Gestational diabetes birth

In this post we look at gestational diabetes birth. From timing and mode of birth, to reasons why gestational diabetes birth may mean you are advised differently to what you had originally planned. We will also look at results from surveys we have collated and what the national guidelines recommend with regards to a gestational diabetes birth.

gestational diabetes birth

Gestational diabetes birth, what makes it different?

Having gestational diabetes means that there may be risks of complications which require the baby to be delivered at an earlier gestation and in a place where there is suitable facilities and professionals to assist if necessary.

HOWEVER, this does not mean that just because you have been diagnosed with gestational diabetes all your birth plans have to be thrown out of the window.

water birth

Having a gestational diabetes birth means understanding what risks are associated, how those risks may or may not apply to you and being able to make an informed decision on what YOU feel is the best thing to do

The national guidelines on gestational diabetes timing and mode of birth

NICE Guidelines for England, Wales and Northern Ireland

Timing and mode of birth
1.4.1 Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. [new 2015]
1.4.2 Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between 37+0 weeks and 38+6 weeks of pregnancy. [new 2015] 
1.4.3 Consider elective birth before 37+0 weeks for women with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications. [new 2015] 
1.4.4 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. [new 2015]
1.4.5 Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015]
1.4.6 Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. [2008]
1.4.7 Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]

NICE guidelines, NG3 – Diabetes in Pregnancy, 1.4 Intrapartum care
SIGN Guidelines for Scotland

7.9 DELIVERY
National audit data in Scotland indicate that delivery in women with diabetes is generally expedited within 40 weeks gestation. No clear evidence was identified to inform the optimal timing for delivery. The timing of delivery should be determined on an individual basis.Women who are at risk of pre-term delivery should receive antenatal corticosteroids. If corticosteroids are clinically indicated for pre-term labour, supervision by an experienced team is essential to regulate diabetic control. Women with diabetes have a higher rate of Caesarean section even after controlling for confounding factors.
>Women with diabetes requiring insulin or oral glucose-lowering medication who have pregnancies which are otherwise progressing normally should be assessed at 38 weeks gestation with delivery shortly after, and certainly by 40 weeks. ƒ
>Women with diabetes should be delivered in consultant-led maternity units under the combined care of a physician with an interest in diabetes, obstetrician, and neonatologist. ƒ
>Women with diabetes should have a mutually agreed written plan for insulin management at the time of delivery and immediately after. ƒ
>The progress of labour should be monitored as for other high-risk women, including continuous electronic fetal monitoring. ƒ
>Intravenous insulin and dextrose should be administered as necessary to maintain blood glucose levels between 4 and 7 mmol/l.

SIGN Guidelines 116 – Management of diabetes, 7.9 Delivery
HSE Guidelines for Republic of Ireland

5.4.4 Timing and mode of delivery
In the setting of excellent glycaemic control, adherence to treatment and absence of maternal and fetal compromise, women with diabetes may await spontaneous labour up to 39-40 weeks gestation.
Vaginal delivery is preferable unless obstetric or diabetes complications necessitate caesarean delivery.
Macrosomia and shoulder dystocia occur more frequently in pregnancies that are complicated by diabetes; these risks should be taken into account when planning mode of delivery.
Sonographic estimation of fetal weight should be combined with the clinical judgement of an obstetrician experienced in the management of pregnancies complicated by gestational diabetes when evaluating the most appropriate mode of delivery for the patient.
The frequency of fetal monitoring should be increased if the pregnancy is allowed to progress beyond 40 weeks’ gestation.
The delivery plan should be clearly documented within the patient record

HSE Guidelines for the Management of Gestational Diabetes Mellitus, 5.4.4 Timing and mode of delivery

What are the risks associated with a gestational diabetes birth that may impact birth?

