A diagnosis of gestational diabetes does not mean that a waterbirth is off the cards. In this post, I will share your birthrights in the UK alongside evidence-based research and other helpful information to help you achieve a gestational diabetes waterbirth.
Waterbirth stats and facts
46,088 low and intermediate risk singleton term spontaneous vaginal births in 35 NHS Trusts in England were included in the analysis cohort. Of these 6264 (13.6%) were recorded as having occurred in water. Waterbirth was more likely in older women up to the age of 40 and less common in women under 25, those of higher parity or who were obese (BMI 30–34.9). Waterbirth was also less likely in black and Asian women and in those from areas of increased socioeconomic deprivation.There was no association between delivery in water and low Apgar score or incidence of OASI. There was an association between waterbirth and reduced incidence of postpartum haemorrhage and neonatal unit admission.
CONCLUSION In this large observational cohort study, there was no association between waterbirth and specific adverse outcomes for either the mother or the baby. There was evidence that white women from higher socioeconomic backgrounds were more likely to be recorded as giving birth in water. Maternity services should focus on ensuring equitable access to waterbirth.1Aughey H et al. (2021)
Can I have a waterbirth with gestational diabetes?
YES! But only if they have a birthing pool and facilities available for use. You cannot insist a hospital allows you a waterbirth if they do not have the facilities available for use, or if they do not allow you to use the facilities they have.
Can I choose to give birth in a birth centre? Yes. 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.2Birthrights UK
You may be told that your pregnancy is classed as ‘high-risk’ due to gestational diabetes, but can you have a waterbirth if your pregnancy is high-risk?
What if the birth centre says I’m too ‘high risk’? 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).3Birthrights UK
High BMI and waterbirth
Many hospitals have policies around the use of birthing pools and BMI. Evidence is lacking around denying the use of a birthing pool with high BMI and so you may wish to challenge this.
it is important to remember when discussing and planning for labour in someone with a high BMI that there is no evidence that a waterbirth is unsafe, any more than there is evidence that it is more safe. There is simply no evidence to support either hypothesis.4AIMS article, Amber Marshall, Founder of Big Birthas
Why is gestational diabetes classed as high-risk?
Left undiagnosed or untreated, gestational diabetes can cause macrosomia (excessive growth) in the baby. Macrosomia can lead to difficulties when delivering the baby, causing birth trauma and injuries to the baby.
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.
Conventionally early 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.
I’ve been told gestational diabetes carries a higher risk of stillbirth
You may be advised against a waterbirth as you should be induced early or should deliver in a consultant-led birth unit because gestational diabetes carries a higher risk of stillbirth.
It is also critical to distinguish GDM [gestational diabetes mellitus] from PGDM [pre gestational diabetes mellitus or pre-exsiting diabetes] pregnancies when deciding on the timing of delivery. Though often treated similarly, the risk of stillbirth is dramatically different.5Berger 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].6Stacey T et al. (2019)
I’m being advised to have an induction
Induction of labour before 40+6 is not advised unless there are maternal or fetal complications7. 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.
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 with accuracy dependent on multiple factors such as the baby’s position during the scan and the skill of the sonographer. Less than 1 in every ten are wrong8 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.9Zafman K et al.(2018)
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).10Alberico 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.11Biesty L et al.(2018)
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 delivery5Berger 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.12Worda K et al. (2017)
I’ve been told I need a sliding scale during 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 parameters7.
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]
For those who are insulin-treated, blood glucose levels can continue to be managed with insulin and food/drink as necessary to maintain stability.
I’ve been told I require continous fetal monitoring during labour
One of the most common reasons we see people being declined for a waterbirth with gestational diabetes is the need for continuous fetal monitoring (having fetal heartbeat continuously recorded and monitored) during labour. 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 monitoring13.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.13Jabak S, Hameed A. (2020)
How to achieve a waterbirth with gestational diabetes
Do your homework
Request as many NHS Trust policies as you can in advance so that you can see what exactly is policy within your hospital. Many Trusts have information online, or you can write a Freedom of Information (FOI) request by letter or email.
Freedom of Information Request further info
You can also request to mee or speak with the PMA (Professional Midwifery Advocate). PMAs should be experienced registered midwives who have undergone specific training in the role. Part of the PMA’s role is to help advocate for the birthing patient. In Scotland, Wales, and Northern Ireland, there is a similar role for “supervisors.”
You may want to look at all hospitals in your area. Don’t be afraid to switch hospitals if need be, as a hospital a few miles further down the road may have completely different policies and guidance. To find out basic information on your birthing choices and facilities in hospitals local to you, take a look at the Which? birth choice site. Read the NICE guidelines and understand what is recommended and when (this is guidance for England, Wales & Northern Ireland). It is only guidance; hospitals do not have to follow the recommendations. Check the SIGN guidelines if you are in Scotland. You can also find the NICE & SIGN guidelines for gestational diabetes on my Gestational Diabetes Birth page.
