Saturday, November 6, 2010

Third Stage

I am devoting this post to the third stage of labor, also known as delivery of the placenta, because my two experiences with this stage have been uncomfortable and the most recent was just downright bad.

The first time, after they put my son on my belly, it felt awkward, and I didn't really want to be with him right away. The best antidote to this apprehension probably would have been plenty of time with him just then, but alas, it could not be. They took him away almost immediately because there had been meconium (baby poop) when they broke my water and meconium when he came out, and they needed to check him out to make sure he wasn't overly stressed out. This seemed justified to me. So naturally, with the baby out of my hands, all I had to think about was the delivery of that danged placenta. I kept asking my doctor, "When is it going to come out?" Of course he couldn't answer that question, so he just assured me that it would come out, and the only thing he could do to expedite the process would be to pull on the cord but he also added, "but you don't really want me to do that, do you?" The reason he cautioned against pulling on the cord is because doing this before the placenta has separated from the uterus may cause the uterus to invert. Pressing on the belly before the placenta is delivered can cause the placenta to separated incompletely. I think both can lead to hemorrhage, and retained placental fragments can also lead to infection. He may also have known how uncomfortable it would be without an epidural.

With my most recent birth, it was even worse. Or maybe it's just because it's fresh in my memory. In any case, it was sub-par. First of all, they took my son, whom I was delighted to meet, away before I realized what was happening. I think I thought they were going to bring him right back after a minute or two, but it was a lot longer than that. And secondly, the residents attending my delivery insisted on pulling on the cord and pressing on my belly. I asked them to stop, which they did for a while, but after 30 minutes had elapsed, they got antsy again and insisted, threatening that otherwise they would have to go up there with their hands (which I'm not sure would have been much worse) to pull it out. The other thing they were trying to do at the same time was sew up a second degree perineal tear that I had sustained.

So here's the scenario: I'm shaking uncontrollably. I'm tense, because I'm freezing cold. I can barely hold my head up much less my legs and my torso. They are tugging on the cord, every bit of which I can feel. And my legs are propped up in stirrups so they can finish as quickly as possible (which I had asked them to do because I just wanted them to quit messing with me). At some point, I felt her stitching together something that I was pretty sure didn't need to be stitched together and told her so. She told me I was wrong. And my baby is somewhere else...I think in the room, but I'm not sure where...and all I can think about is being done with this awful business. Yuck.

A couple of post-delivery observations. I'm fairly certain that a chunk of my placenta came out a few days after I got home from the hospital. Also, that part that I told her I didn't think she should be sewing together? About a week later, one or two of my perineal stitches snapped, so I'm pretty sure I wasn't wrong about that. I was horrified by both of these things at first, then I was angry, and now I am just resolved for it not to happen again.

After this, I did some reading on third stage management (in the midwifery text Heart & Hands: A Midwife's Guide to Pregnancy and Birth by Elizabeth Davis) and found out the following:

Adrenaline drops immediately after delivery, and oxytocin increases. Adrenaline and oxytocin oppose one another. Oxytocin promotes bonding with your baby, breastmilk production, and (here's the kicker) delivery of the placenta! So what's at least one effective way to promote oxytocin in mom? Keep the baby with her. But guess what else? If you are cold, adrenaline remains high, "which can disrupt placental separation by opposing oxytocin" (129). Also, "A drop in adrenaline levels moments after the birth makes it difficult for [the mother] to stay upright." These are ALL the problems I experienced during third stage: freezing cold, couldn't stay upright, and tension and anxiety because they took my baby away.

"The placenta usually delivers twenty to thirty minutes after the birth, although it may take an hour or more." Maybe my placentas just take a little bit longer to deliver than others? Given the fact that my babies seem to like to stay inside for longer than other babies, maybe my placenta has a hard time letting go, too. Completely speculative, but no one else seems to have any theories about why some placentas come flying out in 10 minutes and others take their time.

Perineal tears do not need to be repaired right away. This is one thing that could have waited. I asked them to just get it over with, but I might have been able to rest and bond with my baby if I hadn't been propped up for the repair.

In the name of efficiency, they took my baby away to clean him up and do their testing, and they worked on my perineal repair while they waited for the placenta to come out. In fact, though, it may have been more efficient for them to let me hold and nurse my baby, lie down, and cover me up with blankets. This would have spurred oxytocin secretion, which would have facilitated delivery of the placenta, and they could have sewed up the perineum after the placenta had been delivered and I was comfortable again.

All of these things created a toxic combination that have given a sour foot-note to an otherwise thrilling birth experience.

Part of the problem may be that hospital care providers are unfamiliar with the sensations that a lot of women experience after delivery without an epidural. With an epidural, you probably won't feel the discomfort of the contractions after pushing the baby out, and you won't feel the discomfort of the tugging on the cord on the pressing on the belly, and you won't feel if the stitches are being done in the right place.

My last note is this. In total fairness to my providers, they were trying their best to keep me comfortable. At one point, while I was wincing from a combination of cord-pulling, perineal-stitching, still-having-contractions pain, the resident said she just couldn't bear the thought that her work (stitching the perineum) was causing me pain, so she gave me an extra shot of local anaesthetic, thinking this would solve the problem. Unfortunately, she misunderstood the source of my discomfort, so it was not effective relief. And no doubt they were anxious is because I was anxious, confused, in pain, and didn't know what I wanted or needed and was making incoherent, contradictory requests. A good friend that had a similar hospital experience asserted that care providers should know what women need and want post-delivery when they are shaky, cold, and weak. Well, they didn't; but next time, I will.

Thursday, November 4, 2010

Funny Story

We are right now living with my parents. Every two weeks, two latina women come to clean their house. These two ladies were eagerly anticipating my son's birth, and last week, they had a chance to meet him. Their reaction to the circumstances surrounding his birth made me smile because of the contrast that I usually experience when I tell other (usually white) friends.

The first question: "Cut or regular?" By this, the older of the two women meant, "Did you have a c-section or a vaginal delivery?" Somehow the terms "cut" and "regular" bring into focus the reason that vaginal (regular) delivery is so important to me. Vaginal deliveries are "regular", and usually you can't beat the design God gave you. On the whole, women's bodies recover faster from vaginal delivery for that reason. Babies often recover faster, too (nursing and breathing may come more easily to vaginally-delivered infants). "Cut" also brings into focus the fact that a c-section is a major abdominal surgery, which always carries additional risks. I do not believe that c-sections and vaginal deliveries are equally good ways to get your baby out.

Don't hear what I'm not saying - c-sections are necessary for mom or baby's health somewhere between 5-10% of the time. And most women and babies that go through them do just fine. But a national c-section rate of upwards of 30% is grossly out of proportion to what is considered necessary by the WHO, and I don't think it's just because U.S. citizens are horribly unhealthy, as some doctors may claim. It's largely a product of fear, both on the part of women (fear of the pain of labor, lack of control) and their doctors (fear of being sued if they contradict ACOG protocols for individuals that don't fit the traditional mold, and lack of control).

The second question: "Libras (pounds)?" When I told them that my baby was 9 and a half pounds, they exclaimed, "Healthy! Strong!" This made me smile because what I normally hear from people is, "What a gigantic monster! That must have been horrible!" But the fact of the matter is that my baby is healthy and strong, and it's time that we stopped thinking about big babies as monstrosities. So be proud of your big babies, ladies.

