# Type 1 diabetes and natural/out of hospital birth



## lc81002 (May 2, 2005)

I am not a diabetic, but I have a friend who is type 1. With her first, she developed mild PIH and started contracting/dilating at 36 weeks. So her doctor decided to just induce her, then bullied her into getting an epidural she didn't want. She ended up with a c-section for failure to progress and "CPD." Baby was rather large, over 9 lb at 36 weeks, but she feels that if she had been allowed to labor without the epidural and wasn't stuck in bed the whole time, she could have pushed him out. She is pregnant again and wants a VBAC this time, but she says that she has to stay with a high risk OB (and the same one that pushed her into the induction and epidural, because that's the only one in her area) for her care because she will need an IV glucose drip during labor, extra monitoring, etc. This doesn't sound right to me, since her diabetes is well controlled with an insulin pump and diet, plus I know I have seen some natural birth stories from type 1 moms before. But I am having trouble finding info that is specifically about type 1 diabetes and pregnancy/birth. Everything I'm finding is about gestational diabetes, so I'm not sure if it can be applied to her situation.

Anyone have any good resources or info?


----------



## guestmama9916 (Jun 24, 2006)

Sounds like she might need a doula more than anything to keep her from being bullied into an epidural this time. Has she looked into hiring one?


----------



## lc81002 (May 2, 2005)

She is considering that, but cost is a factor so she might need to find someone that is a newbie to be able to afford it. I think she would really rather switch care providers if she can but she feels like this one is her only option because of the diabetes.


----------



## alegna (Jan 14, 2003)

I wonder if she would need a glucose drip if she were allowed to eat normally in labor?

-Angela


----------



## lc81002 (May 2, 2005)

Yeah, I've wondered about that too. My guess is they don't want her eating because they assume she will end up with a section anyway. I doubt she'd ever convince her OB to let her eat instead of having the drip.

Quote:


Originally Posted by *alegna* 
I wonder if she would need a glucose drip if she were allowed to eat normally in labor?

-Angela


----------



## mamaverdi (Apr 5, 2005)

It's very common for diabetics to be given D10 during labor EVEN when they are eating.


----------



## nashvillemidwife (Dec 2, 2007)

Quote:


Originally Posted by *lc81002* 
This doesn't sound right to me, since her diabetes is well controlled with an insulin pump and diet

But labor is not a well-controlled process. It is taxing on the body and increases the body's demand for glucose. In my opinion, insulin-dependent diabetics are much more safely cared for in the hospital.


----------



## kate3 (May 4, 2007)

Quote:

she will need an IV glucose drip during labor, extra monitoring, etc. This doesn't sound right to me, since her diabetes is well controlled with an insulin pump and diet, plus I know I have seen some natural birth stories from type 1 moms before.
This is actually standard for type I diabetics in labor. As Nashvillemidwife said, labor is unpredictable, and blood sugars in labor are completely unpredictable for type I diabetics, even if very well controlled otherwise. There is usually a combination of an insulin drip and glucose drip, with hourly monitoring of blood sugars.


----------



## lc81002 (May 2, 2005)

Ok, thanks for the info, that makes sense. I do wish she didn't have to stick with this doctor that pushed her into an epi when she didn't want it though, and I wonder if she will have any support for a VBAC.


----------



## ~pi (May 4, 2005)

I'm type 1 and I know of a few rare T1D women who have managed NCBs or VBACs. One woman I know had a home waterbirth with her second child a few weeks ago, and there is a T1D woman here on MDC who had an attempted HBAC recently. These are rare cases, but IMHO, that's largely because change is so hard to achieve.

Technology moves so fast in diabetes -- much faster than clinical research and opinion. It wasn't really so long ago that T1D women were living within the Steel Magnolias paradigm. (In the film, Julia Roberts' character has type 1 and is strongly discouraged from having a baby.) When I was diagnosed, my parents were told I might not ever have children.

The landscape of treatment options is completely different now. We have good insulin pumps, continuous glucose monitoring systems, new synthetic insulins that more closely mimic that which is produced by human pancreases, and so on. It's highly possible to have a healthy pregnancy and baby, but the fear remains.

I think the whole CSII (insulin pump) vs. IV insulin and dextrose during labour is kind of crap. I'm actually doing some academic work on this that might turn into an RCT, because, quite frankly, right now it's very much dependent on the whims of the individual care providers. There is no good evidence either way.

Quote:


Originally Posted by *nashvillemidwife* 
But labor is not a well-controlled process. It is taxing on the body and increases the body's demand for glucose. In my opinion, insulin-dependent diabetics are much more safely cared for in the hospital.

