Type 1 Diabetes And Pregnancy Delivery | Sarah's Story Part 3

This week we are back with Sarah, our Type 1 diabetic. This is part three of her story. You can find part one right here and part two here.

Today, we're going to talk about how we plan for her delivery.

Scenario one: Sarah’s blood sugars are not under control

In the third trimester, we are seeing Sarah twice-weekly for fetal nonstress tests, and we are watching her blood sugars to make sure they're staying in the normal range.

Here's where the path can diverge a little bit. Insulin requirements go up in pregnancy. Sarah is trying to do the right things, but her glucoses are really bouncing around. Glucose control is a factor in determining when we deliver a baby. If glucoses get more difficult to control as you get closer to your due date, then we may decide to deliver the baby a little earlier. There is a higher risk of stillbirth with uncontrolled diabetes. Sometimes it's better to have an early baby that is admitted to the NICU than to consider the alternative - not having a live-born baby.

In Sarah's case, her glucoses are getting more difficult to control. One thing we can do is put her in the hospital for the last few days leading up to delivery. Those last few days of glucoses are important in determining what the baby's initial glucoses are going to be after delivery. If mom's glucoses have been high, then the baby's getting more glucose and is starting to make a lot of insulin to try to get those glucoses down. Think about what happens when Sarah delivers the baby and the cord is clamped and divided - the baby is still making releasing lots of insulin, but is not getting all that glucose anymore from Sarah. The baby's glucoses may go way down. This is one reason why babies of diabetic mothers are admitted to the intensive care nursery. They may need early frequent feeds until blood glucoses are better regulated.

Scenario two: Sarah’s glucoses are great

Let's look at another scenario. Let's say that Sarah's glucoses are outstanding. She's doing a great job of keeping them under good control. We're seeing her twice a week, looking at fetal growth monthly, and we're getting within a month of her due date.

We have talked about a plan, but now it's getting real. In her third trimester, her A1C has come down to six. Her baby is moving and fetal testing looks great. With well-controlled diabetes, we usually recommend delivery by your due date. It doesn't necessarily have to happen early. If you go into labor on your own in the weeks right before your due date, fantastic!

Remember with diabetes, sometimes even if your glucoses are well controlled, babies can be bigger, and bigger babies have a higher risk of birth injuries. The head is the biggest part of the baby. It's supposed to come out first so that the shoulders and the rest of the body can slide right out. 

With diabetes in pregnancy, babies can grow bigger through the shoulders and abdomen, so when the head comes out, the shoulders and abdomen don't want to follow. That's a really scary condition called shoulder dystocia. Sometimes we have to work to get babies out, or we have to do an emergency cesarean delivery. Babies can have shoulder injuries or nerve injuries. Moms can have pelvic floor injuries from us pulling and repositioning you trying to get the baby out.

We prefer that emergencies not happen. In order to prevent this, we watch the baby's estimated weight. Sarah is 38 weeks, or two weeks from her due date. The estimated fetal weight is seven pounds and ten ounces, which is a pretty average weight for a baby at that point.

In Sarah’s case, we're just going to keep following her twice a week, keep testing, and then talk about inducing labor if she doesn't go into labor by her due date.

Getting to your due date with gestational diabetes

When you get to your due date, even if your glucoses are really well-controlled your placenta is more likely to start to deteriorate a little bit and the risk of stillbirth becomes higher.

If your glucoses are pretty well controlled and you haven't had the baby, the baby is going to keep on growing. And then you run the risk of having a baby that you won't be able to deliver vaginally.

For Sarah, we have made the decision that we're going to induce labor the day before her due date if she hasn't started labor on her own. When Sarah comes in to have labor induced, her cervix is dilated one centimeter. We give her medicine that helps her cervix get soft and mushy, so when we start medicine to induce contractions, labor can progress more smoothly. When you have diabetes in pregnancy and you're on insulin, we usually stop your scheduled insulin in labor. We put you on IV insulin and titrate that up or down depending on what your glucoses are. We try to keep your glucoses between about 70 and 110 during the labor process. If your glucoses drop below 70, then we might add a little sugar to your IV. If they go above 110, we will start an insulin drip at a low level to keep your blood sugars exactly where we want them. We usually do finger sticks every hour or two in labor for well-controlled diabetics.

Blood sugar after delivery

After you have your baby, whether you deliver vaginally or by C-section, we have to recalculate your whole insulin regimen. Usually, we start by putting you on about half of the insulin that you were taking just before delivery. Then we spend a few days seeing where your glucoses land. We may put you on a sliding scale, which means we check your glucoses before or after you eat and give you insulin based on what your glucoses are.

After a day or two, we figure out what your total insulin requirement has been. Then we place you back on scheduled insulin. If you were a Type 2 diabetic, and you were on an oral medication prior to pregnancy, we may put you back on that and stop insulin altogether.

In conclusion

Sarah has done a great job all through her pregnancy of taking care of herself, because she knows how important it is, both for her and her baby. Who doesn't want to stay healthy enough to see their babies grow up?!

Thanks for watching Sarah’s story. We really did throw every complication at her during her pregnancy.

Remember last fall, when I had a diabetes course ready to launch, then I got COVID and all those plans got derailed for a while?

That course still exists and I'm launching it soon. Stay tuned!