This is how diabetes can affect the mode of child delivery

35-year-old Priyanka Bhavnani, who had a smooth journey during her pregnancy until 24 weeks, suddenly found her glucose tolerance positive during a routine test.

Her risk factors were the family history of diabetes, pregnancy at the late age and overweight (high BMI). After further investigations by her doctors, she was advised to be on a diabetic diet and regular exercise with prenatal yoga.

“Babies born to women with diabetes have an increased chance of having breathing difficulties, low blood sugar (hypoglycaemia) and jaundice during birth. The maternal variables, like, gestational age at the time of delivery, onset of labour, mode of delivery, pregnancy complications and blood loss during pregnancy are contributing factors to NICU (Neo-natal Intensive Care Unit) admission of the newborns,” said, Dr. Nupur Gupta, Consultant, and Unit Head, Gynaecologist and Obstetrician, Well Woman Clinic.

Excessive birth weight. Extra glucose in the bloodstream crosses the placenta, which triggers baby's pancreas to produce more insulin. This can cause the baby to grow too large (macrosomia). Very large babies – those that weigh 4 to 4.5 Kg or more — are more likely to become wedged in the birth canal, sustain birth injuries or require a C-section birth.

“Early (preterm) birth and respiratory distress syndrome. A mother's high blood sugar may increase her risk of early labor and delivering her baby before its due date, or her doctor may recommend early delivery because the baby is large,” added Dr. Gupta.

Babies born early may experience respiratory distress syndrome — a condition that makes breathing difficult. Babies with this syndrome may need help breathing until their lungs mature and become stronger. Babies of mothers with GDM may experience respiratory distress syndrome even if they're not born early.

Low blood sugar (hypoglycemia). Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Severe episodes of hypoglycemia may provoke seizures in the baby. Early feedings and sometimes an intravenous glucose solution can return the baby's blood sugar level to normal.

Type 2 diabetes later in life. Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life.

Untreated gestational diabetes can result in a baby’s death either before or shortly after birth.

Photo Courtesy: Thebreastcaresite

Complications that may affect the mother:

“Gestational diabetes (GDM) increases the chances of certain pregnancy complications. So close antepartum care and follow-up are needed. Possible risks include higher chances of needing a C-section, miscarriage, preterm birth, high blood pressure and future diabetes. High blood pressure and preeclampsia. Gestational diabetes raises the risk of high blood pressure, as well as, preeclampsia, a serious complication of pregnancy that causes high blood pressure and other symptoms that can threaten the lives of both mother and baby,” ”added Dr. Gupta.

Future diabetes. If one has GDM, there are more chances to get it again during a future pregnancy. Chances of developing type 2 diabetes become higher as one gets older. However, making healthy lifestyle choices such as eating healthy foods and exercising can help reduce the risk of future type 2 diabetes.

Of those women with a history of GDM who reach their ideal body weight after delivery, fewer than 1 in 4 eventually develop type 2 diabetes.

Factors determining the mode of delivery in a diabetic mother are estimated foetal weight (clinical and by ultrasound), duration of pregnancy and blood sugar control. The aim is to achieve the most desirable results for both the mother and her offspring.

Dr. Gupta further added, “Management options include expectant management, induction of labour and Caesarean delivery. There are many variations in practice since patients and providers have different perceptions of the potential benefits and risks of management approaches. Most women who have GDM deliver healthy babies. However, gestational diabetes that's not carefully managed can lead to uncontrolled blood sugar levels and cause problems for both mother and baby, including an increased likelihood of needing a C-section to deliver. Labour and delivery management of women with GDM can affect neonatal and maternal outcomes in millions of women.”

Elective Caesarean delivery or planned Caesarean delivery is one of the suggested options for a suspected macrosomic (large) foetus. Although there is a greater chance of needing a C-section, many women with GDM have regular vaginal births.

We know that there is a higher rate of maternal morbidity and mortality with Caesarean as compared with vaginal delivery. Also, it has been observed that women delivering a macrosomic infant by pre-labour Caesarean section have 3 times greater risk of postpartum infection and 11 times greater risk of wound complications.

“But sometimes there's no other option than surgery. Reasons for a C-section vary from the development of preeclampsia – high blood pressure and excess protein in the urine after 20 weeks of pregnancy, to a previous C-section, failed induction, obstructed labour, excessive foetal growth, and malpresentation,” said, Dr. Gupta.

Diabetes and pregnancy expert Dr. Lois Jovanovic says, that independent of the type of diabetes, glucose control or complications, the women with diabetes have poorer myometrium contractions than the women with normal glucose tolerance. The authors' conclusion that each pregnant diabetic women should thus be treated uniquely during labour and delivery proves that women with diabetes truly are special. 

At the same time, if macrosomic babies (4 to 4.5 kg) are given a trial of vaginal delivery, they are likely to suffer from shoulder dystocia and brachial plexus injury.

Some questions that can be asked when Gynecologist plans for a C-section:

Why does my baby need a C-section?

How accurate is the estimation of birth weight? Could the baby be smaller than expected?

What are the risks to the baby if C-section is not performed?

What are the risks if a C-section is performed?

Normal Vaginal Delivery (Natural Birth)

Vaginal deliveries are the best mode of delivery for any mom: there’s a better recovery. A C-section is a major surgery with increased blood loss and risk of surgical complications.

It has been recently observed by the researchers at Liverpool, the UK that women with diabetes have poor uterine contractility i.e. even if they push for hours will never succeed. These women had a higher chance of induction, instrumental deliveries (forceps, vacuum) and C-sections.

“We tend to induce women with diabetes 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 foetus is fully developed. The downside of induced labour is that it may double the odds of a C-section birth,” said Dr. Gupta.

To conclude, the more you learn about your bodies, the better you can work with what you've got, and feel empowered about your birthing experience. Optimising outcomes for women with gestational diabetes mellitus (GDM) and their foetuses requires not only careful metabolic management but also appropriately applied foetal surveillance techniques and thoughtful selection of the most advantageous timing and route of delivery.