Re: Is an induction really necessary?

Hello fellow Type 1s....

I am 36 weeks today.  Baby is doing very well as per all the tests I've had to do.  Baby measures normal for all parts of her/his body (they measured EVERYTHING!).  I have a normal amount of amniotic fluid (not too much, nor too little).  They told me that the placenta looks healthy and it sitting high.  Baby is estimated at around 6 pounds.  Fetal echo came back great.  The doctors were happy to tell me that all appears normal.  I have had an A1C of around 6.0% for the entire pregnancy (with a lot of work) and I have been wearing my CGMs the whole pregnancy.  I finish my non-stress tests very quickly as baby likes to break dance - so is moving a lot.  Very normal.  I feel great (better than I did prepregnancy) and I do not have any complications nor do I have blood pressure issues.  I was working until this last week - and would have kept working if the doctor allowed it. 

My problem is this - my OB told me early on that he wants to induce me at 38 weeks.  He said (at our first appointment) that "we always induce diabetics at 38 weeks".  This seems like a one-size-fits-all kind of mentality and I don't see how this is reason enough to induce me.  He told me that he'd give me his final decision next week.  I would prefer not to have an induction if at all possible since, as far as I've read, the research on inductions is old - and is more suitable to type 1s who are in poor control or type 2s.  I do know that if I have a pattern of lows, that means that the placenta could be failing and I will go into the hospital right away.  I am prepared to do that.  I have also been doing fetal counts periodically throughout the day to make sure that baby continues to break dance - and I am prepared to go to the hospital if movement slows.

My questions for you ladies are:

1) How many of you were able to go into labour on your own (i.e. without having to be induced)?  If you did, how were you able to convince your OB to let you stay the course of pregnancy?  Did you go into labour preterm?  If not, when did you go into labour? Were there any concerns about the placenta failing?

2)  For those of you who were induced - when were you induced and what was the reasoning for being induced?    How was the induction and did it end in a C-section?

3) For those of you who had C-sections - how was it decided for you to have a C-section? 

4) For those of you currently pregnant, what has your OB told you?  Are any of you going full-term? 

5)  How can I convince my OB to let me go further than 38 weeks?  Does anyone know of any other research that would be good for me to read for either side of this argument??   Would you recommend that I go ahead with the induction or stay the course??

Many thanks!  I have so appreciated reading all of the posts.

~ Tracy

Type 1 for 28 years, no complications, first baby!!, on a pump for 6 years, on CGMs prepregnancy and throughout pregnancy

Tracy,

 I don't have answers to many of your questions because I'm currently 18 weeks along.  I will say though that I was also told that it was hospital policy to induce Type 1 Diabetics at 39 weeks.  I too was not happy with this news.  I have been pleading with my team to try and let me go further.  I have also been a Type 1 for a long time (22 years) and am in excellent control, last A1C of 6.0.  

 It seems to me that being induced might cause more problems rahter than prevent them.  I feel that if I am induced that I will end up having an unwanted c section due to putting the baby in stress.  I understand inducing if the placenta fails or if there are other complications, however if baby is healthy why can't they stay in there until they are ready to come out?

 Thank you so much for asking all of these questions, I am excited to hear what everyone has to say.

Brigid

Thanks for responding Brigid.  I'm sorry to hear that you are in the same boat as me.  I have also read research that states that being induced may cause more problems than prevent them - especially in terms of fetal lung development (this research is from 2009 - but I don't have much research past 2009).  And that around 50% of mothers induced with Pitocin end up having a C-section due to exactly what you were saying - stress on the baby.

Congrats on the pregnancy and on the great control, it is not easy...

Where do you live, Brigid?  I'm in British Columbia, Canada.  So, I'm not sure if perhaps you are also in Canada and your OB is basing your induction around old research.

Thanks,

Tracy.

Hi Tracy.  My understanding is that they induce us because, due to being diabetic, our placentas can go bad very quickly & without warning which could result in stillbirth. So the logic is basically to remove the baby while it is known to be healthy.  Technically, a baby is full term anywhere between 37-42 weeks, so there really isn't any risk to inducing at 38.  In the end, its your choice.

I'll answer your questions that I can,

1) Can"t answer this one. I didn't go into labour.

2) Can't answer. I wasn't induced.

3) I had a C-section which I opted for.  I had it at 38.5 weeks after a very successful and healthy pregnancy (I had been diabetic for 21 years at that time).  I chose C-section instead of induction because it wasn't likely an induction would be successful for me (my cervix was still really high and totally closed) and I didn't want to cause the baby unnecessary stress.  My son was born completely healthy, but did have low blood sugar shortly after being born.  