Communication is key
It is very important to discuss your feelings with your health care professionals. Your Community Midwife, GP, Diabetes Specialist Midwife, Diabetes Specialist Nurse, PMA and Consultant can all discuss any concerns you may have.
If you don’t understand why certain things are being advised, then question the reasons and ask for further information. If your consultant is advising an induction, for example, ask for facts and figures and ask for the reasons behind advising the induction in your particular case.
Be prepared that many mothers diagnosed will be advised that waterbirth with gestational diabetes will not be possible. If this is the case then ask for the reasons behind this so that you can understand why it is being advised to help make an informed decision around your birth. You can also ask for a second opinion if you wish.
In situations where you feel your questions are going unanswered, or you feel rail-roaded into things you are not comfortable with, you could ask to speak with the PMA (Professional Midwifery Advocate). Many previous members of my Facebook support group have been able to discuss birthing plans which were different to what is ‘standard policy’ or guidance with the PMA and have been able to draw up birth plans which they are more comfortable with as a result.
Considerations for your gestational diabetes waterbirth
- How would you feel about a homebirth where you could have a waterbirth instead of birth in a hospital?
- How would you feel about being induced instead of awaiting spontaneous labour if they allow you to use the birthing pool? Or deliver on the midwife-led unit?
- How do you feel about continuous fetal monitoring? Do they have mobile monitors? Do they have wireless waterproof monitors? If not, you may want to negotiate for intermittent monitoring instead?
- Would you be happy to use a birthing pool to help with pain relief but deliver out of the pool?
- Would you like to return to the pool after giving birth?
- Would a bath in the hospital help with pain relief and be something you would be happy to add to your birth plan as a compromise?
Stand your ground but be prepared to negotiate
However your gestational diabetes is managed (diet-controlled, Metformin or insulin-controlled), regular conversations with the senior midwives, consultants and diabetes team should allow some flexibility to enable you to make birth choices that you are comfortable with. But, be prepared to negotiate! Be realistic and remember why the policies and guidance are in place. Choose your battles; there is no point battling everything your consultant advises when you could negotiate a very comfortable birth that you are happy with – at the end of the day, you both want the same thing, your baby delivered safely.
If you feel you are not being listened to. Your midwife and doctor should provide you with information and personalised discussions to help you make informed choices about your care. When you make your decision, your midwife should support you. They should listen to you and respect what you say. They should help you to get the maternity care you choose. If you are struggling to find this support, contact the Director or Head of Midwifery at your hospital. If you don’t know the details for the Head of Midwifery, you can ask your midwife and/or the Patient Advice and Liaison service (PALS) (in England and Wales) to put you in touch. The Trust website will have a page with PALS details on it. If you are worried, you can look these details up in case you need them. The Nursing and Midwifery Code says that all midwives must treat people as individuals and respect and uphold their rights. Your midwife is your advocate. They should support you even if your decision doesn’t fit the hospital or birth centre’s guidelines.Birthrights UK
Draw up three birth plans
- a wish list – this is your best case scenario, the perfect birth plan!
- a compromise – this is your plan you would be comfortable and happy to settle for
- a worse case scenario – this is if anything does not go to plan, but still a plan which conveys your wishes in an emergency situation
Be flexible with each of them. You should be looking for you and medical professionals to both agree that you’re looking for a safe birth delivery and in the event of any complications, you will, of course, submit to medical advice as long as you are kept fully informed.
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. There are many decisions to 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 decisions that are right 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”.5Berger 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.
- 1.Aughey H, Jardine J, Moitt N, et al. Waterbirth: a national retrospective cohort study of factors associated with its use among women in England. BMC Pregnancy Childbirth. Published online March 26, 2021. doi:10.1186/s12884-021-03724-6
- 2.Can I choose to give birth in a birth centre? Birthrights UK. Accessed March 2022. https://www.birthrights.org.uk/factsheets/choice-of-place-of-birth/#birthcentrechoice
- 3.What if the birth centre says I’m too “high risk”? Birthrights UK. Accessed March 2022. https://www.birthrights.org.uk/factsheets/choice-of-place-of-birth/#highriskchoice
- 4.Marshall A. High BMI waterbirth – time for trusts to take the plunge? AIMS for a better birth. Published July 20, 2019. Accessed March 2022. https://www.aims.org.uk/journal/item/waterbirth-high-bmi
- 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.Diabetes in pregnancy: management from preconception to the postnatal period. NICE. Published December 16, 2020. Accessed March 2022. https://www.nice.org.uk/guidance/ng3/chapter/Recommendations
- 8.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
- 9.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
- 10.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
- 11.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
- 12.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
- 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
Other Research and Helpful Articles
The Home Birth Reference Site is a great resource to look further into planning a home birth and shows some birth stories from mothers that have had homebirth with gestational diabetes.