Childbirth and diabetes were once considered mutually exclusive. Thankfully, those days are over. But aiming for a healthy baby — and an uncomplicated birth — when you're living with diabetes is still a very tall order. It can be scary. And no one really wants to have a C-section, right? (I sure didn't, x3). Today, D-author and fellow mother of three Amy Stockwell Mercer joins us once more for a special report on new research providing insight into the precise effects of the Big D during childbirth.
Special to the 'Mine by Amy Stockwell Mercer
The myth that women with diabetes can't have babies is almost extinct. Shelby's premature death in the movie Steel Magnolias has slowly been replaced by images of healthy, vibrant women like former Miss America Nicole Johnson and fellow D-blogger Kerri Morrone Sparling as they navigate diabetes, pregnancy and motherhood. We've come a long way in understanding the importance of prenatal care for women with diabetes and as a result, more women are having healthy babies than ever before. However, 45%-70% of these pregnancies result in cesarean births and until now, no one could explain why.
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Researchers at the University of Liverpool have recently discovered that women with diabetes have "impaired uterine contractility." That means that even if we push for hours, some of us may never succeed. This groundbreaking research is based on 2010 United Kingdom government statistics, which show a high induction of labor rate (39%) and a high C-section rate (67%) in women with type 1 and type 2 diabetes (compared to 21% of the general maternal population).
"We need to think about the enormously high C-section rate rather than just accepting it," says co-author Dr. Susan Wray. "As scientists we asked the question, could it be that these women's uterus' cannot contract as well as other women's?"
Even though I'm personally finished having babies, the idea that my uterus might not contract as well as other women came as both a shock and a relief. For years I felt like a failure because of my three C-sections, as if I hadn't tried hard enough or labored long enough to get the baby out on my own. Instead of a natural birth like my mom had, I was induced, stuck with IV's, and rushed into the operating room for an emergency cesarean after 2 ½ hours of pushing. Two more C-sections followed, leaving me with three healthy boys and a permanent scar.
Seeking more information, I contacted Dr. Jennifer Ahn, one of the experts quoted in my book, The Smart Woman's Guide to Diabetes, to ask her opinion on diabetes and delivery. Director of the Diabetes in Pregnancy Program, and a type 1 diabetic Dr. Ahn explained that, "We tend to induce women with diabetes (pregestational or gestational) on medications (whether insulin or oral meds) around 39 weeks gestation. The reason for this is that women with diabetes are at a greater risk for stillbirth, and 39 weeks has been shown to be the time when the fetus is fully developed."
The downside of induced labor is that it may double the odds of a C-section birth, and for women with diabetes (I know this all too well), once you've had a C-section, your chances of delivering naturally are slim. "Vaginal deliveries are the best mode of delivery for any mom," adds Dr. Ahn. "There's a better recovery. A C-section is a major surgery with increased blood loss and risk of surgical complications. Plus, moms end up having multiple C-sections, and can have a lot of problems in subsequent pregnancies."
But sometimes there's no other option than surgery. Reasons for a cesarean vary from the development of pre-eclampasia (high blood pressure and excess protein in the urine after 20 weeks of pregnancy), to a previous C-section, failed induction, obstructed labor, excessive fetal growth and malpresentation.
Cheryl Alkon, author of Balancing Pregnancy with Pre-Existing Diabetes, actually chose a C-section because of her retinopathy. "I was given the choice to do an elective C-section at week 37 for my son's birth, or else a vaginal delivery with forceps and vacuum so I wouldn't put any pressure on my eyes. I didn't hesitate to pick the C-section, and honestly, it was really a great experience."
Melissa Partridge, mother of 4, also had C-sections. I met Melissa at last year's DiabetesSisters conference, and emailed to ask about her experiences. "My doctor said he would induce me at 38 weeks with my first pregnancy. At the time my placenta looked great in the ultrasound and the baby didn't look too big, but I wasn't dilated or effaced at all, and the doctor wanted the baby out. After about 9 hours on pitocin (a synthetic hormone used to induce labor), he decided to break my water, hoping it would get things moving. Nothing happened. Four hours later, I was sent in for a C-section. My honest feeling is that my baby wanted to stay in and my body wasn't ready, but since it was nearing the middle of the night, and the doctor had already broken my water, he opted for a C-section." Melissa adds, "I often wonder if I had been more in control of my birthing experience if I would have been able to have a natural delivery."
But how do we get more control of our birthing experiences? Would Melissa's experience be different if she'd known about her uterus? The new Liverpool study is the first to show that contractions in women with diabetes are smaller and shorter lasting.
Dr. Wray says, "There is a reduction in muscle mass that could come from poor blood glucose control, but even with good control there is muscle mass reduction." They also discovered that the mechanism for getting calcium into the uterine muscle cells, needed to promote contractions, is decreased in women with diabetes. There's no way of knowing the strength of a woman's uterus before she goes into labor, and we can't improve our uteruses' with push-ups or yoga. "I don't want women to think 'why bother,'" Dr. Wray says, "There are women with diabetes who are able to contract well, and women without diabetes who are unable to contract well, so the answer is that one size does not fit all."
Elizabeth Edelman, co-founder of Diabetes Daily, is a good example of someone who was able to contract well. She told me she tried to do everything possible to prepare for a natural delivery. "I worked with a wonderful doula who had worked with another woman with type 1 diabetes, so I felt confident. My team of OB's was very supportive. They did say that if I went over 40 weeks they wanted to induce, but luckily for me they didn't have to. I went into labor at 39 weeks spontaneously. I worked very hard, counting every carb I ate, wearing a CGM, and practicing yoga to make sure that I could deliver naturally. I also took Bradley classes that helped me prepare."
Preparation is like second nature to those of us with diabetes, and giving birth should be no different. We need to be our own advocates and that means seeking the latest information, being engaged in decision-making, and communicating with our OB/GYN's. Dr. Wray says women should be individually monitored during pregnancy and delivery, and talk with doctors about the possible need for "a longer duration or higher dose of oxytocin (natural hormone to induce labor) during labor to counteract the inherent poor uterine contractility."
I also reached out to Dr. Lois Jovanovic CEO & Chief Scientific Officer of Sansum Diabetes Research Institute and a pioneer in her work with diabetes and pregnancy, to get an expert point of view. She's the one who called this new study groundbreaking.
"The results clearly show that independent of type of diabetes, glucose control or complications, the women with diabetes had poorer myometrial contractions than the women with normal glucose tolerance. The authors' conclusion that each pregnant diabetic women should thus be treated uniquely during labor and delivery proves that women with diabetes truly are special!" — diabetes & pregnancy expert Dr. Lois Jovanovic
Dr. Jovanovic is right, we are special and we've come a long way toward understanding the needs of a diabetic pregnancy from start to finish. The more we learn about our bodies, the better we can work with what we've got, and feel empowered about our birthing experience.