With gestational diabetes there is a higher risk of the following complications: –

  • Macrosomia – your baby being large for its gestational age i.e. weighing more than 4kg (8.8lbs). Macrosomia increases the need for induced labour or a caesarean birth, and may lead to birth problems such as shoulder dystocia (see below)
  • Shoulder dystocia – this is when your baby’s head passes through your vagina, but their shoulder gets stuck behind your pelvic bone. Shoulder dystocia can be dangerous, as your baby may not be able to breathe while they are stuck. It’s estimated to affect 1 in 200 births. Following shoulder dystocia deliveries, 20% of babies will suffer some sort of injury, either temporary or permanent. The most common of these injuries are damage to the brachial plexus nerves, fractured bones, contusions and lacerations, and birth asphyxia.
  • Premature birth (your baby being born before week 37 of the pregnancy) – This can lead to complications such as newborn jaundice or respiratory distress syndrome (RDS).
  • Stillbirth – the death of your baby around the time of the birth (an extreme complication but usually only seen in cases where gestational diabetes is not diagnosed and blood sugar levels are not controlled)

Please note: Whilst these are all complications associated with gestational diabetes, the risk of them is significantly reduced if you are diagnosed and monitoring blood sugar levels

Complications associated with gestational diabetes which are a risk, even when diagnosed and monitoring blood sugar levels: –

These are the complications that are more commonly seen, as we cannot control these things by lowering and stabilising blood sugar levels alone. This means that these are the risks that your medical professionals will be assessing and may be factored into advice around your timing of birth: –

  • Placenta insufficiency – premature ageing of the placenta, also known as placenta deterioration, placenta dysfunction or placenta failure. A direct complication linked to gestational diabetes which causes abnormalities and complications in the placenta. For further information on placenta deterioration, read more here.
  • Polyhydramnios – Excessive amniotic fluid – detected by ultrasound. Polyhydramnios can be caused by polyuria (frequent urination) and lung liquid production of the baby. Detection of polyhydramnios can be the flagstone for gestational diabetes testing in mother’s who have not yet been diagnosed.
  • IUGR – Intrauterine growth restriction is a condition where a baby’s growth slows or ceases when it is in the uterus, also known as SGA or small for gestational age (under 10th centile for gestational age) – detected by ultrasound. A shock to many as it’s contradictory to the usual complication of macrosomic (large for gestational age) baby.
  • Oligohydramnios – Too little amniotic fluid – detected by ultrasound.
  • Pre eclampsia – Pre-eclampsia is a condition that affects some pregnant women, usually during the second half of pregnancy (from around 20 weeks) or soon after their baby is delivered. Early signs of pre-eclampsia include having high blood pressure (hypertension) and protein in your urine (proteinuria).  In some cases, further symptoms can develop, including:
    • swelling of the feet, ankles, face and hands caused by fluid retention (oedema)
    • severe headache
    • vision problems
    • pain just below the ribs
Here are the results we [Gestational Diabetes UK] found when asking 1,035 women with gestational diabetes what complications associated with GD they or their baby experienced: –

It should be noted that participants were asked to tick all complications that applied to them

Gestational Diabetes Birth Choices – Mode of birth

Will I need to be induced?

Induction of labour is the process of starting labour artificially. Induction of labour may be advised if your medical professionals feel it is necessary for the baby to be delivered earlier for medical reasons.

A diagnosis of gestational diabetes no longer = definite early induction of labour

Previous NICE guidelines recommended that all women with gestational diabetes should be offered induction of labour at 38 weeks. This meant the majority of women diagnosed with gestational diabetes were induced or had planned cesarean sections at around 38 weeks.

In Feb 2015, the NICE guidelines were updated, recommending that women with gestational diabetes should be advised to give birth no later than 40+6 weeks, but to consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications.

It should be noted that hospitals take time to roll out new procedures and so although NICE guidelines changed in 2015, some hospitals have taken some time to update their policies. It should also be noted that whilst there are recommended guidelines, hospitals do not have to follow them and may have their own protocols and policies which they follow instead.

