Gestational Diabetes: A Particular Problem for Mamas on Bed Rest

January 29th, 2010

Gestational Diabetes (GD) can be particularly problematic for mamas on prescribed bed rest. Previously a common indication for bed rest, with all of the medical advances and therapies most pregnant women who develop GD are easily managed as out patients. Unfortunately, women who are prescribed bed rest for another medical condition are at increased risk for developing GD as a result of inactivity and weight gain. Women who develop GD are at increased risk of developing Type II diabetes later in life as well as Metabolic Syndrome.*

Gestational Diabetes is defined as impaired (improper) glucose metabolism during pregnancy. Some women become insulin resistant, meaning that the insulin their bodies produce does not properly carry glucose from the bloodstream into the body’s cells as it should. Sometimes GD develops  because a woman has gained too much weight, a common cause of insulin resistance. Other times the increased hormones of pregnancy interfere with glucose metabolism.  Finally, a woman with a genetic predisposition to diabetes may manifest her first symptoms during her pregnancy. This woman is at increased risk of developing Type II diabetes later in her life.

Testing for gestational diabetes is typically done between 20 and 28 weeks of pregnancy. The normal ranges of blood glucose are:

  • 70-95 mg/dL  Before breakfast (fasting)
  • 70-140 mg/dL  1 hour after eating a meal
  • 70-120 mg/dL  2 hours after eating a meal

Women who have blood sugars that fall above these ranges during testing will be diagnosed with GD. It is essential that women diagnosed with Gestational Diabetes are treated aggressively and that they achieve and maintain tight blood sugar control. Blood sugar control is essential to ensure the health of both mother and baby. When blood sugars are not controlled during pregnancy, Some unfortunate complications can result such as:

  • High blood pressure in the mother caused by preeclampsia
  • Excessive birth weight  (exceeding 9 pounds, 14 ounces)or Macrosomia
  • C-section delivery
  • Hypoglycemia (low blood sugar) in the baby at birth
  • Jaundice (yellow skin) in the baby at birth
  • Respiratory distress syndrome (breathing difficulties) in the baby at birth
  • Low blood calcium levels in the baby at birth
  • Red blood cell disorders in the baby at birth
  • In very rare cases, stillbirth of the baby at 28+ of pregnancy
  • In very rare cases, death of the baby in infancy
  • Increased risk for type 2 diabetes in both mother and baby later in life

Treatment of Gestational Diabetes is actually quite simple. From many women, adherence to a “diabetic diet”,  a regular exercise regimen and regular blood sugar testing are all that is needed. However, for many other women, blood sugar cannot be adequately regulated and controlled with diet and exercise alone, so they are prescribed oral medications or Insulin injections.

Unfortunately most pregnant women on prescribed bed aren’t able to exercise enough reduce insulin resistance with diet and exercise alone. However it is still very important, perhaps even more so, that they follow the dietary instructions from their OB or a nutritionist and that they stretch and do some muscle strengthening and toning while in bed. If women on bed rest are diagnosed with gestational diabetes, they should request a referral to a physical therapist or exercise specialist** so that they can learn safe exercises that they can do while on bed rest.

It may seem unfair to be diagnosed with gestational diabetes while on bed rest for another condition. Try not to become too discouraged. Gestational Diabetes is easily managed and with careful adherence to your obstetrician’s directions, you and your baby can be just fine.

**Bedrest Fitness is a set of simple yet effective modified prenatal exercises that a pregnant woman on prescribed bed rest can do from her bed with her obstetrician’s approval. Order Bedrest Fitness here.

Please share your comments or questions on this post below.

High Risk, On Bed Rest, You Still Have Delivery Options

January 26th, 2010

Having a high risk pregnancy and being on prescribed bed rest does not mean that a woman doesn’t have delivery options. I was just reading a comment on another website from a woman who had read my post “To C or not to C That was the Question.” She shared her story of how she had had a cesarean section with her first child and then her doctor had allowed her to have a VBAC with her second child.  Her second pregnancy had been miserable and she had considered requesting a cesarean for the birth. However,  she decided to follow her doctor’s recommendation; he believed that she could deliver naturally so she did. She does not appear to have had medical complications but it was a difficult delivery that she still vividly recalls some 16 years later!

