In this post, I look at Gestational Diabetes Birth. I will start by sharing what the current guidelines in England, Wales, Scotland and Northern Ireland recommend for timing and mode of birth for those diagnosed with gestational diabetes. I will then share evidence-based research on gestational diabetes birth. Last, I will look at birth choices and informed consent around gestational diabetes birth.
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 it 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 (if indicated) by caesarean section to women who have not given birth by this time. [2015]
1.4.5 Consider elective birth before 40 weeks plus 6 days for women with gestational diabetes who have maternal or fetal complications. [2015]
Mode of gestational diabetes birth
1.4.6 Diabetes should not be considered a contraindication to vaginal birth after a previous caesarean section. [2008]
1.4.7 For pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus, explain the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]
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. [2008, amended 2015]
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. [2008, amended 2015]
Post birth
1.5.1 Advise women with diabetes to give birth in hospitals where advanced neonatal resuscitation skills are available 24 hours a day. [2008]
1.5.2 Babies of women with diabetes should stay with their mothers, unless there are complications or abnormal clinical signs that mean the baby needs to be admitted to intensive or special care. [2008]
1.5.3 Carry out blood glucose testing routinely at 2 to 4 hours after birth in babies of women with diabetes. Carry out blood tests for babies with clinical signs of polycythaemia, hyperbilirubinaemia, hypocalcaemia or hypomagnesaemia. [2008]
1.5.6 Do not transfer babies of women with diabetes to community care until: they are at least 24 hours old and you are satisfied that the baby is maintaining blood glucose levels and is feeding well. [2008]
SIGN Guidelines2 for Scotland
The SIGN Management of Diabetes Guideline (171), updated May 2024
Timing of gestational diabetes birth
Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by Caesarean section if indicated) to women who have not given birth by this time.
Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications.
WHO (World Health Organization) Induction of labour in gestational diabetes3
If gestational diabetes is the only abnormality, induction of labour before 41 weeks of gestations is not recommended. Participants in the WHO technical consultation acknowledged that labour induction may be necessary in some women with diabetes – for example, those with placental insufficiency and uncontrolled diabetes.
Our findings on advised timing of birth
Of 3,270 women with gestational diabetes, 86% (2,819) were advised to have an induction of labour or c-sections before 40+6 weeks despite the current guidelines only recommending this if there are maternal or fetal complications.
Our findings on mode of birth with gestational diabetes
Of 3,270 women with gestational diabetes, 45.6% (1,491) had an induction of labour. Of the 1,491 induced, 20% (294) resulted in c-sections due to lack of progression into labour.
32.8% (1,075) had c-sections. Of 3,270 women with gestational diabetes, 21.5% (704) had planned c-sections and 11.3% (371) needed an emergency c-section due to reasons unrelated to gestational diabetes.
30.4% (996) had spontaneous births.
Commonly asked questions about gestational diabetes birth
Do I have to be induced with gestational diabetes?
NO. Induction of labour before 40+6 is not advised unless there are maternal or fetal complications. If you are advised to have an early induction of labour, this is advice and ultimately the choice is yours to make and consent to.
Can I have a spontaneous birth with gestational diabetes?
YES. The guidelines recommend offering elective birth by either induction of labour or cesarean section after 40+6. Still, the critical point here is that the guidelines recommend offering this, and ultimately the choice is yours to make and consent to.
Do I have to have a caesarean section with gestational diabetes?
NO. Being diagnosed with gestational diabetes does not mean you cannot have a vaginal birth. However, you can request a caesarean birth if you would like one.
Can I have a waterbirth with gestational diabetes?
Yes, although this may be against medical advice and depends on what facilities are available for you to use.
Can I have a home birth with gestational diabetes?
YES, although this may be against medical advice.