4) I am currently pregnant again and have already told my OB I want a C-section again.  I plan to go to 38-39 weeks if I can.  Like I said, 37 weeks is considered full term so I'm fine with that plan.

5) Its your choice if you want to refuse an induction.  For me, it was more like "ok, we know he's healthy and well-done, lets meet him already before something can go wrong!!"

Congrats to you and good luck!!

Hi, Tracy! Great questions!

I'm so glad you are trying to think through this and not just take everything your doctor says for gospel. No one cares more about you and your baby than you do, even your doctor. Studies show that for most babies, an induction prior to 39 weeks is detrimental to the baby's health (See an article from the Wall Street Journal online.wsj.com/.../SB10001424052748704615504576172291331227676.html)

And of course unnecessary inductions lead to a much, much higher risk of cesarians, which have their own risks and long-term affects on the both the mother and baby. (For some of these, see www.americanpregnancy.org/.../cesareanrisks.html)

Especially in your situation, your A1Cs are very close to those of a non-diabetic woman, who would not need to be induced early. If I were you, with such great A1Cs, I would push to let the baby decide on its own when to come. If your A1Cs were in that range without you having to work to keep them there, the doc would most likely not even consider you high-risk

Your doctor, most likely, is operating on old information, the time when diabetic moms could not keep such good control as you have been, and thus is still using the blanket "we always induce diabetics early" approach. Diabetes alone is not a good enough reason to induce early these days of CGMs, pumps, and near-normal A1Cs that hard work can accomplish. (Actually, you are likely more healthy than a non-diabetic woman because you haven't been stuffing your face, satisfying all your cravings like they have!)

Also, it's you and it's your baby, not the doctors. He is there to help and give his professional opinion, but it is up to you to decide. You are paying him, so it is up to you. (As long as he doesn't "fire" you as a patient.)

Here's the only problem: if the doctor wants to induce you early, he may be tempted to find a reason. He may agree to let the baby come on its own "if all is well", and then tell you around week 38 that such-and-such is a problem and that the baby needs to come right now. You'll never know whether that's the truth or not, so you'll give in to the doc just to make sure.

If I were you, I'd either go with an independent midwife and a home-birth (if you can find one that will take you) or just go along with what the doctor says.

Here's my story:

I found a doctor who said he'd let me go to 40 weeks, but scared me with the possibility that the baby must come sooner. My control was not nearly as good when she was conceived (7.6 A1C, with subsequent A1Cs of 5.9 and 6.2) so I was getting a little worried too.

But I hated the idea of cytotec and pitocin and just laying there in pain for hours without being able to move around during labor, and I was trying to do the whole natural birthing thing. Trying to get the best of both worlds, but I think I got the worst of both instead.

I scheduled the induction 2 days before her due date, but ***-pumped my way into labor two days before that. I also took some castor oil (DON'T take castor oil!). I got my contractions going enough that I couldn't sleep through them, so I was already very tired by the time I got to the hospital at 8:30 in the morning on induction day. I was 3cm dialated (from 0 a few days before). The doctor overseeing my labor knew I didn't want pitocin, so she let me labor mostly on my own all day. She broke my water around 12pm I think, maybe later, and there was meconium (baby's first bowel movement) in the amniotic fluid, which can be dangerous for the baby to drink in. (I was still 3 cm).

I continued to labor all day until about 10pm or so, the doctor checked me again, still 3cm, so she said let's start pitocin. I was exhausted by this time. Had been in labor for 2 days with little progress to encourage me and little sleep. The fetal monitor said that the baby's heart-rate was dropping too low for too long during the contractions though, so she said "We need to do a c-section". I was actually happy about that at the time because I was so exhausted.

So we did the c-section, which was quite traumatizing for me. They don't let anyone come with you while they put long needles up your back for the spinal (or epidural). I was shaking all over, laying naked in front of a bunch of strangers whose faces were covered with masks. They put a catheter in me, which my doc made me keep for 24 hours (still no idea why), blood pressure cuff on that went off maybe every 10 minutes, and cuffs around my legs that squeezed every few minutes (and all through the night while I was trying to sleep too). They tied my shaking arms down, and finally my mom and husband were allowed to come in. (They usually only let one person in). I was relieved when I stopped feeling contractions, but there was a lot of pushing and pulling pressure, especially when they pulled my baby girl out.

I cried for joy when I heard her for the first time. They showed her to me briefly, then she was whisked away for her bath, APGAR testings, etc. while I got sewed and stapled back up. A bunch of my in-laws witnessed her first bath and check-up, but I, the mother that went through months of carrying her, and then the labor, did not.