Why is it that women, especially high risk pregnant women, on bed rest or not, cede their power to their obstetricians? I am not pointing fingers here, I did the same thing myself. But I am wondering why we do it? Fear. Having a high risk pregnancy carries with it a whole host of fears and worries. Many of us who have high risk pregnancies have tried or have been trying for a long time to conceive. Many of us have lost previous pregnancies via miscarriage or stillbirths. We may have undergone assisted reproductive procedures (in vitro and others) in order to conceive. We’re here, finally, with a viable pregnancy, and now this pregnancy may be in jeopardy. In desperation, we’ll do anything. At one point during my first pregnancy I remember thinking, “I’ll  spin on my head and pull this baby out of my nose if I have to!” I was that desperate-and that afraid.

I have since learned, even if you are having a high risk pregnancy, you have options regarding your delivery. Here are 7 points to consider as you prepare for your delivery:

  • What factors make Cesarean Section Necessary? Just because your pregnancy is high risk doesn’t mean that a cesarean section is imminent. Even if you are having multiples, you don’t necessarily have to have a cesarean section. The indications or cesarean section are if the mother’s and/or baby’s life are in danger. In our culture we have moved towards “preemptive” cesarean sections to “avoid any potential complications.” Every pregnant woman needs to keep in mind that a cesarean section is major abdominal surgery and carries with it its own risks and potential complications. If you want to try to have a vaginal birth, and there are reasonable indications that this could be successful, clearly and definitively make your wishes known to your doctor and see if you can come up with a solution that will enable you to at least try vaginal delivery.
  • Will  I have to be induced? We know that the vast majority of inductions end in cesarean section. If your physician is recommending that you be induced, ask specifically why this needs to happen. I s the baby in danger? Is your health at risk? What is he/she looking to accomplish and what do they think will be the expected outcome? Having this information will allow you to communicate any fears or objections and to reach a peaceable agreement on your delivery.
  • The Epidural. An epidural is a type of anesthetic that is injected into the spinal cavity between vertebrae in the lower back to numb  you from the waist down. Some birth educators and women say that an epidural slows labor and makes it difficult to push because you can’t feel the contractions. Others say that it’s a way to be able to withstand the discomforts of labor and delivery. Whatever your decision, know your doctor’s opinion on epidurals and other pain management. Some doctors won’t have women in labor without an epidural. Others are more flexible. Also know that there is a certain time when epidurals are administered and if you progress further than that point, you may not be able to have the epidural.
  • Episiotomy. An episiotomy is a surgical cut in the perineum made my your doctor so that you won’t experience a “traumatic tear” during delivery. The necessity of episotomies is controversial. Discuss with your obstetrician their philosophy regarding episotomies and whether or not they think an episiotomy will be necessary.
  • Infant Care. This is one area where I wish I had asked more questions. While having a high risk pregnancy doesn’t automatically mean that your newborn will have complications, you may in fact have a higher likelihood of having complications and your baby requiring intensive care. I never even contemplated that there would be complications with my baby and was completely unprepared when she was whisked away to the neonatal intensive care unit (NICU). The NICU is a very intense unit and if at all possible, get some information about it before you deliver and visit. It can be a scary place, but the people who care for such little treasures are very special and are your best advocates if you need them.
  • Educate yourself. You may not be able to attend a birthing class at a hospital, but you can read information and watch videos, perfect skills for online birthing classes. Some high risk pregnant women dismiss birthing classes feeling that they won’t be able to use any of the skills. This couldn’t be further from the truth! Knowing what you may face and being able to prepare goes a long way to a smooth birth.
  • Communication is Key. A high risk pregnancy that has resulted in prolonged bed rest doesn’t mean that you don’t have options. Many obstetricians have a predetermined “protocol” as to how they manage various situations, and yet they are not averse to making changes. If there is something that you would like, make your wishes known. You may not get everything, but you’ll get more of what you want if you ask.

To “C” or Not to “C”? Cesarean Section-That was the Question.

January 22nd, 2010

I’m not sure if I am the person to write about whether or not to have a cesarean section delivery given that I have had 2IMG_3750 1x13 c-sections myself. My history of Uterine Fibroids, surgery to remove them as well as repeat miscarriages made both of my “successful” pregnancies high risk. According to the surgeon who removed my fibroids, he had to do several cuts to remove the tumors and vaginal birth posed too great a risk of uterine rupture in my case.

I had a lengthy discussion with my OB during my first (successful after miscarriage and surgery) pregnancy to see if there was any chance that I may be able to deliver vaginally. Her response was, “Well, we could try but I would only allow it if you delivered in a surgical suite with an epidural so that if I had to do an emergency c-section, we would not lose any time. While I was mulling over her words over my husband piped up with, “Are you out of your mind? After everything we’ve gone through to finally have a baby, you want to risk your health and the health of our baby just to say that you pushed her out? No!” So we scheduled the c-section.