The third question: "Boob?" Yes, she actually said "boob." She was asking if I breastfeed my son, which I do. When I answered in the affirmative, she said, "Oh, very good. Very healthy." And it's true. The American Academy of Pediatrics recommends breastfeeding babies for at least one year, for their health, and the American College of Obstetricians and Gynecologists recommends at least six months, for your health. It's worth the sacrifice of time, sore nipples, and other inconveniences.

The conclusion that these ladies had for me and my baby? "Very good. You will be able to have 5, 6, many more children." They hit it spot on and their conclusion was extremely gratifying to me. Because one of my intentions is and always has been preserving my ability to continue to have children until my husband and I deem it imprudent to continue. I would never want the fact that I happened to have an unnecessary c-section or the fact that a doctor is afraid the baby will be "too big to fit" when the baby fits just fine to keep me (or anyone else, for that matter) from future childbearing.

Sunday, October 31, 2010

Birth Story #2: Braveheart


My second son was born at 10:25 p.m. on October 22, 2010.

The story actually begins well before the birth itself. In fact, it really begins in September of 2008 when I found out I was pregnant with my first son, but maybe that's a different, longer story about motherhood. We'll just start a couple weeks from this baby's birthday.

My doctor first suggested induction at my 38 week appointment. It was actually a question: "When would you like to schedule it?" I was unprepared for the question, since I never intended or wanted to be induced. So I deflected and bought myself another week. At my 39 week appointment, we scheduled the induction for 2 days past my due date, but I was still not resolved to do it. I kept just hoping I would go into labor on my own.

The night before my scheduled induction, after all sorts of "natural" induction methods had failed, Jenn called and wanted to make sure that I was comfortable going forward with a pitocin induction. I wasn't, so her call forced me to the point of fully accepting whatever choice I made. I even spoke with my doctor the next morning - the morning I was supposed to show up for my induction - and he (without his typical warmth) affirmed that the choice was, in fact, mine (but that he had already made enough of an exception for me by letting me go to my due date and did not approve of my hesitation). Still unconvinced by his heavy-handed warning about the statistical doom that awaited my child and my pregnancy, I told him that he may or may not see us at the hospital in an hour.

After a three minute discussion with my husband, we decided to go for it (in reality the conversation had been ongoing for weeks and involved many more people than this, but for the sake of brevity, I must cut it off here. Will post more on that discussion later). So we hopped into the car.

We arrived at 8:00 a.m., were admitted, and met our nurse. And after meeting our nurse, I knew that God had prepared this ahead of time for our good. We had a lot in common, and she seemed very excited to help us bring our baby into the world. We even invited her to our son's anticipated baptism.

The pitocin started at 10:00 a.m. I was already dilated 4 cm and 90% effaced, but had similar stats at the beginning of labor with Symeon, so I was not convinced that this didn't have the potential to be a 24-hour ordeal. Contractions gradually gained regularity and frequency, but were weak. I wasn't doing any real work. We read, checked e-mail, talked with each other and with our nurse. We were pretty excited to meet our little man, but I was having doubts about how it would all go down. One bit of luck I had is that one of the residents did an ultrasound before they started the pitocin and she was able to print a picture of my baby for me...and his eyes were open! I can't tell you how much it helped to get me excited to be able to look at a picture of my baby during these waiting moments.

Around 5:00 p.m., I was maxed out on pitocin with not a lot happening. My doctor checked me and I was "5-6 centimeters." In plain English, that means I was probably closer to 5 cm but they wanted to make me feel better about my progress. He wanted to break my water but I wasn't ready. I was still not convinced that I was actually in labor, and if I was, I wasn't sure I was ready for the intensity that would likely follow an amniotomy. I asked them to wait. He stripped the membranes, grudgingly agreed to wait, said he was going home, and told me to let the residents know when I was ready.

Over the next two hours, the contractions became more intense (but I was still talking through most of them). Now I knew I was in labor, so the only obstacle to them breaking my water was whether I was ready for it to go quickly and get hard? After some deliberation, my husband and I decided it would be best to have them break the water.

At 7:30 p.m., when the resident went in with the amnio hook, I was still only "5-6 centimeters." Which meant that no measurable progress had been made. Still, I knew I was really in labor now, and I was emotionally ready to get to work and meet my baby. These are not measurable indicators, but it was still extremely important progress.

Within one or two contractions, the intensity came on strong. I was still on the maximum pitocin dose, so our nurse began to turn it down. After another half hour, I asked her to turn it off, since I did not have ANY break in between my contractions and really needed some time to recuperate. Half an hour after the pitocin was all but removed, I had the peace that I needed in between contractions, but they were still fast, long, and strong. I told my husband I wasn't sure how much longer I could do this. He told me I was doing great.

At 9:30 p.m., I was feeling a lot of "pressure." The experienced reader may understand the difference between "pressure" and "urge to push," but I sure didn't, and thought maybe I was ready to give it a go. I asked the resident to check my dilation, but I was only at 7 cm. Oh, wow, did that news hurt. Like, even more than the contractions did. She told me to continue to try to breathe through the contractions, since my cervix was not really ready to let my baby through.

My pleas for pain relief became more urgent. Thank God that neither my husband nor the nurse believed me when I said I couldn't do it. My husband reminded me that an epidural could make it take even longer, I was already so close, and as much as I wanted to avoid the pain, I mostly just wanted to get it over with and meet my son. So I metaphorically gritted my teeth (but in fact tried to relax my jaw, like all advocates of natural childbirth recommend!), remembered Bradley's advice ("5 more contractions"), and offered my pain to God.

Within 30 minutes, I grabbed my husband and said with urgency: "Tell Jen [our nurse] I can't not push anymore." With calm that did not mirror my urgency, I heard my husband whisper quietly to Jen. "Beth told me to tell you that she can't not push anymore." It made me chuckle because I was fairly certain that neither of them comprehended immediately what I already had: that THIS was the urge to push, this baby was ready to be born now and I was ready to assist.

Jen came over and checked my dilation and lo and behold! I was fully dilated after only 30 additional minutes! I quickly absorbed the good news, which I had intuitively surmised already, and with my next contraction I pushed hard. "OK, I can see baby's head, so I'm going to go get the residents."

Pushing felt good, but getting the baby out did not. Just 20 minutes later, at the very end, there was a lot of screaming and "ow, ow, ow, ow OWWWWW!" My husband said it was hard to watch me in so much pain and he even shed a few tears because of it. But every woman who has ever been there knows that there's no turning back. So you give one last big push and welcome to the world, baby!

He weighed in at a whopping 9 pounds, 8 ounces and 22 inches long. Everyone exclaims what a big baby I have and wow, that must have made labor hard? I laugh and tell them that the size of the baby matters very little to me - as far as I'm concerned, it's probably going to hurt whether you push out 6 pounds or 9 pounds - the biggest obstacle to pushing out babies for me is my own anxiety about it. And I'm not just talking about anxiety over the pain of labor, I'm talking anxiety about being a mother, a parent, responsible for one more new life plus holy living, even after your crankiest, most sleepless nights.