The timing of delivery in GDM [gestational diabetes mellitus] is an important decision, which should be taken keeping in mind the biomedical, psychological, social, and environmental factors operating in the particular person. Such a decision is best arrived at through a process of active, informed discussion with the patient and her family.4
Kalra B et al. (2016)
Evidence-based research on induction of labour with gestational diabetes
The most common gestational diabetes birth question is around the necessity of early induction of labour. This is due to the fact that many people diagnosed with gestational diabetes are told they will be induced, but why? And what does the evidence-based research say about early induction of labour versus awaiting spontaneous birth with gestational diabetes?
Why is induction of labour advised with gestational diabetes?
Conventionally, induction of labour has been used in diabetic pregnancy to prevent stillbirth or prevent excessive fetal growth and associated birth-related complications it may cause, such as shoulder dystocia [where the baby’s shoulder gets stuck behind the pelvic bone when being delivered] and birth fractures.
It’s important to understand that historically the severity of diabetes and level of blood glucose control during pregnancy has not always been considered. The known complications seen in pre-existing diabetes and poorly controlled diabetic pregnancies is often lumped together with gestational diabetes and well-controlled blood glucose. Yet, the associated risks for these different groups will not be the same during birth and, therefore, should not be advised in the same way.
First, let’s address the issue of gestational diabetes and the risk of stillbirth.
It is also critical to distinguish GDM from PGDM pregnancies when deciding on the timing of delivery. Though often treated similarly, the risk of stillbirth is dramatically different5
Berger H, Melamed N. (2014)
A 2019 Action Medical Research, Cure Kids, Sands and Tommy’s funded study led by the University of Leeds and the University of Manchester by Dr Tomasina Stacey, of 41 maternity units in England found that as long as the NICE National Guidelines are followed for screening, diagnosis and management of gestational diabetes, then there is no increased risk in stillbirth.
women with gestational diabetes have no increase in stillbirth risk if national guidelines are followed for screening, diagnosis and management.
Dr Tomasina Stacey, The University of Manchester
Optimal screening and diagnosis of GDM [Gestational Diabetes Mellitus] mitigate the higher risks of late stillbirth in women ‘at risk’ of GDM and/or with raised FPG [Fasting Plasma Glucose levels].6
Stacey T et al. (2019)
Gestational diabetes and excessive growth (fetal macrosomia)
With gestational diabetes, when there is too much sugar remaining in the mother’s bloodstream, this is passed through (fed) to the baby. The baby then has to increase its own insulin production to help process the excess sugars. Insulin is a growth hormone and the result is that the baby’s growth increases, in particular, the abdominal circumference [AC] (tummy) increases. It is adipose tissue (subcutaneous fat) caused by the overproduction of insulin that causes excessive growth.
How is fetal macrosomia determined?
Fetal macrosomia is defined as a fetal birth weight of ≥ 4000g or 8lb13oz. During pregnancy, macrosomia can be predicted from growth scan measurements (head circumference, abdominal circumference and femur length, which determines an estimated fetal weight) taken of the baby during an ultrasound. An example is shown in the image above.
These measurements are estimates whose accuracy is dependent on multiple factors, such as the baby’s position during the scan and the sonographer’s skill. Less than 1 in 10 are wrong7, and there is general acceptance of up to a 15% margin of error.
How accurate are sonographic estimated fetal weights in suspected macrosomia?
A retrospective cohort study in New York City of 502 patients between 2011 – 2017 looking into the accuracy of sonographic estimated fetal weight [sonoEFW] in suspected macrosomia, found an increasingly more significant overestimation in birth weight [BW] the greater the estimated weight.
A total of 502 patients were included, of whom 301 (60.1%) had a sonoEFW 4000–4249g, 135 (26.9%) had a sonoEFW 4250–4499g, 45 (9.0%) had a sonoEFW 4500–4749g, and 21 (4.2%) had a sonoEFW 475 g. In each sonoEFW group, the risk of overestimating BW was greater than 50%, and the likelihood of overestimation of BW increased significantly across sonoEFW groups (69.4, 76.3, 80.0, 95.2%, p < .001)
CONCLUSION In patients undergoing sonoEFW within 2 weeks of delivery, sonoEFWs 4000g are significantly more likely to overestimate than underestimate the true BW. Obstetricians should be cautious about intervening based on sonoEFW alone, given the high risk that this value is an overestimation of the true weight.8
Zafman K et al.(2018)
Our findings on the accuracy of estimated birth weights from growth scans
In 3,270 women with gestational diabetes, we found that 52% (1,734) were given estimated weights which were larger than the weight of the baby when born, with 21% (704) stating their baby’s actual weight was much lower than the estimated weight.
