Should we have our baby induced?

July 24, 2008 10:57 AM

What are the reasons for and against inducing childbirth in cases of gestational diabetes?

I'm seven months pregnant, with insulin-dependent gestational diabetes. I really like my doctors (OB, perinatologist, and endocrinologist) and generally trust their opinions. The OB and perinatologist are both convinced that it's best to have my baby induced, while the endocrinologist disagrees, and says this practice is "old fashioned." Of course, I will keep discussing this with all three doctors (and I will continue to keep my blood sugar under excellent control, and we will continue to monitor the baby's growth, etc.) but I would like more information to use while making this decision. Most of the information I've found on the internet seems to be in the "this is what's done" versus "you shouldn't induce your baby" format, rather than giving the reasons one might choose one option or another.

Incidentally, my own birth was induced. My mom says the labor went really quickly, but she didn't give me much more information.

So, what are the advantages of inducing labor? What are the risks of inducing, or the risks of NOT inducing? If you've been in this situation, what were your experiences?

posted by faustessa to health (14 comments total)

IANAD:
I'd go with the opinions of your OB and your Perinatologist. Unless your Endocrinologist specializes in gestational DM, their experience regarding the health of both you and your child are likely not as extensive as an OB or a perinatologist (same as a Pediatric Neonatologist, I assume?).

However, neither is trying to mislead you, but I think what you should do is ask WHY each of these physicians feel the way they do and ask them for pros and cons and why the endocrinologist thinks otherwise. (Since they are managing you/your pregnancy they are MUCH better to be asking these exact questions you are asking than random internet folks.)

I guess the main advantage of inducing (at 38-40wks presumably) is because in GDM there is an increased risk of large babies who may have deliver late and/or be very large. Large size may lead to problems regarding passing though the pelvis. I do not know what the risks of induction are, your OB will know the answer.

Best of luck, and do not feel bad asking your doctors "how come" or "why" or "explain more" when they give you an opinion. That's what they are there for.
posted by ruwan at 11:15 AM on July 24

There are legitimate reasons to induce. In your case, your baby has a risk for being LGA, "large for gestational age".

I personally think induction could be termed as old fashioned, or a matter of convenience. Although there are many legitimate, medically necessary reasons to induce, I was against it in my healthy pregnancies. I refused to be induced. My midwife knew my wishes and it was not a big deal.

Anecdotally, I can say that ultrasounds are not always precise in determining an infant's weight. I have heard many times that a baby was guessed to be more than a pound heavier than the actual birth weight.

Contractions come in peaks and valleys. With Pitocin it's mostly all peaks and little valleys. I wanted to go into labor naturally. There are statistics to support that more artificially induced labors result in C-section. I am of the mind that things work out better (not necessarily the outcome, but the labor) when our bodies start the laboring process naturally.

Keep in mind I am not a doctor. I am a nurse, but not a L&D nurse. I did end up with a c-section, but not because of artificial induction. Good luck and congratulations.
posted by LoriFLA at 11:18 AM on July 24

I did not have gestational diabetes but I did have a big baby (9 lbs, 10 oz). He spent several days in the neonatal intensive care unit getting his blood sugar regulated. We were told that this is not at all unusual for larger babies. Although he's fine now, and he was never considered to be in any sort of really serious trouble, it was a tough couple of days for everyone. Perhaps your doctors can elaborate on whether this is something that factors into the decision on inducing. In any case, good luck and best wishes to you and your family.
posted by Kangaroo at 11:32 AM on July 24

IANAD.
I did have my labor induced at 32 weeks due to severe pre-eclampsia. I delivered vaginally.

I would follow what the perinatologist says in this case. They are the specialist and they have the experience to make the judgment. In my situation the OB stepped out of the way and let the perinatologist take over. I was sort of surprised about that, but it does make sense.

I think you should opt for the least invasive method to get the baby delivered in the safest and most healthy way possible.

Induction wasn't that bad. In my case, the Cervadil for cervical ripening got the labor contractions going and it only took four hours of Pitocin before I had the baby. This was my first pregnancy and I was bracing myself for 24 hours of Pitocin-fueled labor since that is what typically happens. I had an epidural as well (after IV narcotics did nothing) and that is supposed to draw out induced labor... but in my case everything went pretty swiftly. I remember thinking "I'm going to throw up," then, "I can't take it anymore" and that's literally when I had the baby. It happened so fast, no one was expecting it and my OB was 15 minutes late to my delivery.

I was really hoping against a c-section simply because I did not want the risks associated with abdominal surgery while also trying to care for a newborn. However, it is done all the time with good outcomes, so if I had to have it, I had to have it.
Also I believe there is sometimes some residual GD for some women--after you deliver--and the fluctuations in your BG may have some affect on your healing if you have a surgical delivery? Something to ask your doctors...