My blood sugar was right around 110 at delivery, but sky-rocketed shortly afterwards. I suggest you keep a close eye on it while pushing, because that's when mine rose last time around, too. It's just that this one came flying out so fast that my rising blood sugar didn't have time to affect him! His was 63 at birth and dropped down into the 40s over night, but his condition was stable and no supplemental feeding was necessary. Breast-feeding has been a huge success.

That being said, I highly recommend a second child to any one who experienced a lot of anxiety with their first. I can't believe how much fun I missed out on during the newborn period the first time around! Labor was faster, recovery has been much easier, and my perspective on babies and being a mother is larger, longer, and growing every day. And I'm sure loving the baby snuggles...

Sunday, October 24, 2010

Mom and Baby Doing Great!

More good news from Beth today... She and baby are home and doing well. Baby is nursing well and baby's blood-sugars have been just fine since delivery!! What wonderful news!

Induction was successful and Beth delivered with out any pain medication as she wished!

So thankful to pass on great news from Beth! ~jenn

Saturday, October 23, 2010

Baby's Here!

I know that many of you have followed Beth's story as she has carried her second child and wanted to let you know that as of 10:25pm, last night, she has a healthy baby boy! I haven't heard her story just yet and am so excited to over the coming days! We are praising the Lord for a healthy baby today though! Congratulations, Beth! ~jenn

Friday, October 8, 2010

Induction

So, here it is. This is the post where all my unresolved issues about the risks of induction compared to the risks of stillbirth come out.

My doctor asked me on Friday, at 38 weeks and 2 days, whether I wanted to be induced Wednesday or Friday of next week. Um, is neither an option? How about I go into spontaneous labor before then. That would be great. Yeah.

I was actually surprised by his recommendation, since at my first visit I had thought he was OK with me going to 41 weeks. My first son was born at 41 weeks. Last week, I thought I heard him he wanted to induce at 40 weeks, but I chose to ignore it and assume I had misunderstood, and see if he brought it up again this week. But today it was 39 weeks, and well, that surprised me. I used the "I need to talk it over with my husband" line to give myself some time to think and avoid an awkward, flat-out refusal (to be fair, I have done some serious thinking about it today).

So that brings me to the most important point, which is, why is it that doctors recommend induction for pre-gestational diabetics at 39 weeks? Nothing has changed about my health since I recovered from the migraine at 35 weeks. Blood pressure is slightly high but within an acceptable range. Blood sugars are great and stable. Baby is moving and growing. So what gives? Well, a lot of you probably know that epidemiological studies have shown an increased risk of stillbirth in pre-gestational diabetics. To boot, the risk of stillbirth also increases with gestational age beyond 37 weeks. Statistically speaking, it is more likely that my baby will die before he ever takes his first breath.

So some of you might then ask, why are you complaining about being induced? Seems like a no-brainer for something as serious and terrifying as stillbirth. Well, not so fast. A patient-friendly Mayo Clinic site describes the risks of induction, which include increased risk of fetal distress (due to unusually strong, long, and frequent contractions on pitocin), increased risk of c-section, greater risk of maternal or fetal/newborn infection, and risk of umbilical cord compression. More and more caregivers are recognizing these risks of induction. And while none of these seem all that bad compared to stillbirth, any of these risks may result in further complications or interventions that hurt me or my baby and may impair my ability to have more children in the future. Unfortunately, the possibilities for problems associated with these interventions are endless, which is why standard protocols such as "induce diabetics at 39 weeks" don't always serve mom and baby best.

So I'm trying to process all of this stuff for myself, and decide which risks I am more comfortable with, and which risks apply to my situation. Here's what I discovered.

RISK OF STILLBIRTH FOR PRE-GESTATIONAL DIABETIC WOMEN

This study, published in 2003, describes the rate of stillbirth in 130 pre-gestational diabetic births. Twenty-five ended in stillbirth, which is a rate of 19.7%. That is almost 4 times higher than the rate of stillbirth in a normal, non-diabetic population, which I read elsewhere as hanging out around 5.5%. Several notable things about this study, should give us some hope about our chances:

In half of the stillbirths, the cause was explainable. Fortunately, it was not a complete mystery why some of these women lost their babies. And furthermore, some of these situations may be preventable and/or detectable. Fetal malformations would likely have been detected at a 20-week, comprehensive ultrasound and possibly at growth ultrasounds after that (which are both recommended for diabetics). Intrauterine growth retardation can also be detected by growth ultrasounds, maternal weight gain and fundal height measurements. Ketoacidosis can be prevented by maintaining good, tight blood sugar control. Chorioamnionitis (infection, usually occurring after rupture of the membranes) can be prevented and monitored for, by limiting vaginal exams and cervical checks after the membranes have ruptured and keeping a close eye on mom's body temperature. Tobacco use is apparently associated with placental abnormalities, and those caused some of the other stillbirths, so not smoking may be another way to keep the risk of stillbirth at bay.

The women who experienced stillbirth had suboptimal health compared to the women who did not. Examples of suboptimal health included maternal obesity, smoking, and poor glycemic control. I've got a leg up thanks to nutritional habits I've learned, the terror of tobacco instilled in me from childhood, and an insulin pump (isn't modern medicine awesome sometimes?).

RISK OF STILLBIRTH FOR WOMEN PAST THEIR DUE DATE

It is actually quite common for doctors to recommend that even low-risk pregnancies don't go past 41 or 42 weeks, and for them to recommend induction at that point. This research debate, on the issue, from the year 2000, is quite informative about the risk of stillbirth in women whose pregnancies last until late-term and beyond their due date.

I am not entirely sure, based on the highly technical discussion, but I think that one point made here is that more pregnancies end in stillbirth between weeks 24 and 38 than between weeks 38 and 42 or 43. Which means that I am patting myself on the back for making it to 38 weeks without losing my baby, since my risk of stillbirth is reduced by this mere fact.

The other thing I learned from nosing around in the debate is that the risk of stillbirth increases most dramatically between 40 and 41 weeks. The risk of stillbirth increases from 0.2-0.4/1000 births to 1.2/1000 births during this single week of gestation (I think this is usually presumed to be from placental insufficiency...it gets kind of old and stops supplying the baby with nutrients).



So where does all this research leave me? Well, unfortunately, no one can tell me with certainty whether my baby will live or die, and no one can even tell me with precision what the risks of induction versus the risk of stillbirth is in my particular situation. Ultimately, I think I have good reasons to refuse induction or proceed, and I will just have to make the choice I am most comfortable with. I feel good that I have successfully delivered one healthy baby at 41 weeks, I feel good about the fact that I am generally in good health, including blood sugars that are well under control, and I feel good about the fact that I have already made it to 38 weeks. On the other hand, I respect my doctor and don't want to take a risk that is simply motivated by fear of the unknown (multi-faceted risks of induction and consequent interventions).

I guess all I can say is that I have some more thinking to do. Happy to entertain your thoughts, if you have any you'd like to share. Um, and not that anyone would take the blogosphere this personally, but just don't be offended if I decide not to follow your advice.

Wednesday, October 6, 2010

Saint Gianna Beretta Molla

I have recently read about the life of Saint Gianna Beretta Molla, canonized according to the Catholic Church in May of 2004. This woman gave the ultimate sacrifice - her life - to preserve the life of her child. You can read about the exact circumstances of her fourth and final pregnancy, after and because of which she died, here.

