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 Shelby’s premature death in the movie Steel Magnolias has slowly been replaced by images of healthy, vibrant women like former Miss America Nicole Johnson and fellow D-blogger Kerri Morrone Sparling as they navigate diabetes, pregnancy and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.
Amy Stockwell Mercer - back when!
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.”
Photo: Diabetes Forecast
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.
What I would really love is a study of t1 women and ALL ob/gyne complications. Not everyone w/t1D forgoes children due to diabetes. I just had a D&C for non-pregnancy related symptoms and learned of two studies showing that t1D women not only have a 3x higher risk of endometrial cancer, they also experience menopause 7-10 years earlier than women without diabetes. No one told me these were known complications in the last 29 years I’ve lived with the D.
This is a great post.
I was told that probably due to my diabetes, my pelvic floor muscles, the muscles that need to dilate and allow for delivery were extremely tight. I received intense therapy for this during my twin pregnancy and once I developed preeclampsia I was admitted to the hospital and put on pitosin to start the process. I tried from Monday afternoon to Tuesday night to have a natural child birth. Finally, when my blood pressure was too dangerous to continue, and I hadn’t dilated past 1 cm, they did an emergency c-section. My kids came out fine and I healed well, but I didn’t take pain medicine (my kids were preemies and really sleepy and it scared me to pass along drowsiness inducing medicine to them through the breast milk) so I was in so much pain for weeks and it would have been nice to have a natural delivery. Not to mention my scar is hideous.
Anyway, I began to wonder if that pelvic floor tightness was related to the same issue other diabetic women have that is mentioned in this article-the uterus not contracting properly. Interesting stuff.
One doctor mentioned to me that women with type 1 diabetes who have natural child birth tend to have diabetes for less years than those who need c-sections which makes sense-less time for diabetes to do it’s damage?
That was very interesting! I don’t think I knew that C-sections being more common for women with Diabetes. I’m glad that they are increasingly having more and more healthy babies though! I’m also happy that you had 3 healthy boys!
What an informative post! I had never hear of actual delivery complications for women with diabetes– just all of the worries about when to deliver, fetal size, etc. I also had a c-section, after laboring naturally for 40 hours. I don’t think I had trouble contracting– they actually put some electrodes on my uterus to check before my OB insisted on the surgery. I wish that I had known a little more about these statistics then. Somehow, it may have helped with the intense disappointment I felt about not delivering naturally.
I hope to have kids someday and I really really don’t want to have C section. Sort of disappointing news but at least women with t1 D are increasingly having healthy babies. I wonder how well these studies distinguish women with t1 and t2 or if they just lumped them together. Other “risk” factors for C section would be helpful. I would hate for med professionals to push everyone in that direction just because they have diabetes.
I must say that I love Mercer’s book. I borrowed a copy from our library and had to go out and buy it so I could mark it up. Reading “The Smart Women’s Guide to Diabetes” has turned my d-life around. Thanks so much Amy. My doc thanks you, too.
[...] C-Sections vs. Natural Birth in Diabetic Moms [...]
Women with diabetes have children who are at higher risk of diabetes— and birth by C-section also increases the child’s risk of diabetes. Not a huge amount, but enough that if a c-section can at all be avoided, try to avoid it. Not always possible of course, but sometime possible.
I have type 1 and 2 kids, both born vaginally, but just barely. The first was with a vacuum extractor, and I can’t really recommend that experience. After 26 hours of labor, and 5 hours of pushing. ugh. The 2nd just popped out. My 2nd has diabetes.
My cousin has a blog on natural childbirth and type 1: see http://diabeticbirth.blogspot.com/
i have been diabetic for 37 years. diagnosed at 12. had my first child at 20 years old delivered by C-section. he showed slightly low blood sugars at birth, but now 28 and no signs of diabetes.
my second child was born when i was 22, also a C-section. no complications for her after birth. she is now 26 and no signs of diabetes. my third child was born when i was 27. my OB asked me if i was considering natural delivery, and i opted for a C-section. all children delivered at 37wks and all healthy babies. the third is now 22 and no signs of diabetes. i didn’t do anything special during my pregnancies. i just did what i did everyday. i was not the “perfect” diabetic and i guess, knowing what i now know, i might have taken a little more care.
Thanks for the shout-out, Amy(s). My c-section was also a retinopathy-based decision, but I know a lot of diabetic moms who have had success vaginal delivery. Sharing these stories is important – thanks for sharing yours, Amy!
Amy, thanks so much for your informative post.
I know that women with diabetes were more at risk for a C-Section but I wasn’t fully aware that contractions in women with diabetes are smaller and shorter lasting.