I wonder if you were more aware of the technology that is available to (and used by) many T1D women these days, if you would find that your opinion, while common, does not stand up to careful scrutiny?

I have lived with this disease for 25+ years. If you've been doing it for years, blood sugar management is not actually that scary. It's just life. I do realize that because we are far in the minority when it comes to pregnancy and diabetes, we frighten many HCPs, but if you can maintain excellent control through the hormonal fluctuations and stresses of pregnancy, IMHO you ought to at least be offered the opportunity to give it a shot during labour.

The, "Oh my goodness! We MUST manage her blood sugar for her!" attitude is inconsistent and narrow. Where were you people with your insulin & D10 IVs when I was puking all day in early pregnancy and fighting hypos and rebounds? When I played competitive sports and had to balance a tricky combination of adrenalin and exertion during strenuous multi-day events? When I was hiking for weeks on end and my basals bottomed out? Or how about every time DS starts nursing more than usual and it throws off my ratios again? How come you aren't rushing in to "manage" me then? Certainly in all pregnancy-related examples I listed, the negative outcomes are the same, if not worse. (Worse if instability occurs during organogenesis.)

Type 1 diabetes is a SELF-MANAGED condition. Achieving excellent blood sugar control -- especially throughout pregnancy with its constantly shifting basal rates, insulin to carb ratios, and correction factors -- takes determination, vigilance, attention to detail, and intelligent pattern recognition across a wide variety of situational variables. Someone who has all of those qualities and abilities, should -- *if she wants it* -- be afforded the option to continue to self-manage during labour. Really, it's not like you can't switch to IV if problems occur. IV insulin has a half life of 2 minutes. If necessary, you can very quickly fix anything that goes wrong.

This really, really drives me crazy. Aside from a few enlightened exceptions, the majority of health care providers never seem to consider that this task that they seem to think is so difficult and precarious is something I do every day. All day. Without end. I can manage it myself, thankyouverymuch, and based on quite a bit of empirical data, I can do it considerably better than you can.

Quote:


Originally Posted by *kate3* 
This is actually standard for type I diabetics in labor.

There are some important things to note here. It's standard in *some* places and that could easily be a remnant of a time before insulin pumps surged in popularity. IV is certainly preferable to adapting MDI (multiple daily injections) for labour.

For women on pumps, some hospitals/OBs/peris/endos like to use IV, others are happy to leave the woman on CSII. I know a fair number of T1D women, and there is a wide range of standard of care on this question. Perhaps because there is no evidence on outcomes either way save one old (1988) cohort study that found that CSII was preferable. (Hence the current academic work I mentioned above.)

Quote:


Originally Posted by *kate3* 
There is usually a combination of an insulin drip and glucose drip, with hourly monitoring of blood sugars.

Testing every hour is not nearly often enough if it's truly such an uncontrollable situation. You're talking about IV drugs with very short half lives. It just doesn't make logical sense. If you can manage to keep things stable, there is a very high probability that a woman with excellent control via CSII can do the same on her own.

(Rhetorical question: Why do so few people ever seem to question the assumptions on which the standards of care rest?)

OP, we have a T1 tribe here, and feel free to PM me if you want more resources to send your friend.

Quote:


Originally Posted by *lc81002* 
I know I have seen some natural birth stories from type 1 moms before.

P.S. I would love to see those!


----------



## lc81002 (May 2, 2005)

Wow, thank you for all of that information! I was hoping that someone who actually has T1D would see my post and be able to give some insight. I will definitely share your post with my friend, and I'll let her know about the tribe too.

Here is one of the birth stories:
LINK

I don't have any others bookmarked, so I'd have to do some searching again to find them.


----------



## spero (Apr 22, 2003)

: Mom to a T1D here ... she's only 7, but I often wonder about this stuff as I want her to have plenty of options when the time arrives.


----------



## txtarheel (May 27, 2006)

To the OP, I think if your friend looks hard, she might indeed find a care provider supportive of a VBAC. But, if she thinks she needs the IV D10/insulin drip during labor, she might not WANT to deal with her own blood sugar then. I'd guess if she's well-controlled, she's perfectly capable of doing so, but capability doesn't equal desire.

I'm the T1 that ~pi mentioned that attempted a HBAC recently. My reasons for transfer and subsequent c/s had nothing to do with my diabetes. I've now worn my pump and managed my own blood sugars through two labors (one induced, one that lasted two days), two c/s and two recoveries at two different hospitals with different Drs. each time. For my HBAC, I had not only a CNM, but a CPM and a DEM willing to be my provider. I truly believe my self-confidence and demonstrated knowledge at caring for myself were part of my ability to find care providers.


----------