As diabetics, on average, pregnancy is harder for us. But we do it anyway because having a baby is an incredibly good thing. As a diabetic with good modern medical care, the sacrifices that I take on may never involve the sacrifice of my very life, but it will always involve smaller ones. These sacrifices are sure to include the inconvenience of checking my blood sugar every 2 hours, in the middle of the night, and any other time I feel like I need to; denying myself certain indulgences; going to extra doctor's appointments; exercising; bringing food with me everywhere to avoid lows; and even risking unknown long-term consequences to my health. I only hope that if it does involve as much as the sacrifice of my life, I will offer it willingly for the one(s) I carry within me, as Saint Gianna did.

So, the next time I feel like complaining about how hard pregnancy is, even if I decide to whine about it anyway, I will remember and be encouraged but the woman that sacrificed her whole life for her baby!

Tuesday, October 5, 2010

Blood Sugar Management During Delivery

When I gave birth to my first son, I had basically managed my blood sugars throughout the whole pregnancy, so it made sense for me to do it during delivery, too. I don't think my doctors even suggested otherwise. My husband helped me by checking my blood sugars every hour, and they let me drink apple and orange juice to keep it elevated when necessary. Unfortunately, my blood sugar rose during the pushing stage and was around 180-200 when I delivered, so my son was slightly hypoglycemic despite my best efforts. I attribute this rise to the extreme effort I had put forth and the extreme stress my body was under for so long on very little fuel (about 30 hours without eating).

Now that I am in a new city with new doctors at a different hospital, I am once again faced with the decision about how to do blood sugar management during delivery. If I don't do it myself, I will be on an IV glucose drip and IV insulin, administered by someone else (nurse or doctor?). Has anyone had a positive experience doing things this way (e.g., achieved better blood sugar management this way than if they had done it themselves)?

I'd like to do it again myself because I think I know myself better and will be able to respond to changes in my blood sugar more rapidly than a team of doctors and nurses that haven't lived with my diabetes every day for the last 17 years and two pregnancies. I won't have to wait for the nurse to come in to check my blood sugar or give insulin (since they have better things to do and don't always have time for it when the floor is active!). This time, as compared to last, I will be more vigilant when I see my blood sugar start to rise, and give higher boluses a little sooner to prevent the high from happening. As long as I can still drink Gatorade or juice, I should be OK even if I trend low. I will also try to eat at least a small meal before I go to the hospital and hope that I am not in labor very long after that! I might consider IV glucose and insulin only if I am nauseated and can't keep anything in my stomach.

I am learning that the more and more I rely on someone else to tell me what is going on with my body (e.g., why are my blood sugars doing this?), the more often I am disappointed. There are too many things about diabetes that we still don't understand, and every individual is too unique to explain according to the epidemiology. My experience has taught me that careful self-observation has led to the best results, since I am the only person in the world with my entire blood sugar management history in my brain. And sometimes that involves going with my gut, which even care based on the best epidemiological studies doesn't accomodate well.

Would love to hear if your experience during delivery has been different.

Monday, September 27, 2010

All I Really Want for Christmas

I love Minimed's Carelink program. I love charts, and graphs, and having a record of my blood sugars and insulin doses in one place. I think it improves my ability to care for myself. But I have a few gripes about it.

I really wish that Minimed would update Carelink so that it supported Macintosh's Safari internet browser. Anyone else with me? Currently, the only internet browser they support is Microsoft Internet Explorer. I would use it much more if Minimed would just make it a little easier to upload.

Also, there is something really annoying about having Carelink prepare "reports." It just seems like sometimes it takes 15 minutes for it to pop up with the .pdf. Isn't there a better way? Also, a way to customize reports so that you can pick and choose exactly which data points you want to see?

I have a good friend who wrote a proposal on these and other ways that Minimed might expand their Carelink software to make it more useful for diabetics and their care providers. For example: how cool would it be if your blood sugar meter sent your BG reading to your pump, your pump then sent it and all bolus information you enter to your cell phone, and then you could enter all the things you ate on your phone, and then your phone would send it up to Carelink?! That would be a dream. I have never been able to reliably write down everything I eat in a day, but if I had a way to enter it to my logbook at the same time I'm dialing up my insulin bolus, I would have a beautifully complete record.

If anyone wants to read this proposal, or try to convince Minimed to take it on, or do something similar themselves, let me know and I'll send it to you.

Friday, September 24, 2010

Late Third Trimester

It's been a wacky couple of weeks. As with my last pregnancy, my insulin needs increased dramatically at 34 weeks. Fortunately, last time, they remained fairly stable until delivery. I'm currently at 36 weeks, and feeling good, but it's been a wild ride!

This pregnancy, when my blood sugars spiked around 34 weeks, indicating increased insulin needs, neither my endocrinologist nor I responded with the dramatic changes necessary to counter them. That resulted in 7-10 days of high (150-200) 2-hour post-meal blood sugars that made me EXTREMELY uncomfortable (not physically, but psychologically). As a result of my anxiety, I ate very little and very infrequently, fearing that would only prolong the high blood sugar.

This instability in my BGs was the background for a massive migraine I experienced over the course of 5 days during my 35th week. I was unable to drink anything that didn't come back up for about 18 hours, and unable (and afraid) to eat anything for about 36 hours. The headache lingered for several days after I resumed mostly normal functioning. My doctor helped me rule out meningitis, preeclampsia/toxemia, and a brain aneurysm (yeah, I freaked out a little bit), showed me an acupunture pressure point on my palms to help relieve the pain, and recommended Tylenol.

My suspicion is that the high blood sugars and the headache were related, somehow. I think that the headache may have been the result of poor nutrition for the 7-10 days prior. I wasn't eating enough because I was afraid of high blood sugars, but I happened to be restricting my food intake at the very same time that my baby and my body were requiring extra amounts of food to support the baby's growth, an increase in amniotic fluid and blood volume, and so forth. My OB had mentioned some concern about poor weight gain during a few of my previous visits. My body's way of saying: pay attention.

The alternative diagnosis is that I had an incidence of ketoacidosis, resulting in dehydration and imbalanced electrolyte concentrations and a very severe headache. I have never experienced diabetic ketoacidosis, so I can't be sure on this one - also, my blood sugar was only around 300, which hasn't ever pushed me into DKA before. However, I don't put it out of the realm of possibility because I am pregnant and my blood sugars had been so unstable and tending high for the 7-10 days prior. The other possibility is starvation ketoacidosis, but it may be generous to describe my state as one of starvation. After all, I was still eating; just not enough to gain weight necessary for healthy pregnancy. Needless to say, the causes of ketoacidosis seem complex, so this may or may not have been at issue.

The last possibility is that the same hormonal changes that I was undergoing that raised my blood sugars and made insulin needs higher (progesterone increase? estrogen drop?) also placed me at risk for a headache. I know that migraines are more common in women, and are associated with menstruation and childbearing events for this reason. I haven't had them before in my life, but did have one or two mild migraines during my first pregnancy.

So what I learned from this experience, and will continue to do through this third trimester and that of any other pregnancies I have:

Pay attention when your insulin needs increase dramatically, and respond accordingly. Moderate changes work well most of the time, and prevent lows, but the changes I needed really were dramatic and involved massive adjustments to bolus ratios, basal rates, and insulin sensitivity.