You are so right about preparation though, regardless of having diabetes or not, women need to be their own advocates, understand the latest information, and be engaged in the decision-making and communicating with your doctor. I’m definitely a big advocate for that.
Thanks,
Elizabeth
Diabetes notwithstanding, the c-section rate has been climbing for years. Part of this is the trend towards OB/GYNs wanting mothers to deliver larger babies (when I was born, 5-6 lb was the norm and it was desirable to have full-term children under 7 lb; today, I keep hearing that doctors are wanting babies closer to 8 lb, which can be too large for a mother’s pelvic opening). Another part of this is the desire to schedule births, so that they are most convenient for the parents and the delivery team. In the general population, maternal and fetal health issues would seem to come a distant third in reasons for the high c-section rate.
After many years of “once a c-section, always a c-section” practice, about 30 years ago, there was some interest in VBAC (Vaginal Birth After C-Section). It wasn’t appropriate for every second-or-later-birth mother (it required, among other things, that the original c-section was done with a transverse rather than a vertical incision), and many doctors were against even a trial of labor. I’ve not kept up on the literature, so I’m not sure if VBAC is still an option for mothers (diabetic or not) — and if not, whether the option was pulled for real medical risk or doctors’ fear of malpractice if something went wrong in the vaginal delivery attempt.
Many years before VBAC, some doctors were telling mothers who had cesaerean deliveries that they must not become pregnant again. (It is why one of my grade school classmates was an only child.) I’m not sure if there were medical reasons for this (beyond the stress of a c-section) or not…
I was diagnosed in 2002 with T1. Our first child was born at 37w,4d; induced because of preeclampsia. I had not been seeing an endocrinologist for the first 3-4 months of the pregnancy (very bad idea!). He was 11 lbs 1 oz and a vaginal delivery. Our second was induced at 37 weeks due to some wacky blood sugar numbers at the end of the pregnancy and weighed 9 lbs 14oz. (VD). Our third was delivered via c-section at 39 weeks, 1 day and weighed 10lbs, 14 oz. We choose to have a c-section in the off chance that there would be complications from a vaginal delivery (mostly dystocia). All I know is that I definately prefer VD, but if you think that a C-section is a romote possibility, prepare yourself by talking with someone who has been through it. Even though we thought and prayed about it for the two weeks prior, I still wrestled with the thoughts of somehow failing. Not true because we have a healthy beautiful baby! Try and find people who have been through pregnancy with diabetes or are going through it now to help support you and to encourage you in this important time of your life! I surely could have benefited from spending time researching more information. It seems hard to do, so many things to juggle, but it is so worth the effort!
Maybe I’m just reading the article wrong but did the author not consider the high rate of inductions and c-sections for diabetics to be a result of Drs pushing c-sections down women’s throats already? Diabetes is just the medical excuse they were looking for. Inductions increase the risk of having to have a cesarian so it’s only natural the that rate is so high.
They love inducing diabetics – its the first thing my wife’s Dr said at our first prenatal appointment – “plan on being induced at 39 weeks” Say what?! No concern at all about how her pregnancy will progress. Its become an automatic response. How bout referencing the studies that show the rate of complications from inductions based on the cervixs condition at the time of induction?
im 27, ive had diabetes since the age of 16
im actually scared about giving birth.
im not pregnant, never gave birth before, so totally scared.
i really want a baby.
It is natural, both childbirth and fear of the unknown. It is not bad and it is possible to have a healthy and wonderful pregnancy as a diabetic. Read up on the best ways to control your blood sugar because that is the best thing you can do as you prepare to have a baby. Start by talking with your Endo doc to see what you can do if you a1C is too high. Exercise so you are at a healthy weight and eat healthy. Don’t believe that giving birth to a child is impossible, just because you have diabetes. It is possible!
I thought I would chime in again. I delivered a 7lb baby vaginally at 39 weeks a couple weeks ago. I was induced although I considered allowing baby to come on her own. I think the reason my induction was successful, and did not lead to c/s, was that my doctors were very patient with the process, and there were no emergent factors that came up such as pre-e etc. It took about 48 hours from the time the induction was started. After my water spontaneously broke, the contractions picked up and the baby was born 4-5 hours labor. I don’t think uterine contractility had any factor since the pushing phase was relatively short and once my body took over the contractions (vs the meds), everything went quickly.
I am 29 weeks pregnant and a type 2 since 3yrs. My diabetes is being controlled through high dosages of insuling (i wasnt insulin dependent prior to conceiving). My doc has suggested induction of labour at 37weeks however I did some research and it seems induction leads to doubling the chances of having a C-Section!! I have been debating going for elective C-Section instead of having to go through emergency C-section after a failed induction. My doc says there is no additional risk with elected C-Section. Still cant make up my mind!! Help!