Looking back often wonder if I shouldn’t have pressed further. In the end my daughter’s birth was somewhat of a night mare. I went into labor 3 weeks early and technically because I was at 36 weeks and 6 days, I was in “preterm labor”. The doctor on call for my OB (who was out of town) tried to halt things, but in the end my daughter was coming-I was dilating at least 2 cm an hour and so we took her out. I have often wondered if with such rapid contractions and dilation and since I wasn’t in a lot of discomfort, what would it have hurt to let her come out naturally? My daughter was born 5 lbs 3 oz, and was only 18 inches long. I really think I could have gotten her out with minimal trauma to either of us.

When my daughter was taken out of me, my husband says she was gray and floppy and they had to work on her before she cried. She had fluid in her lungs. Had she been vaginally delivered, her passage through the birth canal would have squeezed much of that fluid out of her lungs naturally. Instead she spent 10 days in the NICU and had moderate to severe asthma as a toddler. Was this due to the fact that she was “preemie”, had had fluid  in her lungs at birth or the fact that there is significant asthma in both my husband’s and my families? There really is no way to tell, and I will probably always wonder if I made the best decision for her. But it really doesn’t matter because I am happy to say that now, at 7 years old and quite the diva, my daughter has not had an asthma attack in 2 years and seems to have no other residual signs of prematurity.

For me, the birth was equally traumatic. Everyone was rushing around frantically, clanging instruments and setting everything up. The epidural immediately made me sick and I threw up throughout my delivery which made the OB’s job harder because my abdominal muscles kept moving while she was trying to do the c-section. Once my baby was delivered, I bled profusely. With each stitch placed I bled and the doctor finally had to inject pitpressin (a combo of pitocin and vasopressin) around where she needed to work so that my uterus would clamp down and help stop the bleeding. I realize that this was more controlled bleeding, not a blow out like uterine rupture would have been, but was it really better? I was traumatized and sick as a dog. My baby had been whisked away and my husband was frantically trying to attend to both of us. Yeah, everything worked out but I will always wonder if a vaginally delivery could have been smoother.

When I was having my son 3 1/2 years later, a much calmer and uncomplicated pregnancy, I wasn’t even offered the option of a VBAC. I had had yet another miscarriage between the two pregnancies and was now 40 years old. Everyone kept telling me that I was lucky to be where I was and to “not tempt fate.” I suppose that I shouldn’t have even contemplated vaginal delivery, but my son went to term (or would have if we had left him alone instead of taking him out at 39 weeks. I hadn’t dilated at all and he was content as could be inside!) and was delivered without complication (except the first epidural was misplaced and only numbed my left leg/side. They redid another which worked but left me with back pain for about 4 months after the delivery). I didn’t bleed after his delivery like I did after having my daughter and although my uterus was “boggy” to quote my OB (who was in town this time and delivered my boy),  the placenta was removed and I was closed without problems.

My children are 7 and nearly 4 and I am quite finished with “baby making”. But often I just wonder….did I do the best thing for my daughter? Should I have fought harder to allow my son to come when he was ready and to vaginally deliver ? Hindsight is always 20/20 and I believe that if my OB had been present with my daughter, I would have been able to give vaginal delivery a try. Likewise, had I even been offered a VBAC, I would have tried it with my son, especially since my OB was present at the delivery.

For me, the question of vaginal delivery versus c-section is moot. For other women mulling over their options, I suggest you get as much information as you can not only about vaginal deliveries and cesarean deliveries, but also about your particular situation. Ask your clinician what he or she thinks is the likely scenario in your case? Do they suspect that you would have a hard time delivering your child? Do they suspect bleeding as was the case with me? Are there other complications they are considering that are influencing their recommendation for you? Learning these facts helps you make an informed decision about your delivery and the birth of your child. Don’t settle for, “I just think a cesarean section is best in your situation.” Ask why they they think it’s best, get the specifics. If the cesarean recommendation is not based on clinical evidence or suspicion of a complication stop and consider all your (other?) options. Work with your clinician to plan for the birth of your child and be clear (as you can be) on what is  “expected” for your delivery and what will happen in the event of an emergency. I had no such plan (didn’t know I had that option) and I got what I got. I have no regrets but with more information I certainly would have done things differently.

Did you have a cesarean section? How did you make the choice? Please share your story in our comments sections.