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VBAC Cubby - vaginal birth after cesarean

So You Want to Have a Diabetic VBAC
by JanB
Part 2: Complications and How to Prevent Them

Now the potentially scary part: complications. Complications are the reason some doctors shy away from treating diabetic pregnant women, or encouraging diabetic VBACs. They are the bugaboo of diabetic pregnancies. They are the reason you will receive more intense medical care, more frequent trips to the doctor's office, more monitoring, and more testing during your pregnancy. They are the reason so many diabetic women wind up with c-sections or early inductions. I'll go into a little detail here about exactly what complications we're talking about, and how to avoid developing them.

The name of the game here is tight blood glucose control. If you achieve tight blood glucose control (in other words, maintain the target numbers I mentioned earlier), you will reduce or eliminate your risk of developing most of the complications of a diabetic pregnancy. This tight control needs to start even before you start trying to conceive. Most sources suggest achieving tight control three full months before trying to conceive.

Why is tight control important? Here's a look at what happens during pregnancy when the mother has uncontrolled diabetes:

In the first few weeks of pregnancy, when the fetus's organs are forming, the heart and spinal tube may not form properly if the mother's blood glucose is too high. Spinal tube defects such as spina bifida, or heart valve defects, are the most common serious birth defects of diabetic pregnancies; other possible defects include cleft palate, hare lip, and other such problems. The high blood sugar level in the mother prevents the organs from developing properly. (Taking a folic acid supplement can help prevent spinal tube defects; more on this in a subsequent section.)

Later, once the organs are developed, high maternal blood glucose levels can still harm the fetus. Glucose crosses the placenta, but insulin does not. So when the mother's blood glucose is too high, the fetus receives the excess glucose, but has to manufacture its own insulin. One of the things that insulin does in the body is to help cells store fat, so with all the extra glucose and therefore extra insulin in the fetus's body, the fetus starts to put on a lot of extra weight. You may have read about diabetic mothers giving birth to 10-pound, 11-pound, or even bigger babies; this is why. These overly large babies also tend to have underdeveloped lungs, and to put on the weight in the upper torso and abdomen, rather than evenly distributing it throughout the body. The effect of this can be what my obstetrician refers to as "the ultimate nightmare scenario", in which the baby's head emerges through the birth canal, but the shoulders and torso get stuck. This situation, called "shoulder dystocia", can lead to a broken collarbone in the baby, or worse. The possibility of having this occur is what leads many providers to simply recommend c-sections for diabetic women.

The other major effect of excess insulin in the baby is that when the baby is born and is no longer receiving the excess glucose from the mother, it takes awhile for the insulin production to come down to a normal level, and so the baby can experience hypoglycemia, or low blood sugar. If not immediately treated, this can cause convulsions or even brain damage. Your baby will be tested for low blood sugar after the delivery, no matter whether your blood sugar was in excellent control or not, simply because doctors don't want to take any chances. Also, a baby born to a diabetic mother will occasionally develop low blood sugar after the delivery even when the mother's blood glucose was in excellent control. Nobody is exactly sure why this happens, but checking the infant's blood glucose levels is an easy safeguard.

Now that I've scared you to death, I'll tell you that most of the above complications are completely preventable as long as you maintain excellent blood glucose control. This needs to start, as I mentioned earlier, at least three months before you even try to get pregnant, because a lot of the organ development in the fetus takes place before you even get the positive pregnancy test. You should also be taking a folic acid supplement, because folic acid is known to lower the risk of spinal tube defects. The minimum recommended daily supplement is 400 micrograms; my doctors prescribed 3 milligrams daily for me, which is 7 times the minimum. Their feeling was that you can't overdose on folic acid, and it's better to take more than to not take enough. You should continue to take folic acid at least through the first trimester. It wouldn't hurt to keep taking it for the duration of the pregnancy.

One thing it is important to remember about tight control, before I go on, is that tight control means you are in the normal target range most of the time. Diabetes is an unpredictable disease, and it is not possible to achieve your target numbers 100% of the time. If you think this is an achievable goal, you are only going to drive yourself crazy and be miserable and frustrated. Occasionally you are going to see a number that is higher or lower than it should be. If you can, try to figure out what caused the high or the low so that you can prevent it next time. But be aware that sometimes there isn't going to be a good explanation. Highs and lows happen; it's the nature of the disease. What you need to do is to try to stay in the target range most of the time. High blood sugar has a cumulative effect; in other words, a few high numbers won't do too much harm, but consistently running higher than normal for a period of time will. (A quick note: if you talk to someone who has gestational diabetes, you may be very discouraged to hear her talk about how she never sees any numbers over 130, or how she only tests three times a day and is in perfect control, or something to that effect; remember that gestational diabetes is a different problem from pre-existing diabetes during pregnancy. Gestational diabetics are often just barely on the wrong side of normal, and can often have a much easier time controlling their blood sugar levels. This does not mean that you are a "bad" diabetic or that your diabetes is worse, or that your control is poor; it just means that you have a different form of the disease. Don't stress out about it.)

Tight blood glucose control will not only help prevent your baby from developing birth defects or growing too large, but it will also reassure your doctor that your diabetes is under control and that you are at lower risk of experiencing complications. This can be important when the time comes to discuss labor and delivery options. If your diabetes has been in poor control, your doctor may be reluctant to even discuss VBAC. But if you have records from your entire pregnancy showing your excellent numbers, he or she may be more open to VBAC.

So to sum up, there are two simple ways to avoid most of the complications of a diabetic pregnancy: first, maintain excellent blood glucose control; second, take your folic acid supplements. That doesn't seem so hard, does it?! (I'll leave the room while you throw things at your computer screen.)

Next page: VBAC Considerations

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