In any situation, remember you will do what's best for the baby and when it's all over you will have such a prize. Congratulations and good luck!
posted by FergieBelle at 11:34 AM on July 24

We've induced with both of our children at 38 weeks. My wife is also insulin dependent gestational diabetic. IANAMD, and IANYMD, however, here are the pros and cons to early induction as they were explained to us. First, there's an increased risk of a still birth with a baby carried to term by a gestational diabetic. I don't recall the exact figure, but 5% sticks in my head at 40 weeks. That's the big pro for early induction. As you probably already know, babies of gestational diabetics are generally larger. That increases the risk of the birth process, particularly if you're petite, like my wife. Even though the babies are larger, they're also more likely to have underdeveloped lungs. That's the main con to induction. At worst, if your sugars are controlled (what's your A1C been?), the baby may have to receive oxygen when it's born. For both pregnancies, our OB's goal was to get to 38 weeks to mitigate the risk of possible lung problems.
I'm assuming you're going in for the foetal non-stress tests pretty regularly. Towards the end, we were in our OB's office twice a week. As for the comments from your endocrinologist, remember who's responsible for what in this process. The endocrinologist's patient is you, with a goal of keeping the diabetes under control while your hormones go crazy. The OB's goal is to keep you safe while delivering a healthy baby. IMHO, the endocrinologist is somewhat out of line in trying to tell the OB what to do in this case. Obviously, we'd personally decide on induction, because we did. Twice.
posted by dblslash at 11:35 AM on July 24

Follow up:

A1C is 4.9 currently.
Our endocrinologist specializes in gestational diabetes, and she regularly works with our OB (they even live on the same street) so I'm not worried about any turf wars: I know they've already consulted with each other several times about my case.
posted by faustessa at 12:19 PM on July 24

My situation was a bit similar to yours - I was diagnosed with gestational diabetes, but its more likely a side effect of the steroids I had to take in the 2nd trimester to get my asthma under control. My GD (or faux GD, whatever) was very borderline and easily controlled through diet, so I imagine this means its much less serious since I didn't need to use insulin. I had the countering effect that due to other issues, my son was considered at risk of low birthweight, which countered the risk of high birthweight from the GD. In the end he was tiny, and we had to stop the induction and have a c-section because he was too weak to cope with the contractions (this was due to the low birthweight issues, not the GD).

I totally agree with LoriFLA that ultrasounds are a very unreliable method of guessing birthweight, they estimated almost a pound too high with my son. From what I understand, the high birthweight and associated risks to you are one concern, along with the baby's blood sugar level being elevated, and having to be controlled immediately after birth. Other considerations are that if your OB and perinatologist consider your delivery to be high-risk, they would prefer the controlled circumstances of knowing exactly when it is going to happen, so everyone can be there in the hospital, ready and prepared. They are worried about the risk of you going into labor early, at home/on the street or whatever, and something going unexpectedly wrong before they can get to you. They are being conservative in order to increase the chances of a happy, healthy delivery, and also to cover their own arses if something goes wrong.

This is part of the same argument about increased rates of C-sections - medical professionals are being increasingly conservative and opting for the controlled circumstances of induction or C-section because if something goes wrong, they end up on the wrong end of a lawsuit. Its not the happiest reason to choose your delivery method, but personally, I am totally OK with being conservative about my son's delivery, because the only important thing to me was that he was safe. Of course induction and C-sections have associated risks too, but my OB felt they were lesser than the risks my son would face from a natural delivery, in my particular situation. So that's really the crux of the situation, ask your doctors to lay out what they feel the risks are associated with leaving it for a natural delivery, and what the risks are if you induce. Which way has a greater chance of ending in an emergency c-section? Also, ask yourself, how important is "the birth experience" to you? I personally am not crunchy enough to worry about having a natural experience with a birthplan and music etc. I wanted to be in the hospital, with lots of doctors around in case something went wrong, have an epidural etc etc. C-section was not what I wanted, but that's what happened, so I dealt with it. It was fine in the end, the recovery was slower than a vaginal delivery but it certainly wasn't the end of the world. So really the answer partly depends on you and how important a natural birth experience is. I know some women are devastated if they miss out on it, but I am not one of them. Sorry that was tremendously long, hope it was helpful in some way. Good luck and congrats!
posted by Joh at 1:07 PM on July 24

IANAD, but wife was induced, with gestational diabetes at 39 weeks.

From how it was presented to us, the concern was the performance of the placenta degrading past a certain point in the pregnancy, which could compromise the level of oxygen/nutrition/etc. getting to the baby. Had labor started, great. It didn't, so we induced.

In fact, even during the induction, the docs watched the baby's heart rate like hawks during contractions, looking for extended durations of low bpm. They called them "decels." Again, in the interests of making sure he was getting enough oxygen.

Ultimately, someone made a judgment call that the decels were going on for too long, and the best option was a c-section. Our understanding was this was a likely event anyway, so we weren't too surprised when they told us.

