Advice needed re Induction/Medical Intervention

[Caramello]

Some time ago I was diagnosed with gestational diabetes. I have been taking insulin overnight (up to 18 units so far) and controlling the diabetes by diet during the day.

My Obstetrician warned me that if the baby's weight spiked at the 36 week ultrasound I would at the very least either be having an induction or an elective caesarian. I reluctantly agreed, understanding the logic that if the baby was too big it was better to use these methods so that he was not under stress. The Obstetrican gave me an induction date during my 38th week of pregnancy.

I have had the 36 week ultrasound today and the results which have come back are at the very least puzzling if not downright upsetting. The baby has dropped from the 45 percentile in week 32 to the 25 percentile now. There is nothing wrong with the plaenta or cord and his heartbeat is fine. His biological father is only 5.2" and I'm thinking that he would have been a small baby also.

Am I right in thinking that if the baby is this small he needs more time in the womb, which means he should not be induced at 38 weeks? I am seeing my Obstetrician tomorrow and I'm thinking that the induction dates need to be pushed back.

I am also very, very cranky with the dietician who tried to make out that the occasional hot chocolate would have a bad affect on my baby. Obviously it is not.

Advice greatly appreciated!

[Nelle]

Yay for stress.

Well...I'm thinking that an induction would be better than a c-sec...can you just be monitored? So reassess when you get to 38 weeks? Go as long as you can? I'd be reluctant too, for baby to be born before it's ready - if your health can be monitored and managed for as long as possible...is that do-able? xo

[skybie]

Basically, even without the slow down in growth, why wouldnt your ob allow to try and birth a larger baby? that for me instantly rings alarm bells! unless the baby physically wont fit through your pelvis, there is no need for a c/sect if everything else is fine.
Dnt stress too much on the lack of growth, they can get it horrifically wrong. i was told that DD2 was a few weeks behind for dates, she was born 2 days later, 4 weeks early weighing a VERY healthy big 3550gms (7pd 8).
You will be fine, dont let them scare you. YOU CAN do this
much love hun, have been following u from the sidelines
xxxx

[Traveller]

If you have concerns about being induced early then you need to discuss this with your doctor and be prepared to say "no" or "I want to think about it". If he was initially concerned about the baby measuring big, and that is no longer the case, then it could be that he will happily wait for you to labour spontaneously. If he refuses to back down from the induction date then do not be afraid to ask lots of questions such as "what are the alternatives" and "what happens if I do nothing".

Most obstetricians are happy to negotiate with an educated woman so you will probably find he is very willing to discuss your specific situation and happy to address your concerns.

[onthefly]

So I guess the good news is that your baby doesn't seem to be overly big! You must be doing a good job controlling your GD.
My main question would be - if the baby is a reasonable size (and even if big, it's not necessarily a problem) is there any other reason you need to be induced early? Having been induced at 42 weeks I'd be very wary of an early induction UNLESS my doctor can give me a good reason why continuing with the pregnancy would be riskier.
I wouldn't stress too much about the discrepency in size (or, try not to), good placenta, heartbeat and cord are all excellent news!
Hope your appointment goes well tomorrow.

[skybie]

Marcellus sorry to put my 2 cents in, but even women who have perfect control of their diabetes can have macro babies.
i'd hate to think women who have had macro bubs with perfect diabetes control would blame themselves
xxx

[Jennifer13]

Well done on controlling your GD so well, hun! I can't believe you're already 36 weeks. Where has that time gone??

I guess you need to have a big discussion with your ob, but this is good news for you being allowed to continue the pg and go into labour naturally surely. FWIW my u/s at 37 weeks was wrong about baby's weight too - it suggested over 6 lbs at 37 weeks and she was born two weeks later weighing a mere 5 lbs 10 oz. So if anything, the u/s might even be underestimating your LO's weight.

GL with your next appt.

[BellyBelly]

Have you read my posts stickied in this forum? The Cochrane database, based on studies, concluded that induction of labour for GD did not reduce rates of sholder dystocia or any other 'big baby' issues. Just increased rates of c/s. Ultrasound, especially late in preg, is much more inaccurate in measuring size.

[onthefly]

Thanks Skybie, I didn't exactly mean to say it like that.

[melbel]

The thing you have to keep in mind at this stage is that you are on insulin....Insulin is a growth hormone as much as anything else and as such it accelerates the life cycle of the placenta. This means that it may be that the placenta gets to the point in its cycle where it starts to break down earlier than what would happen in a normal pregnancy. If this happens it becomes a serious issue. This is where fetal monitoring becomes so important. You can negotiate the dates and I think you should be able to go to at least 39 weeks f there are no other issues but you will almose certainly need to be having at least twice weekly CTGs and scans to make sure the placental blood flow is still on track.... My obsetrician was happy to go to 39 weeks if all was okay with us but no further because the risks become too great ( as it was connor decided he was ready much earlier than that). That 39 weeks was dependent on close monitoring.

Also the presence of diabetes does not always mean a macrosomic baby, what a lot of people dont realise is that it can just as easily lead to a growth restricted baby as general circulation/blood flow to the placenta can be compromised in some people with diabetes. The size of your baby is no indication of "maturity" either.....he/she could be small but have perfectly formed lungs etc etc.....you may just be baking a perfectly normal for dates small bubba.

Personally I think you are doing just fine...you need to talk your obstetrician and express your thoughts and fears and see what they say, ask questis lots and lots of questions and dont stop asking questions until your are happy you have all the information you need to make this decision... because at the end of the day the decision is yours. How much do you trust your OBs opinion? With me my Ob was a straight shooter and exceptionally well qualified and experienced in the high risk field so when she made comments or suggestions I trusted that she had the best interests of both Connor and I in mind.

