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.

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