23% (762) were given accurate estimated birth weights.
Does induction of labour and delivering a smaller baby reduce the risk of birth-related complications such as shoulder dystocia and birth fractures with gestational diabetes?
The GINEXMAL research trial of 425 women affected by GDM in Italy, Slovenia, and Israel between 2010 – 2014 looked into the maternal and perinatal outcomes after induction of labour versus expectant management in pregnant women with gestational diabetes at term.
The participants were split into 2 groups, 214 were randomised to induction of labour and 211 were randomised to expectant management (twice-weekly electronic fetal heart rate monitoring and biophysical profiling until 41+0 weeks of gestation).
As expected, the babies born in the induction group were born earlier and weighed less. 12.6% of those induced ended in caesarean section, versus 11.8% in the expectant management group. No maternal or perinatal deaths occurred. No significant difference was found in postpartum haemorrhage, severe perineal tears, maternal blood transfusion, management of the third stage of labour, and ICU admission.
There was a two-fold increase of 10% versus 4.1% in hyperbilirubinaemia (neonatal jaundice) in babies born in the induction group versus expectant management.
In the induction group 13 cases, 6.1% were reported macrosomic, versus 24 cases,11.4% in the expectant management group.
Shoulder dystocia occurred in a total of 4 cases (0.9%): 1.4% of the induction group and 0.5% in the expectant management group, all of which were resolved without any significant birth trauma, showing that in this study induction of labour did not reduce shoulder dystocia.
In women with gestational diabetes, without other maternal or fetal conditions, no difference was detected in birth outcomes regardless of the approach used (i.e. active versus expectant management).9
Alberico S et al.(2016)
There is insufficient evidence to clearly identify if there are differences in health outcomes for women with gestational diabetes and their babies when elective birth is undertaken compared to waiting for labour to start spontaneously or until 41 weeks’ gestation if all is well.10
Biesty L et al.(2018)
But does gestational diabetes always mean a macrosomic (excessively large) baby?
Left undiagnosed or untreated, gestational diabetes can cause macrosomia in the baby.
But if blood glucose levels are monitored and controlled with diet and/or glucose-lowering medication or insulin, macrosomia can be prevented, therefore meaning the birth is no higher risk than that of a non-diabetic person.
Our findings on birth weight in babies born to mothers with gestational diabetes
We found 36.7% (1,200) had babies weighing between 7lb – 8lb (3.175kg – 3.628kg). 27.8% (908) had babies weighing between 6lb – 7lb (2.721kg – 3.175kg).18.7% (611) had babies weighing between 8lb – 9lb (3.628kg – 4.082kg).
Only 5.6% (183) of 3,270 women diagnosed with gestational diabetes had babies weighing over 9lb (4.082kg) in weight.
Induction of labour in insulin-controlled gestational diabetes
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 (elevated BMI, marked insulin resistance as manifested by insulin requirements, polyhydramnios and increased fetal abdominal circumference) 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 delivery.5
Berger H, Melamed N. (2014)
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.
we would favor routine induction of labor at 40 weeks of gestation until studies are published which document a clear advantage of earlier delivery. In women with a LGA [large gestational age] fetus, inadequate metabolic control, or overt diabetes , we would emphasize a more individual approach.11
Worda K et al. (2017)
Our findings on length of induction with gestational diabetes
68% (1,811) of women with gestational diabetes who were induced gave birth within 48 hours after being induced.
Can I opt for a caesarean birth?
If early elective birth is necessary, you may be advised to have an induction of labour but have reasons for preferring to have a caesarean section instead. You are within your rights to request a caesarean birth if you wish.