I got to hold her before going to bed that night, and ***-feed. She latched right on, no problem the first 3 times she tried. In the morning though, they said she had an infection and had to be kept for 24 hours on antibiotics, possibly 7 days. They would know with more tests how long to keep her. When the tests came back, however, even though the results were good, they still needed to keep her for such and such a reason (I get the feeling that only 24 hours was never an option- they planned to keep her from the start). So they gave her some bottles and pacifiers when I couldn't be there to nurse her, which meant she struggled to nurse for the first few weeks.

I think the infection was probably due to her swallowing the meconium that she passed, which was due to the castor oil that I took to get labor going "naturally".

As for me, everyone said I bounced back quickly (for a c-section) but walking down to the NICU for 7 days was incredibly painful and I had to walk slower than a 90-year-old grandma. Coughing, laughing, and sneezing all shot fiery bolts of lighting through my lower abdomen, causing me to avoid those activities at all costs for like 3 weeks. I have a big ugly scar and belly fat that won't go away even though I've lost all the baby weight now, plus about 7 lbs. more. (I weigh about 120).

By the way, my baby girl was 7 lbs. even, 20 inches long, and had APGARs of 9, 9, and 9. Her blood sugar never dropped too low, and she was strong- could hold her head up for a couple seconds from the day she was born. I feel confident that she would have been perfectly healthy if we had let her come when she was ready.

So anyway, long story to say: either do it your doctors way, or go all-natural and wait for the baby to come when it's ready. (But at least wait for 39 weeks!) And whatever you can do to avoid a c-section is worth it. As a diabetic, if you have a c-section, you will probably never be allowed to give birth any other way. I am going to push hard for a VBAC the next time around, but I'm not too optimistic.      

Good luck, and remember, no matter what happens, you have done your very best, with the information you have, to give your child the best start in life! No one can ask more than that. And 99.99% chance your baby will be born healthy, beautiful, and strong. Good luck and God bless!

Thanks Katherine for your response and the links.  I am glad that you told me about trying to "induce yourself" via the use of castro oil and *****pumping.  I was going to go along those same lines if the doctor told me that an induction was necessary (if he scared me into it with some type of information or another).  Thank you for warning me not to.  I'm so sorry that you had to go through what you did - and I cannot thank you enough for sharing your story with me.  I would have done exactly what you did!!

I have a doula who will be there at the birth and she knows about what I prefer and I believe she will help as my voice if I need her to (which I am very thankful for!!).  Since I am in Canada, I am not "paying' the doctor - he gets paid by our provincial health care, but he could request that I see another doctor (not that I think he would).  He seems to be a reasonable doctor - so I'm hoping that he will allow me to continue on.  I also think that he has rarely seen a diabetic with a CGMs so, I think that may help to change his mind.  He's worried about the lows more so than anything.   If he does try to get me to go for the induction, I will likely refuse.  He had also told me early on that there is a 1 in 10 chance that it will be him delivering my baby - since he has a practise - so, I am not worried if I have to see another doctor anyways.

I just really want to make sure that I make the right decision.  I have been doing a lot of reading of medical journals - but the unfortunate thing is, there is not a lot of new research on pregnancies complicated by diabetes - and even less information on diabetic mothers being allowed to go full-term.

I will see what information the doctor gives me either way - or if there is a reason other than what I already know for inducing a diabetic.   I have also read that lung development for an infant of a diabetic mother is often slightly delayed, so that was my main worry about being induced at 38 weeks.  I'm not sure about the rates of still birth for diabetic mothers - so that is a concern if that is why he is choosing an induction.  I will have to see what I find on that (thanks for that, spaghettio!).    

I wish you the best of luck with your next pregnancy Katherine...

Many thanks to all for the responses,

Tracy.

Tracy-

I'd had type 1 for 28 years when my son was born (he's now a healthy 6 year old).  My pregnancy was healthy, I felt great and had a 5.1 A1c.  I worked up until the end and did Moms in Motion yoga and water aerobics classes.

In the labor and delivery classes the nurses told me to pay special attention to the cesarean info because as a diabetic I would probably have a cesarean.... I thought they were wrong because I was so healthy.

But OBGYNs don't really differentiate when it comes to diabetics.  It's considered a high risk pregnancy and so for liability and safety reasons they want the delivery to be completely controlled.  Frankly it hurt my feelings.  My doctor was proud of how well I'd done through my pregnancy and I had no pregnancy complications, but when I got close to the end he made it sound like I was making a terrible choice if I didn't induce early.  