Be prepared to eat every 2 hours in the final weeks of pregnancy. As a corollary to the above, I would prefer the risk of making dramatic changes and having my blood sugars run low because for me, highs are much more difficult to deal with psychologically. I'm happy to be tied to my food every 2 hours. Keeps the weight gain up in any case, which keeps me, my OB, and my baby happy (even if my postpartum self disagrees. We'll deal with her later). My 16-month-old son is my snack-clock. I make sure I eat every time he does, which is at least 5 times a day.

Try Gatorade rather than juice or water. I should clearly get paid for this plug, but I have decided that Gatorade is an absolute necessity for me from here on out. I get more fluid per carb than I do with juice, which is important at this stage. It seems to be absorbed as fast, if not faster than, juice, when I'm dealing with a low. I don't have to go to the bathroom as frequently as I do if I drink just water. And it helps restore electrolyte concentrations, which is an important part of hydration and avoiding headaches. I'm hoping it will keep the charley-horse leg cramps that wake me up at night away for the rest of the pregnancy, too.

Sunday, September 5, 2010

Cholesterol during Pregnancy, part 2

So I did a little research on elevated cholesterol levels during pregnancy, because I was curious to know why my blood cholesterol was elevated when it was checked a month ago. I also wanted to know whether I needed to do anything differently (while pregnant or afterwards). During pregnancy, it appears as though the long and short of it is: eat well and don't worry about it. Stress may actually increase cholesterol. In fact, most doctors don't recommend checking blood cholesterol levels during pregnancy until at least 6 weeks postpartum.

I did not do a thorough search, but I don't think there are any medications recommended for elevated cholesterol during pregnancy. That means my only option for managing elevated cholesterol is diet and exercise. Even still, though, some people believe that cholesterol-restricted diets may be harmful during pregnancy, since the baby needs cholesterol for brain growth (e.g., Dr. Sears).

This study determined that cholesterol increased in the second and third trimesters of most average pregnancies, and that it increased more in subsequent pregnancies. So it even makes sense for me to have high cholesterol levels during my second pregnancy. Interestingly, LDL and triglyceride levels (i.e., "the bad stuff") seem to rise more than HDL. The same study indicates that women experience lower HDL (i.e. "the good stuff") in their subsequent pregnancies. That seems unfortunate, and the authors of the study suggest that it may adversely affect long-term heart health (not a proven hypothesis). But my thought is that if it's a temporary change, it probably won't hurt me in the long run (but that just helps me sleep at night, so I wouldn't blame you if you're disinclined to believe me).

Another study indicates that diabetics aren't any more likely to have an excessive increase in blood cholesterol levels. The only caveat to this is that they may be more likely to start out with high levels from the beginning. The only thing this tells me is that if I didn't have a problem with high cholesterol before getting pregnant, I wouldn't need to screen for it in this or future pregnancies.

The apparent reason for a rise in cholesterol in pregnant women is that cholesterol is necessary for the manufacture of hormones, and plays some part in the development of the baby's brain.

I think my elevated cholesterol level is probably due to pregnancy, rather than because I have an ongoing problem, but I may get them re-checked after the baby is born anyway just to be sure. I read in a couple of places that breastfeeding may help get them back down, and we're big fans of that here.

Wednesday, September 1, 2010

Super Cool All Natural Birth Stuff

I wish I'd thought ahead to research more "natural" ideas about babies and birth than simply the labor itself when I was pregnant; but alas, I couldn't see past the Main Event ;) Thankfully, there are ladies who do, and I wanted to share this cool postpartum post on another blog I ran across today. I haven't read much of this blog at all, but this posting on how to make a homemade postpartum kit was very relevant to going natural with birth.

I was thinking about home births just a couple of days ago and wondering what you did if you birthed at home and didn't have a nurse tech to bring you one of those ice-packs and a "squirt bottle" like they do in the hospital (ps... if you haven't had a vaginal birth yet, this may make NO sense to you, but ask a friend who has, she will explain the ice pack and squirt bottle). :)

Anyhow, after reading Lindsay's post, I know what you do when you have a home birth to care for yourself! And if I give birth again, I think I might just prepare these remedies ahead of time for home or the hospital!

Thursday, August 26, 2010

Growth Ultrasounds

I had a growth ultrasound last week, at 32 weeks, and it went well, despite my fears. In this post, I describe what makes me so nervous about growth ultrasounds, and how they are sometimes interpreted by doctors.

As many of you probably know, diabetic babies undergo growth ultrasounds because of the concern that mom's high blood sugars may send too much juice to the baby, who then gets too big to be delivered vaginally. Either the baby doesn't fit through mom's pelvis at all in vaginal delivery (cephalo-pelvic disproportion, although an artificial variant of it) or the shoulders get stuck after vaginal delivery of the head (shoulder dystocia). If the doctor believes, based on growth ultrasounds, that the baby is or may grow too large to deliver vaginally, the doctor may induce early (38 or 39 weeks) or schedule a c-section.

When I was pregnant with my first son, I had a growth ultrasound at 28 weeks. This is right at the beginning of the third trimester, and when the first growth ultrasound is usually done. They are often done at three week intervals after that until the baby is born. Now, with my first son, I was tentatively prepared for a baby that looked "too big," and planned to ask my doctor to let me try a vaginal delivery even if the baby looked large on the ultrasound. I might have even considered induction at 40 weeks.

Much to my surprise, my son turned up in the third percentile. I was prepared for a baby that was too big, but not one that was too small. I was hospitalized overnight for possible intrauterine growth restriction, which the radiologist that read the ultrasound chalked up to a complication of my diabetes. Fortunately, my obstetrician, with good prudence, sought a second opinion for me. The ultrasound the next day at a different clinic showed a baby in the 35th percentile. I was still on bed rest for a couple of weeks, until they could get a good showing after some time had elapsed, but he continued to be within a normal range for the rest of the pregnancy.

As it turns out, the first ultrasound technician's measurements were just off. So thousands of dollars (including the cost to me, who had to pay my deductible and co-insurance, my insurance company, who was stuck with the rest of the bill, the hospital, whose charges are often written off by the insurance company, and my employer, who lost two weeks' worth of work from me but still paid me for my sick leave) and days of frustration and anxiety later, we were back to a healthy, basically low-risk pregnancy. Now do you understand a little more about why I am afraid of growth ultrasounds?

So what have I learned about growth ultrasounds and why am I anxious about the way doctors use and interpret them? Please keep in mind that all of my observations below are based on the premise that inductions and c-sections should be avoided with more rigor than they are avoided at the present time by many doctors, and that a baby "too large" to deliver vaginally can be avoided with good blood sugar management.

Doctors that are nervous about your diabetes may attribute ANY possible problem to your "condition." The radiologist that read the ultrasound for my first son at 28 weeks assumed that the reason my baby showed up in the third percentile was a result of my diabetes, or the fact that I was jogging at the time (which she said can sometimes result in really small babies). The real problem? An ultrasound technician that didn't take the measurements correctly. My diabetes and my exercise habits were blamed for a measurement error, and resulted in a costly hospital stay and a huge shot to my confidence.

