What do you mean draw the line, Jenn? Well, as a woman with diabetes there are many tests your doctors will want to do to either ensure your baby's health, gather information they feel is useful for your pregnancy and delivery, or cover themselves when it comes to medical liability. Unfortunately, it's hard to decide what tests are good for you an your baby, what tests are beneficial, what tests are medically necessary, and what tests may be over your line.
As a diabetic woman, I was offered genetic testing (Alpha-fetoprotein screening (AFP), or the Multiple marker screening or "Triple screen") early in my second trimester as nearly all pregnant women are these days. Because of our beliefs, my husband and I declined these tests, knowing that no matter what the tests told, our plan for the baby would be the same. We were pregnant and seeing the pregnancy through to the end. Therefore, this round was easy, no thanks, we would pass.
Next came the "big" 20 week ultrasound and fetal echo cardiogram. We agreed that these tests would be helpful for our doctors in caring for both our baby and myself and consented to them. Are you thinking, who would pass up an ultrasound, lady? Well, during my first pregnancy we didn't do our homework and had to make tough decisions on the spot about procedures we later wished we did not undergo. I am no doctor, remember. But I'm hoping to give you an idea of what I experienced with my two pregnancies and the decision-making process I underwent through those pregnancies.
So, the "big ultrasound" is pretty common again for normal and high-risk pregnancies, however the fetal echo cardiogram is not. Not all specialists will order this test, however, if you have insurance that would cover it due to your diabetes, it is nice information to have. This study outlines all of the scarier things that could happen when blood sugars are not well controlled during the first trimester of a diabetic pregnancy. Knowing the problems our babies could encounter, we were comforted by this ultrasound during both of our pregnancies. During this 20-weekish ultrasound, all of our baby's organs were visualized and checked, the spine, the brain, and the baby's growth baseline was established.
Ultrasound growth measurements were recommended by my doctors every four weeks there after. Again, we consented to this test, but with the opposite motivations of my doctors I'd imagine. I wanted "proof" that my baby was not too large for a vaginal delivery, while they wanted records to back up their recommendations of c-sections due to the baby "measuring large". My son measured in the 80 - 90th percentile during the last 8 weeks of pregnancy or so. While my daughter measured in the 50th percentile until 34 weeks at which point she shot up to the 75th percentile. My son was in the 90th percentile at birth and my daughter in the upper 80th percentile at birth.
Ah, the NST or "non-stress test". It is described on the web page linked as "a simple, non-invasive test performed in pregnancies over 28 weeks gestation. The test is named “non-stress” because no stress is placed on the fetus during the test." They also mention that
"The test involves attaching one belt to the mother’s abdomen to measure fetal heart rate and another belt to measure contractions. Movement, heart rate and “reactivity” of heart rate to movement is measured for 20-30 minutes. If the baby does not move, it does not necessarily indicate that there is a problem; the baby could just be asleep. A nurse may use a small “buzzer” to wake the baby for the remainder of the test."
Ok, so here's the deal with the NST for our family...we didn't like it. Our specialists seemed to live or die by it, while our natural-friendly OB liked to see that the baby's heart was beating. We were with him. My doctors started this test around 30 weeks, once weekly and went to twice a week at 32 weeks. During my first pregnancy I didn't understand the test until I fell apart in hysterics on a doctor over it and they finally fully explained it to me. They used this test for me to a) make sure the baby's heart was beating and b) make sure it looked like my placenta and the umbilical cord were continuing to function well. The doctor explained to me that later that during any pregnancy, and they "think" earlier in high-risk pregnancies, the placenta begins to break down and not function to give the baby the oxygen and nourishment he may need. They used this test to judge the baby's "reactivity"...ie: did the baby's heart respond as the text book said it should to the baby moving in my belly?
My son "failed" this test every stinking time from 34 weeks on. Dude! I was pregnant for the first time and some nurse was telling me my baby was failing a test about his heart and it could mean they needed to "get the baby out". Hello? Do we see why I got all mama bear on the doctor? Now, to "help" your baby "pass" this test, nurses have several tactics. They may "buzz" your baby, shake your belly, have you change positions, or give you caffeine or food. Do you see the problem? If you cheat the test, doesn't it invalidate the results? ("A total of nine trials with a total of 4838 participants were included. Fetal vibroacoustic stimulation reduced the incidence of non-reactive antenatal cardiotocography test" So, if you buzz the baby they will pass.)
The buzzer. Ok, so really it's called a vibro-acoustic stimulator. But, anyhow, it's this THING they put right up next to your baby's head on your belly and then it sends a sound wave (although I've googled extensively I can't give you a better definition of what the stimulator is actually DOING) through the amniotic fluid that causes a reaction in baby, mine jumped when they did this.
I can't give you the best understanding of the buzzer, but I can tell you how I felt after my baby was "buzzed"...guilty. I felt horrible. I felt all wrong, and I was angry. Jack was buzzed at three appointments to help him have a "reactive NST". Thereafter I refused this procedure and my husband stood by me. He saw the guilt and agony this procedure caused me and agreed that this was not healthy for me and we were not sure that it was healthy for our child no matter how many doctors tried to convince us of it's safety, and therefore, we would not consent to this again. Audrey was never "buzzed".
I should have devoted a posting to this test because I could go on and on about it. I'll end with this: all mamas and all babies are different. I was 23 when I was pregnant with my son, I was a runner and ran until I was 7 months pregnant. No doctor would expect my heart to accelerate the way an obese woman's would if we stood up and walked ten feet to the door...why should they expect my baby's heart (that of a very healthy and young mama) to respond as urgently as that of a baby in an obese-type two mama? I wrote the test off during my second pregnancy, I allowed them to monitor the baby for 30 minutes and no more - pass or "fail". I did not allow any Bio-physical profiles of my second child if she did not satisfy the doctor with her NST as well.
And that brings us to the Biophysical Profile. This test was administered to me twice after my son had a "non-reactive" non-stress test. (a bit more on that...my son's heart rate always responded by elevating when he moved, but not for the length of time or the number of beats the text book required to consider it a pass). Ok, so take one of the biophysical profile: I will have an ultrasound that measures amniotic fluid levels (part of the NST anyhow) and then the ultrasound will continue for up to 30 minutes until my baby 1. shows breathing movements for greater than 20 seconds, has two distinct episodes of gross body movement, AND flexes a limb or hand. And I am crying 10 minutes into the thing that I want it to stop, that my baby is fine, and to leave us alone!
Baby was a trooper and passed within about 12 minutes of his first biophysical profile. However, the second time we were told the doctors needed to do this test to ensure our baby's safety he took about 28 minutes to pass and I was a guilty, agonized, wreck at the end of it. My unborn child had just been under continuous ultrasound for 30 minutes straight! I don't care how safe everyone says ultrasound is, I don't want my baby subjected to it for 30 minutes straight. And so, that was the end of biophysical profiles for our family. Now, I do believe these tests have saved the lives of children. I am NOT contesting the validity of these tests, well not totally...
However, this posting is about where we choose to draw our line. We based our decision being the most informed we felt we could be. We spoke at length with the doctors about these tests, their risks, benefits, validity, and how they varied from individual to individual. We based our decision on my diabetes control, my blood sugars were near that of any average pregnant woman with an A1C of less than 6.1. We made decisions that we could live with.
I've got to draw the line on myself at this point because this posting is so long, and there is more to say on this subject when it comes to baby's birthday, but there's some insight into remembering that you are driving this pregnancy. I felt much better during my second pregnancy when I was informed and choosing which procedures I would consent to rather than having my doctor order the standard fare. Here's to drawing the line ;)