I had reservations about being induced because my body didn't feel ready.  But I took my doctor's advice and was induced at 38 weeks.  I was not allowed to get out of bed once the inductions started at 6pm Monday.  At 6am Tuesday morning they started pitocin, which helps contractions progress but also makes the contractions more painful.  A nurse physically broke my water because my labor was unproductive and hospital policy is that you have to deliver within 24 hours of water breaking.  Think she was trying to put me out of my misery. =)  At 3am on Wednesday I had a cesarean.  After being in bed so long and going through labor and the cesarean, it took me a long time to recover.

If I had to do it again I would only choose to be induced if my body was close to ready to deliver (if baby had dropped and cervix was dialating).  If my doctor was insistent for some reason about not waiting to deliver at term, I would have scheduled a cesarean.  

Everyone's pregnancy is different and it's important to respect the recommendations of the medical professionals you are working with.  But I wish I had trusted my instincts more.

At the end of the day I was fine and my son was too.  It will all work out for you too. When your baby arrives you'll realize that all of the time you spent worried about your pregnancy and delivery is just a blip on the screen, the real part starts when you meet your baby.  Congratulations on becoming a mom.  It is a wonderful blessing.  

-Jenna

I was induced at 37 weeks and I am so glad that I was! First off, I was supposed to be induced at 39 weeks, but because I started having hypertension they induced early. I am a first time mom, I was scared to death! Everyone told me the contractions would be so much more painful! Well, I had a difficult labor but I would do it all again infinite times to have my daughter. It was worth it. I pushed for over 2 hrs, had an episiotomy and 2nd degree tears. I was 128 lbs at the time (I was 97 pre-pregnancy so I did gain a healthy 31 lbs) and I delivered a 8 lb 10 ounce baby. She was WAY to big to come out of me. I just remember pushing and pushing. I was so exhausted and I couldn't do it anymore. They were actually prepping an OR room for me I was going in for an emergency c-section when my dr finally gave me the episiotomy and she finally came out! And like I said, this was at 37 weeks! If I had of went to 39 weeks or longer she definitely would have been way to large to come out and I would have needed a c-section. Each pregnancy is different. I don't think my labor and delivery was "perfect" by a far shot. It didn't go the way I wanted, but I AM happy that I didn't have to get a c-section! And really in the end, it does NOT matter how your delivery goes so long as you have a healthy little baby!

I grew up in Vancouver, B.C. but currently live in Los Angeles. My baby girl was born in LA in February and is doing great. I know an OB in Vancouver and was told that it is the standard there to induce at 38 weeks.

I was lucky to have OB's in LA who did not assume that my pregnancy would have to take a certain course just because of my diabetes. I told them about what happens in B.C., and they said it is a bit of an older theory of how to treat a diabetic pregnancy, and that they would instead followed me closely, and if my body, baby, and placenta wanted to go full term that would be fine with them. They did say that they wouldn't let me go more than a day or two past my due date.

That being said, my placenta did not want to do it's job until my due date. My A1C was 6.9 at conception, then 6.2 during pregnancy. I have had diabetes for 12 years, never have had complications, this was my first pregnancy and I am otherwise in great health, eat well, exercise, etc. As a posted under a different thread, I had low amniotic fluid noted on my non-stress test at 35 1/2 weeks of gestation (I was having NSTs twice a week). Because of this I was induced but it actually went really well for me. I was given cervadel to ripen my cervix and that jump started my body in to labor so I didn't need pitocin or any other drugs. I did not need a C-section. My daughters lungs were a bit underdeveloped so she was in the NICU for 8 days, but is now doing great!

Daytrip00... I don't know if you will be able to convince your OB to go against the standard of care in the province in which he/she is practicing. Maybe you can try and get info from the American College of OBGYNs and see if they have a statement about recommendations for diabetics and then share that with your OB.

Good luck to you all.

I appreciate the responses and the info on the births.  I will try to get info from the American College of OBGYNs... thanks rishmack.  I will see what happens - but I appreciate the info.

~ Tracy.

Just an update.. My OB ordered another ultrasound for next week - this last time (yesterday) they guess that baby is almost 8 pounds (again, give or take a pound).  He'll advise me on Friday as to what he suggests I do.  He said that he did not want to induce me unless the baby had dropped - so that's a hopeful sign.  Baby is still doing well - moving about and all is good - so I'm hopeful that I can keep on.  I told him that I was really reluctant to go on Pitocin - and he said that that is usually the last step in the induction "process".  I will have another ultrasound next week so if I am induced - it would likely be into my 39th week which I feel slightly more comfortable with.  