Since the update in the NICE guidelines in 2015, we are seeing a decline in the amount of women being advised to have earlier inductions within our support group compared to earlier years, with an ever increasing amount of spontaneous births.

According to the NICE guidelines for Inducing Labour, Induction should not be advised based on the possibility of a large (macrosomic) baby: – 

1.2.10 Suspected fetal macrosomia

1.2.10.1 In the absence of any other indications, induction of labour should not be carried out simply because a healthcare professional suspects a baby is large for gestational age (macrosomic).

 

For further detail around induction of labour, methods of induction, things to consider and deciding whether to accept or decline induction of labour, please see our induction page.

Gestational diabetes and increased need for caesarean section

Gestational diabetes diagnosis alone is not a reason to be advised to have a caesarean section. However, caesarean section may be advised for complications related to gestational diabetes such as suspected macrosomia and related complications from birthing a macrosomic baby, such as shoulder dystocia. 

c-section

Gestational Diabetes UK findings on mode of birth in mothers with gestational diabetes

Mode of birth

1,350 responses: –
47.8% (645) Induction of labour
17.3% (233) Spontaneous birth
15.6% (211) Planned caesarean section
10% (135) Failure to progress with induction leading to caesarean section
9.3% (126) Emergency caesarean section due to other reasons

Gestational Diabetes Birth Choices – Sliding scale during labour

A sliding scale (variable rate intravenous insulin infusion, sometimes abbreviated to ‘VRIII’) is an intravenous drip with insulin and glucose.

The sliding scale helps to stabilise blood sugar levels by adding glucose if blood sugar levels drop too low, or by adding insulin if your levels raise too high, straight into the bloodstream.

Birth plans may include the timing and necessity of using a sliding scale during labour for some women with gestational diabetes.

Sliding Scale gestational diabetes

The use of a sliding scale is recommended for use when blood sugar levels fail to remain within 4 and 7 mmol/litre.

If a sliding scale is being advised from the start of induction, or labour as per a hospital ‘policy’ i.e. just because you have a label of gestational diabetes on your maternity notes, rather than assessing your individual needs, then you may want to discuss the option of only using a sliding scale if and when necessary as part of your birth plan.

Please see our sliding scale post for further information.

Gestational Diabetes Birth Choices – Hypnobirthing

Hypnobirthing can be extremely beneficial to a gestational diabetes birth. Whilst some may believe hypnobirthing is only for certain people or certain births, techniques learned during hypnobirthing lessons can empower and provide the mother with ability and opportunity to have the birth she plans and wants without fear.

To see more about hypnobirthing with gestational diabetes, please take a look at this guest post written by Keri Jarvis, a hypnobirthing teacher.

Gestational Diabetes UK findings around timing of birth, gestation and birth weights

To find out more about gestational diabetes birth outcomes, we collated the following results via a Google forms survey which was shared on our Facebook, Twitter and Instagram accounts: –

Timing of delivery
Of 1,348 responses, we found that 61.7% of women were advised to have their labour brought forward due to gestational diabetes. Of that 61.7%, 2.6% declined induction of labour
Gestation at birth

Gestational Diabetes Birth Choices – Water birth

Women diagnosed with gestational diabetes are usually classed as a high risk pregnancy which means being under consultant led care.

This means that many women with gestational diabetes may be told straight away that a water birth is not an option, or that they are “not allowed a water birth”.

However, many women are able to transfer to midwife led birthing units if their gestational diabetes is well controlled and so this may be an option for discussion and consideration, based on the individuals level of insulin resistance, blood sugar control and growth of baby.

If your gestational diabetes is not causing any medical concern to your medical professionals, then you should be treated no differently than a non diabetic pregnant mother and as such should have the same facilities and care such as birth on a midwife led birthing unit with a use of a birthing pool if they have them.

gestational diabetes water birth

Pools for water birth tend to be situated on midwife led birthing units for those who are not having high risk pregnancies and births. However, in some hospitals there are also pools available within consultant led areas. Therefore it is worth having a discussion around this matter if you wanted to consider a water birth, even if you have higher insulin resistance.