And thanks for that Skybie. I had the best control my Obstetrician (who is in the top 2 in this country for high risk and D pregnancies) has ever seen before in a type 1 during pregnancy and I still had a 4.4kg baby at 36 weeks...it is estimated that if he had gone fullterm he would have been in the 11-12 lb category...I kinda resent the inference that his size was somehow related to poor control......it often has very little to do with control...in fact the better control often means a bigger baby because higher doses of insulin are involved to achieve that perfect number which all goes back to the insulin being a growth hormone issue.


Oh and pffft to your dietcian.....what a knob!!! Only you know what foods work for you at this stage as it is such an individual thing how we respond to diff things.

[Artechim]

I would be asking for another scan at 38 weeks and going from there. If bub has dropped percentiles again then induction could be considered more but if bub is travelling well and the placenta/blood flow are all looking good then you could ask for monitoring and go a bit longer.

I had GD in my first pregnancy and was taking about 120 units per day by the end. I had a scan at 36 weeks that showed DS to be around the 50th percentile. They wanted to induce me at 38 weeks but settled for CTG monitoring every second day until I was induced at 39+3. DS was 8lb, so not huge and was perfectly healthy. I didn't want to be induced but at the end of the day I was taking quite a lot of insulin and the stats were a bit worrisome - we didn't want something to go wrong and live with the 'what if's' so we decided it was best for us if we went ahead with the induction.

It is a really hard call and basically all you can do is listen to all the advice and then go with what you are comfortable with.

[Arcadia]

it sounds like a tough decision.

It seems like the size if the baby may not be the only reason why your Ob wants to induce early. In that case, some careful monitoring of the cord and placenta may alleviate the Ob's fear, meaning you can wait longer and hopefully go into labour spontaneously.

[Caramello]

Thanks everyone - I am seeing the Obstetrician tomorrow which is why I am so glad for the feedback today. I am having the CTG scans once a week anyway - as I'm on leave now its no big issue to have them every couple of days.

Kelly - I haven't read those studies - I will have a look.

Mel - the reason I went with this Obstetrician is because of his experience with IVF babies. However given that I have been under at least 5 gynocologists/obstetricians over the past 25 years before this current one (including having a really bad experience with the one that is currently running the AMA - shudder) as well as 3 Fertility specialists (one brilliant, one good and one that was an idiot) my trust levels are not incredibly high, which I discovered when I was seeing someone else about my anxiety levels. However he is a straight shooter and I just need to keep a balance between my reactions as well as be willing to let go and trust. Thanks for the information on the placenta too - I had not realised that this could happen.

I will meet with my Obstetrician tomorrow and take it from there. Thanks everyone for your input.

[onthefly]

Hope all goes well tomorrow and you have a plan in place for the next few weeks that you are comfortable with.

[YoYo]

I hope all goes well for you tomorrow.

I was 'supposedly' diagnosed GD, never had to go on insulin, but was testing constantly maintaining it all with diet.

I always maintained that my DD was only a little one. They weren't going to allow me to go over my due date with her (DS was 9 days over), but I wasn't ever told to go early. I guess sometimes LESS information, scans etc helps Sometimes we all just have way too much information!

How do you feel...does the baby feel massive to you? DD ended up only being 6lb 13oz....so I was right!

[Caramello]

Yules he doesn't really feel that big at all, but this is my first time, so...

[belfie]

Seachange - I think you've had some great advice in this thread, and good on you for questioning and querying (and pfft to that dietician!). Just to throw in my own experience, I was also told that i should be induced (and was also on 18 units of insulin a day). When I queried it with both my endocrinologist and my obs, it wasn't based on baby size for either of them (especially not the endo - ha ) it was based on placenta health and the slight unknowns/risks that go with insulin - NOT the baby size. Melbel gave a very good description of some of the risks that can go with GD babies, which is why the extra monitoring. For example I'm sure i remember reading that GD babies can tend to have more breathing difficulties than non-GD babies, and sometimes the risk relates to the size of the child relative to it's organ maturity IYKWIM. This is where I always felt the the extra monitoring was great to keep my peace of mind that bubba was baking happily away. Both my obs and I were adamant that there was no point doing a sizing scan, and as he said - would it change my desire to birth vaginally IF bubs was big. I said no. Plus of course there is all the literature around the inaccuracy of the sizing scans which made me concerned it could just be a scare-mongering exercise in my particular case. Bear in mind that i'm a shrimpy 5'2" and DH is a towering 6'4" - even the middies looked nervous for me hahaha!

My obs was also happy to negotiate when we induced. He said if I had been on 60-70+ units of insulin per day he would have wanted to go at 38 weeks, but given my lower level and good CTG results (yes I did have monitoring and found it reassuring ), we compromised and I was to be induced at 39 weeks. In the end bub was born vaginally at 39+1 at a pleasant 7lb 7oz. My understanding is certainly that different hosps/obs will have slightly varying criteria around management of GDM patients & birth, but I think for your own peace of mind to get a really thorough understanding of why induction is recommended - from the horses mouth !! Then hopefully you will feel you can make an informed and considered decision about what is right for you and bub, and to feel GREAT about it .

GL with the appt today.

[Caramello]

Well I had a talk with the Obstetrician. As well as pointing out the risk factors I have - over 40, IVF baby, gestational diabetes - he also stated that the risk of me having a stillborn once the baby hits 39 weeks is pretty high. And he reiterated what Mel and Belfie have both said - because I am over 40, and have GD, the placenta may not be functioning as well as it could be. So there is absolutely no chance of him changing the date. So some straight talking and a little bit of a shock (again) really. I just hope now that baby stays ok.