You can ask for a caesarean birth even if your doctor or midwife doesn’t think that you have a medical need for one. This is called a maternal request caesarean birth. Your hospital must listen to your reasons for wanting a caesarean birth and have good reasons for saying no.
You should be given the opportunity to discuss the benefits and potential risks of caesarean birth compared to giving birth vaginally. However, once you have made your decision it should be respected. An individual obstetrician can say no to your request on the basis that they do not want to carry out an intervention that they believe to be harmful. However, they must refer you to a doctor who is happy to carry out a caesarean section. If all obstetricians in a unit take the same view, you should be referred to an obstetrician in a different hospital who is willing to carry out the surgery.12
Birthrights UK
Blood glucose levels in labour
Current guidelines recommend that blood glucose levels remain between 4.0 – 7.0 mmol/L during labour for those with diabetes. A variable-rate insulin infusion (sliding scale) may be used if levels go beyond these parameters.
It is important to note that just because a patient is using insulin therapy to control blood glucose levels, no guidelines recommend the immediate or preventative use of a variable-rate insulin infusion (sliding scale) during labour. It is only if blood glucose levels fall outside the guideline parameters (4.0 – 7.0 mmol/L).
This is another area where research is lacking, especially in differentiating gestational diabetes from pre-existing diabetes. Current research is underway on this matter: the GILD study [Glucose control In Labour with Diabetes]
Our findings on the use of a variable rate insulin infusion (sliding scale) during labour with gestational diabetes
Only 2.9% (69) of 3,270 women with gestational diabetes required a sliding scale during labour to help control blood sugar levels. 7.8% (254) were given a sliding scale because it was routine protocol in their NHS Trust, and 7.7% (251) were prepped with an IV for a sliding scale, but it was not needed.
From these findings, it is clear that a sliding scale is not needed or necessary in the majority of women with gestational diabetes, and it should only be used when they are needed to control blood sugar levels.
Gestational Diabetes Birth Choices – Place of Birth
There are 3 main places where birth can take place: –
- A consultant-led birthing unit (at hospital)
- A midwife-led birthing unit (at hospital or birthing centre)
- At home
1. Consultant-led birth with gestational diabetes
Consultant-led birth is birth on a maternity unit in a hospital where doctors are available to assist if needed. Patients are usually cared for by midwives, and doctors only intervene if and when necessary. The setting is usually more medical-like, with hospital beds, wards with cubicles and curtains (although some have individual rooms or private rooms available for use or hire). In most consultant-led maternity units, the highest amount of pain relief options is available (although epidurals may not be available 24 hours a day in some). Maternity units often have fewer birthing pools, which can mean they are not available for use when in labour.
2. Midwife-led birth with gestational diabetes
A midwife-led birth usually occurs in a Midwife Led Unit (MLU) or birthing centre, in the same hospital as the consultant-led maternity unit, or in a separate building. The unit is run by midwives and is usually more home-like to help relax patients. They often differ in appearance to the typical hospital setting, with furnishings similar to homes, such as bean bags, cushions and large comfy beds, in individual rooms. There may be other features such as altering lighting use music, and some may offer aromatherapy. MLUs often have birthing pools or more pools than the consultant-led maternity units, so the chances of a pool being available for use are more likely.
Learn more about gestational diabetes waterbirth here.
The government says everyone in the UK should be able to choose between giving birth in hospital, in a birth centre, or at home. You should be offered a full discussion of the risks and benefits of the options you are considering. If there is no birth centre in your area, or you want to use a different birth centre, you can ask your GP to refer you or you can refer yourself.