Weight measurements on ultrasound are sketchy at best. I know of a woman who was told that her baby would be too big to deliver vaginally (estimated at 9 pounds). She was scheduled for a c-section and, lo and behold, the baby was only a little over 7 pounds. Most ultrasound technicians and radiologists will tell you that measurements can be up to a pound off anyway, on a good day. So how does that help me? If my ultrasound shows an 8 pound baby, I may be looking at delivering a 7-pounder or a 9-pounder anyway, just within the NORMAL range of ultrasound variability.

How often are babies really "too big" to be delivered vaginally? I'm not sure who knows the answer to this question, but I am skeptical that it occurs very frequently. Even skinny women deliver 9 pound babies all the time. A doctor's intuition may be well-developed in this regard, but it may also be developed by a sense of fear and lack of confidence in your ability to deliver your baby.

How often does a diabetic woman have a genetically large baby that would have been large no matter how well her blood sugars were controlled? Again, I'm not sure who knows the answer to this question, but I also suspect may happen sometimes too. Someone's baby is setting the 95th percentile mark, even apart from diabetes, and it could be you (or me, as the case may be right now)!

Now, I hope I haven't caused anyone to get uppity with their doctor about going for growth ultrasounds. But if your growth ultrasound shows "problems," I would ask yourself and the doctor a few questions about it:

Can I get a second opinion? See if you can find another clinic that's willing to do another ultrasound for you. This will help if it's a measurement error or if it your practitioner has offered an overly-cautious interpretation of the one you already have. Especially if it can help you avoid unnecessary hospitalization or a c-section, your insurance company shouldn't be too hard to get on board.

Which fetal measurements are driving up the weight estimate?
Typically, if the baby is growing too large because of uncontrolled blood sugars, radiologists expect to see large trunk measurements. If it is the baby's head that is large, or limbs that are long, it may be more related to genetic factors, especially if your A1Cs are well-controlled (less than 6.5).

Are there any other indications that your baby is large? Other indications, albeit much less precise than ultrasound, include fundal measurements (centimeters should be about equal to weeks of pregnancy, or at least growing steadily, not jumping ahead) and your weight gain. Weight gain, however, is extremely variable from woman to woman, so it wouldn't be good to assume your baby is too big just because you've gained 40 pounds and you are only at 35 weeks. On the other hand, if you have only gained 20 pounds at 35 weeks, you were of a normal weight to begin with, and your fundal measurements have grown steadily, you have one more reason to suspect that the growth ultrasound measurement may not be giving you the best indicator of your baby's true size and your ability to deliver it.

Have you had multiple growth ultrasounds, and have all of them indicated a baby that is "large for gestational age"? Since a pre-existing diabetic's blood sugars will probably be controlled for in approximately the same way throughout pregnancy, given her ability to control them and her prenatal care, it seems possible that if the baby's measurements suddenly jump ahead at 37 weeks, the problem could be one of measurement error, rather than glucose control.

How large are you and the baby's father? I think it is reasonable to expect that the progeny of tall, large-boned, or large-headed (and I'm not talking arrogant) men and women will be tall, large-boned, or have large heads. This may drive up weight measurements.

Are there any other risk factors indicative of induction or c-section? I suspect that doctors may use a baby that's "too big" as icing on the cake to convince a mom that induction or c-section is necessary, when the root of their concern lies elsewhere - mom's high blood pressure, other concerns for baby's development, and so on. These root factors may give good reason for an induction or c-section, but should be identified apart from a baby that's "too big" for you to deliver. It will only undermine your confidence to be told "I don't think you can deliver this baby" when the real concern is for yours or your baby's health.

Is there any reason I shouldn't be offered the opportunity to deliver vaginally, even if it is suspected that the baby truly is larger than he/she should be? Ask your doctor for a "trial of labor," how long he or she is willing to let you remain in your labor trial, what evidence during labor would indicate that the baby really is too big to fit, and if the doctor has any other concerns in handling delivery of a large baby. First-time labors can last a while (a couple of days), so be sure to account for this when you make your plans.

Are you afraid of labor and/or being a mom? If you are told that you have a large baby, does that make you even more afraid of labor? I think I speak universally for parents when I say that pregnancy, labor, delivery, postpartum recovery, and other parts of parenthood will hurt, emotionally and physically. I wouldn't let a baby that's "too big" scare you into a bad decision (unless, as I mentioned, there are other real health factors at play). Better to understand your fear and approach the pain in the most direct, healthy way possible than run away or try to avoid it. My belief is that facing pain bravely and patiently can, in fact, help you establish good parenting habits.

The report from my growth ultrasound was a good one. My son's weight is 60th percentile, with long monkey limbs driving up the weight measurement and a skinny little trunk (just like his daddy).




Cholesterol During Pregnancy

I was recently informed by a blood test that my LDL cholesterol is slightly elevated. I haven't ever made a special effort to avoid high-cholesterol foods, such as egg yolks, beef, pork, and cheese, but I also haven't ever had an elevated cholesterol value. Because I know that high cholesterol is often a concern for type I and type II diabetics, I was worried that this may be the beginning of the long, uphill, often medicated (but not during childbearing years) battle against high cholesterol.

Fortunately, I was told by a maternal-fetal specialist today that high cholesterol is totally normal during pregnancy. The associations floating around in my brain lead me to assume this may be related to myelination of the baby's neurons. Anyone better-versed in the physiology of blood cholesterol levels know how and why this happens during pregnancy? Also, I was surprised that my endocrinologist was not aware of the phenomenon.

Friday, August 6, 2010

Responsible Choices

So, I've had a lot of doctor's appointments lately (not surprisingly, since I'm a pregnant diabetic in my third trimester) and have been reflecting a lot on my care from these doctors. It's been different, but equally satisfying, as the care I received in St. Louis.

I saw my obstetrician the other day, and he gave me a short talk on taking responsibility for mine and my baby's health. As far as I know, it wasn't prompted by any particular behavior of mine; it was simply his way of reminding me that I need to exhibit as much control and self-discipline over the things that are within my realm of influence. These include my blood sugars, exercise, and food intake. Self-discipline in these areas paves the way to healthy outcomes - not just during pregnancy, but in life generally. As we all know, some of us will still experience bad outcomes, but appropriate exertion of self-control reduces the likelihood of bad outcomes. As a bonus, it builds character that all parents need.

So what does it look like to take responsibility for these things? It will look different depending on your situation, for sure. For me, I'm trying out the following this time around, based on what I did last time and liked and what I wished I had done differently.

Eating smaller meals more frequently. Planning to eat a small amount every 2-3 hours, healthy things. Fruit if my blood sugar is low, protein nearly every time.
Eating dinner early, no dessert, and no post-dinner snacking. A large, late meal and eating into the evening makes getting my blood sugars under control before bed almost impossible (and with bedtime being as early as 9:00 some nights, it's important to get a head start!). Special indulgences are not out of the question, but better if they occur early in the day and infrequently.
Low carb meals. I'll still eat brown rice, potatoes, granola, whole grain toast, fruit, and a variety of carbohydrates, but just try to do so in smaller quantities. I plan on treating myself to my favorite salads, vegetable dishes, and plenty of meat.
Walking. Fortunately for me, I have a 14-month old that loves to be taken around the block in a Radio Flyer wagon. This gives me a good excuse to get moving, daily. When I was pregnant with my first baby, I was working and tried to get up early or walk during my lunch break.
Swimming. My son, grandpa, and I all love going to the pool. So we spend some time there a few times a week. I did not have the benefit of a pool membership the first time around, but am really enjoying it this time.

