone to birth at this point, induction of labour will be recommended.
"When I was in the hospital, I felt I didn’t know what was going on. I would have liked more information about that part so I could have been better prepared."Gemma, mum of one
The main reason for induction is to prevent stillbirth. For all women, the risk increases when their pregnancy goes past 42 weeks. However, one study has shown that women with gestational diabetes may be at risk earlier. So for this reason, the guidance in England and Wales states that if you have gestational diabetes, you should not go beyond 40 weeks, 6 days.
An induction or caesarean may also be advised if your baby is very large (macrosomia) – as this may cause difficulties during the birth. On the other hand induction may also be recommended if the team detects poor growth in your baby.
In Scotland, most women with diabetes in pregnancy are induced within 40 weeks. The guidance says that this decision should be determined on an individual basis. If you are taking diabetes medication or insulin, it recommends that you should be assessed at 38 weeks and delivered by 40 weeks.
Choices you might need to make for labour and birth
Most women with gestational diabetes have a healthy birth. But before you make your birth plan, you may need to take some things into account to make sure you and your baby are safe during and after the birth.
If you have gestational diabetes, you will have less choice about where to deliver your baby. This is because you will need to deliver your baby in a hospital that can offer 24-hour advanced resuscitation skills.
If your ultrasound scans show that your baby is large (macrosomia), your antenatal team will discuss the pros and cons of a vaginal birth, induced labour and a caesarean section. Any medical intervention comes with risks of its own, so take your time to talk through any questions and come to the decision that feels right for you.
If you go into labour prematurely (before 37 weeks) you may be given medication to delay the birth - depending on how early you go into labour. You may also be given steroids to help your baby’s lungs develop properly. Steroids can raise your blood glucose levels, so if you are taking insulin, you may need to increase the dose or receive insulin in a drip.
Monitoring during labour
Your blood glucose needs to be monitored every hour during labour to ensure it stays within safe levels. If the levels are high, there is a chance that you may need to receive insulin and glucose through a drip during your labour and birth, which will make it harder for you to move around during labour.
This is more likely to happen if you are already giving yourself insulin injections. If you managed your blood glucose levels through diet alone, you may need very little additional monitoring during labour.
If you are exhausted, if your baby is distressed, or if he is not moving out of the birth canal, you may need an assisted birth. This means either forceps (which cup the baby’s head like spoons) or a ventouse (suction cap) to gently help him out. A ventouse can be used only at 34 weeks or more, once the baby’s head is sufficiently developed for it.
Both of these procedures are commonly carried out when there is an indication they are needed. Your obstetrician will go through the reason why they are recommending an instrumental delivery and any potential risks that are associated.
They may leave short-term marks, such as bumps and bruising on your baby’s head, but these will disappear over time.
What does all this mean for you?
You may have a straightforward birth or it may be more complicated than you hoped. If your birth experience is very different to the one that you had hoped for, it can be difficult to come to terms with this. It is important to remember that labour and birth often does not go to plan, whether it is complicated by diabetes or not. For many women, knowing more about induction and caesarean births (read more below) helps them feel mentally prepared for what lies ahead.
"I'd seen a lot of my friends have children, so I had an idea that labour can change dramatically in minutes. I knew that the ideal wasn't always possible. I think that helped a bit."Michelle, mum of two
If you do feel very emotional about any aspect your birth – even some time after the event – it can help to share your feelings with others. Talk to friends or family about it, speak to your midwife, health visitor or GP, or call one of the midwives at Tommy’s PregnancyLine on 0800 0147 800. It can help to remember that, while everyone would like to have the birth they had planned, the birth is just one step in the journey towards having your baby.
Induction involves starting labour artificially. To induce the birth, your healthcare team will put a pessary or gel into your vagina, a drip in your arm, or both. It can take 24 hours or more for the labour to start. Once it starts, the contractions are different from the contractions in a natural birth. They are often very close together and more intense, and you are likely to find it more painful. You might want to take this into account when considering your options for pain relief.
The team will need to monitor your baby’s heartbeat during the pregnancy. This is usually done with sensors on a wide elastic belt tied around your bump. Sometimes the sensor is placed on the baby’s head through your vagina instead. This can only be done if the waters have broken.
If the first induction does not bring on labour then, depending on how you and your baby are coping, you may be offered another induction, or you may be recommended to have a caesarean section. The team will discuss all the options with you.
"The midwife who I had in labour had herself been induced with a drip. It was nice to have a midwife who had been through the same, because she could understand what it felt like."Gemma, mum of one
If you have a vaginal birth, you can receive the usual pain relief but your blood glucose levels will need to be monitored every hour.
A caesarean – also known as a C section – is an operation in which your baby is lifted out through a small incision in your abdomen.
Your caesarean may be booked in advance, but if it is unexpected – for example, if induction does not work for you – then you may have an unplanned, or ‘emergency’ caesarean. This may sound alarming, but is just the term for caesarean carried out without notice, and does not necessarily mean that you or your baby are in danger.
What happens during a caesarean?
- The procedure is explained to you and you will be asked to give written consent.
- You may be given some medicine to settle your stomach.
- A drip will be put in your arm to give you extra fluids.
- An anaesthetist will give you a regional anaesthetic (an epidural, or a spinal epidural, which is similar) that numbs your abdomen and pelvic area but doesn't send you off to sleep.
- Once you have had the anaesthetic, the midwife will insert a small tube into your bladder to drain the urine. This will stay in place until the next day when you are able to walk to the toilet.
- A small cut will be made along the top of your bikini line and your baby will be lifted out. You won't be able to see what's happening as a screen will be put up.
- After the placenta is removed, you'll be stitched up.
The whole operation takes about an hour, from making the cut to stitching you up afterwards. Your birth partner can be there too. It takes time to recover from a caesarean section, and you will need to stay in hospital for about two to four days.
Your stitches will take time to heal and you may need strong painkillers for two to three days. You may also be on a drip for a while. You'll usually have stitches that dissolve on their own on the inside, and maybe one stitch on the outside that your community midwife will remove in around five days.
- NICE (2015) Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period, National Institute of Health and Care Excellence https://www.nice.org.uk/guidance/ng3
- NCCWCH (2015) Diabetes in pregnancy Management of diabetes and its complications from preconception to the postnatal period NICE guideline 3 Methods, evidence and recommendations. National Collaborating Centre for Women's and Children's Health http://www.nice.org.uk/guidance/ng3/evidence/full-guideline-3784285
- SIGN (2010) Management of diabetes, a clinical guideline, Scottish Intercollegiate Guidelines Network http://www.sign.ac.uk/pdf/sign116.pdf
- NHS Choices [accessd April 2015] Inducing labour http://www.nhs.uk/conditions/pregnancy-and-baby/pages/induction-labour.aspx#close Review date: 12/02/2010
- NHS Choices [accessd April 2015] Gestational diabetes - treatmenthttp://www.nhs.uk/Conditions/gestational-diabetes/Pages/Treatment.aspx Review date: 07/08/2016
- NHS Choices [accessd April 2015] Caesarean section - introduction http://www.nhs.uk/conditions/caesarean-section/Pages/Introduction.aspx Review date: 17/07/2016
- Macdonald S and Magill-Cuerden J (2012) Mayes’ Midwifery, Fourteenth Edition, Edinburgh: Bailliere Tindall Elsevier
- RCOG (2010) Antenatal Corticosteroids to Reduce Neonatal Morbidity (Green-top Guideline No 7) Royal College of Obstetricians and Gynaecologists