Birth centres often have rules, called admissions criteria, that say people with ‘high risk’ pregnancies cannot use the centre. These are not legal rules and they cannot be applied in a blanket way. The centre should use them only to guide them when making a decision about who can use the centre. The birth centre must only refuse to allow you to use the centre if they feel they cannot provide you with safe care. The centre must have a good evidence-based reason that shows you or your baby are at high risk of harm when giving birth without the support of a hospital obstetric ward. The centre must be able to show that it cannot safely manage that risk. They should consider the risk on a case-by-case basis, looking at what the risks are in your personal situation.
a birth centre might say you cannot use the centre if your labour is being induced and where medical advice strongly recommends the monitoring of your contractions. Or the birth centre’s rules might say that you cannot use the centre if your body mass index (BMI) is above a certain level. However, they should look at what the specific risks are in your case and whether they can be safely managed. They need to have evidence for what they say. They need to discuss it with you, and if they think they cannot safely care for you in the birth centre they need to discuss what alternatives they can suggest (for example, offering similar support such as a birth pool on the labour ward).
Birthrights UK
3. Homebirth with gestational diabetes
Homebirth is choosing to give birth at home, usually with the assistance of a midwife or birthing professional.
Learn more about gestational diabetes homebirth here.
Do I have a right to a home birth? Yes. You have a right to choose where you give birth. You cannot be made to go to hospital. Healthcare professionals may want to talk to you about your plans and any concerns they have. This should be an opportunity to have an open discussion and to share information. They should always respect your views and choices.
Can I still give birth at home if my pregnancy is ‘high-risk’? Yes. Only you have the right to decide where you give birth. No one can overturn the decision you have made. This is the law. The only time that someone else can make decisions about your healthcare is if you lack mental capacity to make those decisions. This is very rare. Even if healthcare professionals advise you not to give birth at home, no one can make you go to hospital. Your midwife and hospital consultant (if you have one) should work with you to make a care plan for giving birth at home. When professionals give you advice and information about where to give birth, it should be based on facts, not personal opinions. Healthcare professionals must not put pressure on you, or threaten you, when you are deciding where to give birth.
Birthrights UK
Continuous fetal monitoring during gestational diabetes birth
A common reason to decline the use of midwife-led birthing units and birthing pools is the need for continuous fetal monitoring (having fetal heartbeat continuously recorded and monitored) during labour with gestational diabetes. However, what does the evidence-based research say about the need for continuous fetal monitoring with gestational diabetes?
Looking at the literature, this is an example of where gestational diabetes has been lumped together with pre-existing diabetes.
In the majority of intrapartum care guidelines, there is no differentiation between GDM [gestational diabetes mellitus] and PGDM [pre gestational diabetes mellitus or pre-exsiting diabetes] regarding the recommendation of continuous fetal monitoring.13
Jabak S, Hameed A. (2020)
A 2020 study reviewed the literature available on continuous fetal monitoring for gestational diabetes, specifically in diet-controlled GDM women with normal fetal growth. They compared three studies involving 482 women with diabetes in pregnancy but found a lack of evidence to support the recommendation for continuous fetal monitoring.
There have been no randomized control trials behind these recommendations. The aforementioned women have comparable outcomes to pregnant women who are not affected by diabetes and can be considered as low risk till any evidence is found.
With the lack of current evidence, we find it difficult to recommend mothers with well-controlled gestational diabetes to give birth in obstetrics led unit with continuous fetal monitoring and deny them a chance to have home birth or birth in midwifery-led birth units. There is an urgent need to conduct large scale randomized controlled trials to establish evidence for or against this recommendation.13
Jabak S, Hameed A. (2020)
Informed Consent
Throughout your pregnancy and birth, and even more so when you have any complications such as gestational diabetes, you will need to make decisions about your care. Many decisions must be made, from additional appointments, scans, medication to timing & mode of birth. Your doctors and midwives should give you all the information you need to help you make right decisions for YOU. This is INFORMED CONSENT.
the clinician should consider the maternal, fetal and neonatal implications of induction of labour versus expectant management, involve the patient in the decision process and as usual follow the maxim of “first do no harm”.5
Berger H, Melamed N. (2014)
You should be given clear & factual information that makes sense to you
Don’t be afraid to ask why certain things are being recommended to you personally.
You should be told both the benefits and the risks for anything that is being advised or recommended
For anything being advised, you should be told both the benefits and risks involved.