For further information on water births with gestational diabetes, please see the home and water birth page.

birth in GD

Gestational Diabetes Birth Choices – Place of Birth

There are 3 main places where birth can take place: –

  1. A consultant led birthing unit (at hospital)
  2. A midwife led birthing unit (at hospital or birthing centre)
  3. At home

1. Consultant led birth with gestational diabetes

This is a birth on a maternity unit in a hospital where there are doctors 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 are available (although epidurals may not be available 24hrs a day in some).

Maternity units may not have, or may have less 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 takes place in a Midwife Led Unit (MLU) which may be 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, or aimed at being relaxing in appearance, with furnishings similar to home, such as bean bags, cushions and large comfy beds (rather than typical hospital furniture), in individual rooms. There may be other features such as being able to alter lighting, use music and some may offer aromatherapy too.

MLUs often have birthing pools, or more pools than the consultant led maternity units and so chances of a pool being available for use is more likely.

Most options for pain relief are usually available, other than epidurals.

A Trust may refuse you to give birth in their MLU if they feel you are too high risk, but if you pose no higher risk than a non-diabetic pregnant mother, then there is no reason why you cannot ask to birth there.

3. Home birth with gestational diabetes

Just like water birth, home birth is usually a mode of birth that medical professionals may say is out of the question with gestational diabetes.

But we still see plenty of mothers go on to have home births with gestational diabetes.

This can come down to many factors, but once again, it is more likely with lower insulin resistance, good control of GD and no medical concern for the pregnancy and birth.

Achieving consent or the ‘go ahead’ for a home birth with gestational diabetes may be a struggle due to the known complications linked to gestational diabetes, however if a mother shows no medical concerns then with a good plan in place, a home birth can be achieved.

In fact, if you wish to give birth at home, then your Trust cannot refuse this and must support you.

Do I have a right to home birth services?
You have a right to decide where you give birth and you cannot be forced to attend hospital. While there is no legal guarantee of a home birth service, the Department of Health guidance, Scottish and Welsh guidance issued to the NHS states that home birth services should be made available to women by all NHS Trusts and Boards.

Can I still give birth at home if my pregnancy is ‘high-risk’?
You are responsible for making your decisions about where you give birth. Your decision cannot lawfully be overridden by anyone else, unless you lack mental capacity to make decisions about your healthcare.

If you are advised against giving birth at home, you cannot be compelled to attend hospital. Your midwife and hospital consultant, if you have one, should work with you to put in place a care plan that respects your decision to give birth at home.

Birthrights UK, Choice of Place of Birth Fact Sheet
home birth with gestational diabetes

For further information on home births with gestational diabetes, please see the home and water birth page.

Use your BRAIN to make informed decisions around gestational diabetes birth

To help make informed decisions over your gestational diabetes birth, use your B R A I N [see image below]

Remember it is your body, your baby and your birth. It is up to YOU to make the decisions, phrases such as “you are not allowed…” should not be used and are not helpful.

Medical professionals will advise what they feel is best, but ultimately it is your CHOICE and you decide what is ‘allowed’.

The Nursing and Midwifery Council state that “a midwife must support the birthing person’s choices even if the midwife doesn’t agree with them”

 

Birth Rights in the UK

What are your rights in pregnancy and childbirth?

  • Every woman has a right to receive safe and appropriate maternity care
  • Every woman has a right to maternity care that respects her fundamental human dignity
  • Every woman has a right to privacy and confidentiality
  • Every woman is free to make choices about her own pregnancy and childbirth, even if her caregivers do not agree with her
  • Every woman has a right to equality and freedom from discrimination

Birthrights UK

Birthrights UK is a charity dedicated to improving women’s experience of pregnancy and childbirth by promoting respect for human rights. The charity explain what rights women have during pregnancy and birth and can offer free advice and guidance. They have lots of factsheets that may be helpful when making decisions around gestational diabetes birth and treatment.