We're not natural birth people, but our health facility classified our particular situation as high risk, so we consequently abandoned any notion of "birth experience" in the interest of the best possible outcome for both mom and baby.
posted by NoRelationToLea at 1:28 PM on July 24

My GD/induction experience was almost eight years ago and therefore my response would be more outdated than many of the answers previous, but I saw this...

I will continue to keep my blood sugar under excellent control

...and just had to say that as you progress through the rest of your pregnancy, that may be more difficult to achieve. I was *religious* about my diet and about testing, and I had a hard time keeping my numbers down, even with insulin, for the last couple of weeks. I was also told that this wasn't particularly unusual.

I've no idea if the technology has improved since 2000, but I had a 37 week ultrasound that estimated my baby at about 9 and a half pounds...two pounds too high.
posted by gnomeloaf at 3:45 PM on July 24

The following is just my personal experience, and not practical medical advice - my son was induced at 40 weeks because of my (diet managed) gestational diabetes. My son wasn't LGA, but they wanted him out, and I was cool with that.

I attribute a lot of the abrupt unpleasantness and the merciful brevity of my labour to the fact that my baby was induced, but want to say right up front that I would still have done it if that was the medical advice I had received. I walked into the hospital on the day he was due, just as happy, healthy, fit and "normal" as I am sitting here today, and within an hour I was very much advanced in first stage labour. This was my first baby, so I'm not 100% sure that this isn't just how labour is anyway, but I went from sitting up happily chatting with those around me to begging for mercy (and drugs). My labour was only five hours from arriving at hospital to holding the young 'un in my arms, with absolutely no lead-up or pre-labour.

I guess what I'm saying is, from a practical standpoint is be prepared for the possibility of a very short blitzkrieg-style labour if you are induced.
posted by lottie at 9:29 PM on July 24

Like gnomeloaf, with my two children (age 10 and 8) I had borderline (10 yr old daughter) or mild (8 yr old son) gd and was told, "your baby will be HUGE!" We induced because my daughter was (according to the ultrasound) fast approaching 9 or 10 pounds, gasp. Well, induction, fetal distress and emergency c-section later, my teensy 6 pound 12 ounce baby is fine. 2 years later, different doctors told me that my son was going to be huge. 6#13 oz. So, now I'm 36 wks pregnant with my third and their saying she's at the 50th percentile. Who knows? How much better at ultrasound are they now??

Regardless, both my kids are perfectly healthy, and after two c-sections I'm fine with having a third. Your risk of c-section goes way up with induction and, I've read, it goes up just with the diagnosis of GD because the doctors are more careful and nervous about complications. FWIW, I was out of the house with each of my babies within a week. C-sections hurt a lot for about a week, then you're fine. Not that you'll necessarily need one, but in case you're worried, as my mother said, "Well, you can hold onto the c-section stitches when you cough..."

Anyway, this time I'm insulin dependent (10 years older and mumblemumble pounds heavier) and relatively well controlled. I'd be interested to know how much insulin you're on and what your diet is like. My doctor is of the opinion that it's better to go WAY down on carbs and keep the insulin low. She also doesn't mind that I haven't gained any weight since May, and only gained 14 pounds total. Mefimail me if you want - I haven't had any luck finding info directly from other insulin dependent people. (Most askmefi posts end with, "but I can control it with diet.")

If you mefimail me after August 12, I will tell you exactly how big the baby is!
posted by artychoke at 9:47 PM on July 24

Groan. "They're" saying she's..."

I'm dumb.
posted by artychoke at 9:50 PM on July 24

GD (diet managed) during my pregnancy. Weekly endocrinologist visits, blood tests, and blah blah blah, but I'm an American who had a baby in the UK. Interestingly enough, despite the similar diets, obesity levels, probable levels of GD in the UK, and potential risks to the fetus, they don't induce for it here. NICE guidelines

My labor was induced for my water breaking (39w 5d, so you would think I would be ready. . .) and then two days with no contractions. Nothing worked easily for me--the Cervidil barely got me to 3 cm, and I wound up on their maximum dose of oxytocin (Pitocin, Syntocin) for the next 24 hours. 36 hours after admission, one 8 lb 4oz boy.

Just a data point. I wouldn't do it again, if I could help it. I think I could have done an unaugmented labor without an epidural but there was no break with the contractions on Syntocin.
posted by marmot at 8:27 AM on July 25

Oh, one other thing I forgot during my typing frenzy... Depending how early your doctors would like to induce, you may need to take steroids in order to accelerate the baby's lung development, so he/she does not need help breathing after birth. These are probably the same sort of steroids I had to take for my asthma (everyone kept saying "at least his lungs will be developed if we have to induce really early!"), which in turn caused me to fail the GD tests. So I would ask about the possibility of having to take steroids, and if so, whether they would worsen your existing GD.
posted by Joh at 4:18 PM on July 25