The last of my "responsible choices" hits home more closely, and challenges me the most of all. It also brings me to my reflections on the second of my doctor's visits this week, a visit to my endocrinologist, and a discussion about blood sugar management. I have always been extremely proactive and hands-on in the management of my blood sugars - and frequently, to my benefit. I am not afraid to adjust my own pump settings as necessary. In fact, during my last pregnancy, I usually simply reported my plans to my OB and my endocrinologist and they said, "sounds good." This suited my independent, "don't tell me what to do" attitude quite well. Now I am with a new endocrinologist who does things a little differently. I am struggling to come to grips with a provider that wants to be more hands-on with my blood sugar management, but in case you have the same fears that I do, let me tell you why I think it's good for me (and may be for you, too).

No matter how good you are at controlling your blood sugars, you could probably do it better. I do not intend this as an insult, though that is usually the way I hear it coming from anyone else. Instead, though, I have to remind myself that the point is improvement to my health, NOT "proving" myself as competent. When I saw that my doctor intended to be very hands-on with my blood sugars, I had to move my ego over and acknowledge that there probably is room for improvement.
A different perspective might help you hone your skills, or highlight problems that you didn't really think were problems. Again, instead of thinking of my doctor's suggestions as just plain criticism (which it almost never is), I have to look at it as striving towards improvement.
Just try it. If you are concerned about a recommendation, just try it for a few days. You may be surprised. Or you may not, and then you can decide how to proceed - talking to your doctor, maybe changing them back, and if your doctor thinks you're full of it but that doesn't make you feel better, finding another doctor.

Thursday, July 29, 2010

New CGM goes into human trials

CGMs, continuous glucose monitors, are a relatively new technology... I tried MiniMed's version that connected with my pump and it didn't really do it for me. I LOVED the information that it gave me, but the calibrations and the fact that if I didn't calibrate at the exact right time was more work than that information was worth for me. (granted if I were to get pregnant I would slap that thing on in a heart beat.) But for right now, no thanks.

I am, however, very excited about this report from San Diego, CA...a new CGM system that is implantable is in the works and looking promising. Love the exciting news. jenn

Wednesday, July 28, 2010

Cool Meal Idea for Mommies

On a fellow diabetes blog, I ran across this web page last week. I've joined to try it out because the dietitian in me couldn't resist and, I'm not going to lie... I LOVE it. MealMommy.com provides 5 healthy menus with recipes and a grocery shopping list for each week. The creator of the site is mother to a type 1 child and shares experiences of other mommies on the site each week. So, if you're a mommy, or mommy-to-be, you will one day face the question, WHAT AM I GOING TO COOK TONIGHT!!?? And for me, for the next few weeks, the decision is, thankfully, made by The Meal Mommy.

From a health stand point, she does a great job with balance and gives nutrition info (carb counts!!) for all of the meals. Hope you enjoy :) jenn

Monday, July 19, 2010

Finding a Doctor

As I mentioned in my last post, these are some thoughts I had based on my experience at a Level II ultrasound, the one they normally do between 18-20 weeks to check for fetal abnormalities such as heart and spine defects. Another thing the consulting doctor said after the ultrasound brought home the necessity of finding a supportive care provider to help you do things differently.

"Good luck getting your doctor to agree to let you go to 41 weeks."

The induction question was one of the first that I asked my new doctor and he's OK letting me go to 41 weeks.

I'm about to sound like every natural childbirth book that has ever been written, but this comment, and indeed, my whole experience at the high-risk clinic, demonstrates how important it is to find a supportive care provider! A provider that is willing to make different assumptions and use different methods, with fewer interventions, to help you. A provider that will treat you like an individual, not just a statistically-average diabetic. Even though diabetics, on average, may have elevated incidence of certain risks, you may not be average! It's OK to ask to be treated as an individual, which may allow you to avoid standard interventions such as early induction of labor and so on. Some tips on finding a doctor from someone who's had to do it in two different locales:

Ask around. You may see if you can find a homebirth midwife amenable to your situation. However, if you want to deliver in a hospital or can't find a homebirth midwife that feels comfortable assisting you at home, which is probably the case for many of us, ask homebirth midwives and doulas who they like to work with. Doctors that midwives and doulas like are generally open to low-intervention birth, and are willing to individualize care beyond standard protocol for diabetics. Maternal-fetal specialist groups often induce pre-existing diabetics at 39 weeks regardless of other circumstances (see Doing Things Differently), so I would avoid them unless complications require you to come under their care. Unfortunately, you probably won't be able to find a nurse midwife or a nurse midwife/OB practice to help you, either in a hospital or birthing center - they usually refer diabetics to maternal-fetal specialists.

Show them your numbers. A healthy pre-pregnancy weight, minimal diabetes-related health complications for you (retinopathy and kidney damage), well-managed blood sugars, low A1Cs, and any children with average birth weights that you have delivered before will help you make your case, particularly to an OB that doesn't normally work with pre-existing diabetics.

Be flexible. Whether you are working with a homebirth midwife or low-intervention OB, be willing to consult with maternal-fetal specialists if complications arise, or for routine ultrasound screening. It is important to be willing to compromise since your care provider may be taking professional risks or receiving criticism from their colleagues to help you with a low-intervention birth. In the end, the specialists will only be doing consultations and making recommendations, and you probably won't have to make any decisions until after you've had an opportunity to talk it over with your midwife or OB.

And just a note, you should be able to ask a doctor that you call for an initial consultation or interview. In my experience, if they are not in the habit of providing this service or resistant to doing so, this can indicate a practice or a doctor that is unwilling to discuss alternatives to standard interventions.

Have you had a great experience with a doctor? I'd love to hear about it. Let's make it civil, though, and keep our criticisms specific to behaviors and actions, rather than people.

Thursday, July 15, 2010

Doing Things Differently

I am currently pregnant with my second child. He is due in mid-October, and I am currently 26 weeks. I recently went for my "Level II" ultrasound, the one normally done at 18-20 weeks to check for fetal abnormalities (heart and spine defects, for example). The maternal-fetal specialist's comments to me during our consultation at the end of this screening reminded me of how and why my husband, my doctor and I did things differently the first time, and also reminded me of why it's so important to find a truly supportive doctor. I'll do two separate posts on these issues, using statements the consulting doctor made to spur my reflections (here's the post on Finding a Doctor).

"Maybe we do things differently here on the east coast, but we've never let a pre-existing diabetic mother go to 41 weeks. We usually induce at 39."

The maternal-fetal specalist was extremely surprised that I went to 41 weeks with my first baby. I was surprised that he had never seen a pre-existing diabetic proceed to 41 weeks. I'm glad I had the opportunity to show him that it could be different. The vibe I get is that it is standard operating procedure for maternal-fetal specialists to induce Type I diabetics at 39 weeks because of the increased risk of pregnancy-induced hypertension, a baby that is "large for gestational age" and therefore "too big" to fit through the mother's pelvis, and fetal demise or stillbirth in Type I diabetics.