You should not feel pressured into making any decisions
Health care professionals should not use coercive language to push you into making decisions. If you feel this is happening ask for a second opinion and/or the support of the PMA (Professional Midwife Advocate). You can also discuss this with PALS (Patient Advice and Liaison Services).
Use B.R.A.I.N to help you ask more questions and to help make decisions
You always have a CHOICE
You can say NO to anything that is being advised or recommended. Your healthcare professionals will respect your decision and will work with you to create a plan to support you as best as they can.
You are the best person to make the right decision for YOU
Once you have the facts, you are the only person who knows how you feel and whatever you decide your healthcare team have a duty of care to support you.
Citations
- 1.Diabetes in pregnancy: management from preconception to the postnatal period. NICE National Institute for Health and Care Excellence. Published December 2020. Accessed March 2022. https://www.nice.org.uk/guidance/ng3/chapter/Recommendations#intrapartum-care
- 2.Management of diabetes, 7. Management of diabetes in pregnancy. SIGN Healthcare Improvement Scotland. Published November 2017. Accessed March 2022. https://www.sign.ac.uk/assets/sign116.pdf
- 3.Induction of labour in women with gestational diabetes. World Health Organization. Published August 2021. Accessed March 2022. https://srhr.org/rhl/article/induction-of-labour-in-women-with-gestational-diabetes
- 4.Kalra B, Gupta Y, Kalra S. Timing of Delivery in Gestational Diabetes Mellitus: Need for Person-Centered, Shared Decision-Making. Diabetes Ther. Published online March 9, 2016:169-174. doi:10.1007/s13300-016-0162-2
- 5.Berger H, Melamed N. Timing of delivery in women with diabetes in pregnancy. Obstet Med. Published online January 15, 2014:8-16. doi:10.1177/1753495×13513577
- 6.Stacey T, Tennant P, McCowan L, et al. Gestational diabetes and the risk of late stillbirth: a case–control study from England, UK. BJOG: Int J Obstet Gy. Published online March 19, 2019. doi:10.1111/1471-0528.15659
- 7.Milner J, Arezina J. The accuracy of ultrasound estimation of fetal weight in comparison to birth weight: A systematic review. Ultrasound. Published online February 2018:32-41. doi:10.1177/1742271×17732807
- 8.Zafman KB, Bergh E, Fox NS. Accuracy of sonographic estimated fetal weight in suspected macrosomia: the likelihood of overestimating and underestimating the true birthweight. The Journal of Maternal-Fetal & Neonatal Medicine. Published online September 3, 2018:967-972. doi:10.1080/14767058.2018.1511697
- 9.Alberico S, Erenbourg A, Hod M, et al. Immediate delivery or expectant management in gestational diabetes at term: the GINEXMAL randomised controlled trial. BJOG: Int J Obstet Gy. Published online November 4, 2016:669-677. doi:10.1111/1471-0528.14389
- 10.Biesty LM, Egan AM, Dunne F, et al. Planned birth at or near term for improving health outcomes for pregnant women with gestational diabetes and their infants. Cochrane Database of Systematic Reviews. Published online January 5, 2018. doi:10.1002/14651858.cd012910
- 11.Worda K, Bancher-Todesca D, Husslein P, Worda C, Leipold H. Randomized controlled trial of induction at 38 weeks versus 40 weeks gestation on maternal and infant outcomes in women with insulin-controlled gestational diabetes. Wien Klin Wochenschr. Published online February 6, 2017:618-624. doi:10.1007/s00508-017-1172-4
- 12.Your right to a caesarean birth. Birthrights UK. Accessed March 2022. https://www.birthrights.org.uk/factsheets/right-to-a-c-section/
- 13.Jabak S, Hameed A. Continuous intrapartum fetal monitoring in gestational diabetes, where is the evidence? The Journal of Maternal-Fetal & Neonatal Medicine. Published online December 13, 2020:1-4. doi:10.1080/14767058.2020.1849117