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VBAC Cubby - vaginal birth after cesarean

So You Want to Have a Diabetic VBAC
by JanB
Hi, my name is Jan, and I had a successful VBAC as a diabetic. When I found out that I was expecting my second baby after my prior Cesarean, I immediately started searching the Web to find out everything I could about attempting VBAC as a woman with pre-existing diabetes, only to discover that there was little to no information available. The few existing resources are geared towards women with gestational diabetes, and even those resources are skimpy and sparse. So I decided to write an article sharing my knowledge and experience, in the hope that it might help other women who find themselves in this situation.

General Pregnancy and Diabetes Information

Before I get started talking about VBAC, I want to provide some basic background information about being diabetic and pregnant.

First, if you have diabetes, there is nothing in the world stopping you from getting pregnant and successfully delivering a healthy baby. You may run into people who still hold the outdated belief that diabetics can't have children. They have probably watched Steel Magnolias a few too many times. With modern medicine, monitoring, and treatment, diabetic women are now able to become pregnant with little or no additional risk to themselves or their babies.

That having been said, a diabetic pregnancy is not a walk in the park. Almost every woman with pre-existing diabetes who gets pregnant will need to begin using insulin at some point. If you are Type 1, obviously you are already using insulin. If you are Type 2 and on oral medications, it is likely that your care provider will want you to switch to insulin before you start trying to get pregnant. The reason for this is that most diabetes medications are contraindicated during pregnancy. The one possible exception is Glucophage (aka metformin), although no clinical trials have been done, so many doctors are still wary of using it for pregnant women. If you are Type 2 and controlling your diabetes solely with diet and exercise, it is likely that you will need to start using insulin at some point during the pregnancy.

The progression of diabetes during pregnancy takes a relatively standard course, although every woman is different. In general, you can expect your insulin needs to drop significantly sometime around the 9-12 week mark. If you are already using insulin, you will need to monitor your insulin needs carefully at this time to avoid having serious lows. Then, at some point in the second trimester, your insulin needs will begin to increase again. During pregnancy, you are producing hormones that increase insulin resistance. This happens even in non-diabetic women, but in non-diabetics, their pancreases are able to manufacture enough extra insulin so that their blood glucose stays normal. In a diabetic woman, on the other hand, this increased insulin resistance of pregnancy can lead to extremely high blood glucose levels, if not carefully monitored and treated. This is the point during pregnancy when women who have not previously been using insulin will probably need to start. If you are already using insulin, your insulin usage will increase, sometimes quite dramatically. During my last pregnancy, my total daily insulin intake more than doubled from the beginning of the pregnancy to the end.

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How do you know when to increase your insulin, or when to begin insulin if you are not already using it? Use the target blood glucose range given to you by your doctor as a guideline. Most doctors consider tight control during pregnancy to be levels of less than 100 before meals and upon waking, and less than 120 two hours after eating. (Some doctors prefer to use less than 140 one hour after eating as their benchmark; this is just a matter of personal preference. Some women like to check at both times for awhile, just to get a sense of what their blood glucose is doing after they eat.) If you already have diabetes, you are probably used to checking your blood glucose on a daily basis. Expect to check it just as often or more often during pregnancy. Many providers will want you to check your blood sugar on waking, before and after every meal, and before bedtime. This seems like a lot, but your insulin requirements can change on an almost-daily basis during pregnancy, so it's important to keep good records and know exactly what your body is doing. (Incidentally, if you run into a doctor who feels you don't need to check your blood sugar regularly, or who has significantly higher target numbers than the ones I mentioned earlier, I would strongly consider switching providers to someone who is more knowledgeable about diabetes care. You do not want to mess around with poor obstetrical care during a diabetic pregnancy.)

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