 

Research publications and resource links

Elective delivery in diabetic pregnant women

Induction of labour at 38 weeks pregnancy for women with diabetes treated with insulin lowers the chances of delivering a large baby.

Women with diabetes or gestational diabetes are more likely to have a large baby, which can cause problems around birth. Early elective delivery (labour induction or caesarean section) aims to avoid these complications. However, early elective delivery can also cause problems. The review found only one trial of labour induction for women with diabetes treated with insulin. Induction of labour lowered the number of large babies without increasing the risk of caesarean section. However, there was not enough evidence to definitively assess this intervention

Induction of labour at or near term for suspected fetal macrosomia

Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The unexpected observation in the induction group of increased perineal damage, and the plausible, but of uncertain significance, observation of increased use of phototherapy, both in the largest trial, should also be kept in mind.

Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis

Women whose labour was induced were less likely than those managed expectantly to have a cesarean delivery. In addition, the risk of fetal death and admission to neonatal intensive care unit were decreased in the induction group.

Delivery Timing and Cesarean Delivery Risk in Women with Mild Gestational Diabetes

Induction of labor in women with mild gestational diabetes mellitus (GDM) does not increase the rate of cesarean delivery prior to 40 weeks gestation.

Induction of labour in women with gestational diabetes

WHO recommendation

If gestational diabetes is the only abnormality, induction of labour before 41 weeks of gestations is not recommended. (Very-low-quality evidence. Weak recommendation.)

  • 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

Insulin-requiring diabetes in pregnancy: A randomized trial of active induction of labor and expectant management

CONCLUSION: In women with uncomplicated insulin-requiring gestational or class B pregestational diabetes, expectant management of pregnancy after 38 weeks’ gestation did not reduce the incidence of cesarean delivery. Moreover, there was an increased prevalence of large-for-gestational-age infants (23% vs 10%) and shoulder dystocia (3% vs 0%). Because of these risks, delivery should be contemplated at 38 weeks and, if not pursued, careful monitoring of fetal growth must be performed.

Induction of labour versus expectant management in gestational diabetes pregnancies

Gestational diabetes and fetal growth acceleration: induction of labour versus expectant management

Managing Labor and Delivery of the Diabetic Mother

Expectant Management Versus Labor Induction for Suspected Fetal Macrosomia: A Systematic Review

Methods of induction of labour: a systematic review

Indications for induction of labour: a best-evidence review

Diabetes in pregnancy and cesarean delivery

Gestational diabetes: is a higher cesarean section rate inevitable?

Diet-controlled gestational diabetes mellitus does not influence the success rates for vaginal birth after cesarean delivery

Vaginal birth after cesarean among women with gestational diabetes

Twin pregnancy outcomes for women with gestational diabetes mellitus compared with glucose tolerant women

Sexual intercourse for cervical ripening and induction of labour

The association of sexual intercourse during pregnancy with labor onset

Index of National Maternity Statistics 

Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)

Outcomes of elective induction of labour compared with expectant management: population based study

Planned home birth: benefits, risks, and opportunities

Benefits and harms of planned hospital birth compared with planned home birth for low-risk pregnant women

Planned hospital birth versus planned home birth

The effect of maternal age and planned place of birth on intrapartum outcomes in healthy women with straightforward pregnancies: secondary analysis of the Birthplace national prospective cohort study

The Birthplace in England national prospective cohort study: further analyses to enhance policy and service delivery decision-making for planned place of birth

How women with high risk pregnancies use lay information when considering place of birth: A qualitative study

The safety of home birth: Is the evidence good enough?

Water birthing: retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection

A retrospective comparison of water births and conventional vaginal deliveries

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing

NICE recommend home births for some mothers (NHS article) 

Birthrights UK

AIMS