During my first pregnancy, which, as I mentioned, went a week past my due date, I was concerned about the aforementioned risks. A few things helped me to decide that, in my situation, it was reasonable for me to assume that my pregnancy was proceeding within the bounds of normal and didn't require induction:
Is my baby too big? Growth ultrasounds showed that my son was hanging out somewhere between the 30th and 50th percentile. Because of the possibility of inaccuracy in growth ultrasound measurements, I think that even if he had been measuring larger than the 50th percentile, I would have asked my doctor to allow me to at least try to push my baby out when my baby was ready before resorting to early induction or a scheduled c-section. I place a high premium on avoiding these interventions.
Pregnancy-induced hypertension: My understanding is that most mothers' blood pressure naturally increases slightly over the course of a pregnancy, and it is more or less normal. Obviously, a simple blood pressure measurement will tell you whether your blood pressure is in a healthy range, and you don't need a scheduled induction to avoid it. At my last visit before my son was born, on Thursday, my blood pressure was, indeed, elevated (keep in mind that I was already 4 days past my due date at this point, which was making my doctor, my husband, and myself itchy to get it over with). My doctor, instead of immediately signing me up for induction, asked me to come in the next day. It was still high. Again, instead of immediately signing me up for induction, he told me to quit work because it was probably stressing me out just to get out of bed in the morning, get dressed, and get myself in the office. Guess what? Two hours after leaving the office, my blood pressure had dropped to an acceptable level. A little more than 24 hours later, I went into labor without induction.
Is my baby going to die before he's born? This was the most terrifying possibility of all three of the increased risk factors I mentioned above. The danger also increases for low-risk pregnancies that progress past their assigned due-dates, which is why induction may be recommended for any woman who has reached her due date. To monitor for this risk, I did kick counts every day after I started feeling him move. In my third trimester, I went into the office for fetal heart rate monitoring frequently to be comfortable that the baby was thriving. Even non-diabetics who reach their due date may be asked to undergo fetal heart rate monitoring.
What about me? Is this pregnancy making my health worse? I am one of the most fortunate diabetics that I know because I have lived with Type I diabetes for 17 years and the only apparent evidence is scars in my fingers from checking my blood sugar level and in my waist area from my pump sites. My eyes are fine, and my kidneys appear to be functioning normally. At such a point when my body does start to show signs of decay, which I expect will eventually come, I will have to decide how comfortable I am with my body getting a little "beat up" in the course of having more babies. That is a deliberation, however, that I hope is many years and many babies away. I once asked an endocrinologist whether there were additional risks of multiple pregnancies on the health of diabetic patients, and whether I should consider limiting the number of children I have based on said risks. He could not think of any reason to limit the number of children I have, or any risks of multiple pregnancies to my long-term health.

Any risk factors I've missed? Would love to hear about your experiences, why you were induced or how you and your doctor chose to do things differently than what is normal for pregnant diabetics. Maybe I can talk another time about why I would like to avoid induction, but many of you will probably already be familiar with the reasons that advocates for natural childbirth like to avoid it.

Birth Story #1: The Pious One

Hi, I'm the other contributor to this site. I hope to tell you a little bit more about my experience with pregnancy and Type I diabetes, particularly as I go through my second pregnancy. For my first post I'll share with you the birth story for my son. I wrote this shortly after it happened:


My first son was born Sunday, May 31, 2009 at 10:46 in the evening, at 8 pounds, 2 ounces, one week past his due date. What follows is some of what I remember.

On Saturday afternoon, I began having contractions similar to contractions that I had periodically for exactly four weeks leading up to this day. After dinner, I confessed to my pregnant friend, who had delivered her first baby unmedicated, not induced and vaginally (all goals to which I aspired), that the contractions were different than they had been before. I wondered aloud, to her and to myself, if I might have my baby this time.

I never fell asleep, and around the wee hours of the early morning, I was quite uncomfortable and worried that the car ride to the hospital might be unbearable if my husband and I waited any longer to leave. But when we arrived at the hospital, I was only 4.5 centimeters. This was not so much progress as it seems, since I was at 4 centimeters prior to the onset of labor. Contractions were anywhere from 4-7 minutes apart. I'm pretty sure the nurse thought I was a pansy. But I'm telling you, they hurt.

We passed the morning laboring quietly. My husband and I had taken a Bradley Method course in natural childbirth, and he assisted me through the contractions. He also checked my blood sugars every hour and helped dial in boluses and give me juice from a straw. We did a lot of things, but mostly what I remember helping was holding myself up with my arms at the peak of the contractions and counting the number of breaths it took to get through them. In the early afternoon, the nurse checked my dilation and I was only at 7 centimeters. That was a blow. The silence in the room began to feel oppressive. Though no one said it, I knew they were all looking at the monitor and thinking that the contractions needed to be closer together and more intense before the baby would come. But I didn't want them to be any more intense. I wasn't sure I would be able to handle this much pain for much longer. They hurt really bad.

I told my husband several times during the afternoon hours that I couldn't do it. He said, "yes, you can." I repeated my statement, thinking maybe he didn't really understand what I had said, or that maybe he didn't really understand how much they hurt. I purposefully kept myself from changing the chorus line because I thought he might give in and let me have the epidural. I thought at one point that I would even be OK with a c-section. I didn't really want that, but I was starting to feel desperate. In fact, it felt a lot like the last four weeks had - waiting, getting our hopes up, wondering how much longer it would be. Except now there was pain and exhaustion times ten.

Around 4:00 in the afternoon, I brought out the big guns. "I
don't want to do this anymore." Without missing a beat, he responded, "that's not true." I bristled a little at that, but only because he was more right than I wanted to admit. How did he know?

My contractions were still 4-7 minutes apart, as they had been since the wee hours of the morning, but at some point, they became longer and the peaks became more intense. I know because I had to count more breaths before they were over, and I was holding myself up with my arms for more breaths. I didn't need the monitor to tell me that.

At 5:45 in the evening, they broke my water, and I cried happy tears, feeling so relieved that I would have my baby soon. About an hour later, I was fully dilated.

I tried squatting, lying on my side, standing on the bed, hands and knees. You know, all the things they tell you to do when you're pushing. At some point, however, I guess I lost the urge. I was exhausted. So after 2+ hours, we still did not have a baby to hold. Discouragement crept in again, only this time it felt more like panic. More tears, this time sad ones. My doctor suggested pitocin to get the contractions closer together, since they were still 4-7 minutes apart. He assured me that the contractions couldn't possibly hurt any more than they already did, so the pitocin wouldn't make a difference. After some deliberation, we agreed. I took naps in between contractions while we waited for the pitocin to begin working.

I don't know whether it was the pitocin or something else, but at some point everything changed. Whatever calm demeanor I had had during the previous day of labor disappeared. I was hot, weak, exhausted, and noisy. I couldn't think of anything else but getting the baby out. Darkness crept in after the sun set. They turned on some really hot lights that made me feel like I was on a stage during the climax of a play. Before, it had been quiet with only brief, gentle interruptions by our nurse. Now, there were people in and out of the room, setting up equipment, looking at me, talking. Everything was messy but I didn't care anymore. I felt guilty for making everyone wait so long. Then I felt the ring of fire.

At the very last, my son's head literally seemed to pop out and it felt weird. I was so weak that I could barely reach down and touch my slippery baby. After 22 hours or so, our harrowing journey was blissfully behind us.


For the first week, I spent some mental energy trying to figure out how I was going to tell my husband that I thought we might be a one-child family. But a short six weeks later, I was already looking forward to the next one...