I was induced at 39 weeks and 1 day-natural labor, no c-section needed. and the only reason they gave me the pitocin was b/c I wasn't dilating fast enough. With mothers who aren't diabetics, they will usually let you go 1-2 weeks past your due date before inducing but diabetics are usually induced at 39 weeks (this was according to me endo and ob/gyn)

My OB told me today  that I am to have an ultrasound on Tuesday and if the baby is less than 4.5 kg - I will be induced on Friday.  But if baby is close to or bigger than 4.5 kg then I should have a C-section.  His concern is shoulder dystocia - which has made me a little more concerned than before.  He said that shoulder dystocia can cause a lot of problems - brain damage, paralysis etc..  So now, I feel a bit more worried than before.  The other problem is that the baby hasn't dropped yet - so when he sees me on Wednesday, he says if the baby hasn't dropped, he would strongly suggest a C-section.  I'm going to guess that now the best course of action would be a C-section - although I had not wanted it.  Feeling a bit more than a bit blue about it all.  : (  I know that the safety of the baby is the most important thing... I'm guessing that a C-section is it.  

With your A1C around the same, normal range as a non-diabetic woman, there should be about the same chance of shoulder dystocia as the baby of a non-diabetic woman (very, very small). And just because your baby is measuring big does NOT mean that he has shoulder dystocia (and the ultrasound may be off by as much as 2 lbs. anyway, so it is NOT a good indication at all). Lots of non-diabetic women have bigger than "normal" babies that are perfectly healthy (my mom's 3 babies were all big- 8 lbs and 10 lbs but she's not diabetic).  

My A1C's were 7.6, 5.9, and 6.2 during my pregnancy and my baby was born 2 days before her due date, 7 lbs. and no shoulder dystocia. She was strong and perfectly proportioned. (BTW, an ultrasound 4 days prior told me that she was 7 lbs. 11 oz. Since she was actually smaller then than when she was born, the ultrasound measured her to be almost a lb. heavier than she really was.)

Also, about the baby dropping. sometimes the baby does not drop until labor begins, and this should be considered within the range of normal, not abnormal.

If you are getting worried about the baby, go ahead with the induction. You may, in the end, still have a c-section, but at least you will have tried. There are many benefits for the baby to go through labor, including squeezing fluid out of it's lungs so they will be ready for it's first breath. A c-section these days is almost a life-sentence to always have c-sections with all your subsequent babies, especially if you are diabetic, and having so many major abdominal surgeries is very detrimental to a woman's health.

Also be aware that c-sections are much, much more convenient and more money for the doctor and hospital. A labor is an art, not a science, with so many variables, so many things to watch and wait for and so many uncertainties for a doctor.  A c-section, on the other hand, is quick, easy, and convenient. Schedule it, get in, get out, get on to the next patient. AND it's more money. What could be better for the doctor? He doesn't have to deal with the lasting scars, both physical and emotional, on the mother (and sometimes the baby). So sometimes (not every time, but often) doctors like to invent reasons to do c-sections. The baby's too big, your pelvis is too small, etc.

With your A1C so near normal range, I would push to wait AT LEAST till 39 weeks, possibly till 40. Then, agree to be induced. If you're uncomfortable with cytotec, cervidil, etc. I would have lots of sex (including orgasms for you), take evening primrose oil capsules, and especially *** pump to get dialated through nipple stimulation before going in. Then agree to low-doses of pitocin if labor is not progressing on it's own by then. (Nipple stim got me to 3cm but not beyond, so I should have gotten pitocin from there).

Anyway, that's my two cents. Good luck! And remember, whatever happens, you will have a beautiful, healthy baby, and that's the end goal anyway! Don't let yourself feel like a failure if things don't go exactly as planned. As a diabetic, having a healthy baby is a HUGE success!!!

-Also, be sure to start ***-feeding as soon as possible, and don't let them give the baby any bottles. If ***-feeding is hard, painful, and frustrating at first, hang in there!  It WILL get better! You can do it! :)

Hi Tracy!

I am also 36 weeks along and the doctors haven't said anything about induction. It sounds like they will let me go to 40 weeks, as long as our little guy keeps passing his NST's and BPP tests. MY last A1C was 5.1 and baby boy is measuring at 50th percentile. I am being seen every week now and things are going great for me too (knock on wood). I am hoping for as normal of a birth as I can have, but preparing myself for the worst as well. Isn't it crazy....in a few weeks we are going to be mommys!! I am so excited!! =) Good luck.