If you are reading this article, chances are you are either pregnant or planning to become pregnant. If you haven’t checked out our comprehensive resources about preparing for and going through each trimester of pregnancy, have a look at these preceding articles first:

How to Prepare for Pregnancy with Diabetes

How to Optimize Blood Glucose Control for Pregnancy

Pregnancy with Diabetes: Your Guide to Each Trimester

Optimizing Nutrition During Pregnancy with Diabetes

Now that you are in the final stretch, you may be feeling anxious about the labor and delivery experience, and that’s entirely normal, with or without diabetes! Most women give birth in a hospital, especially when the pregnancy is classified as “high-risk,” so this article focuses specifically on labor and delivery with diabetes in a hospital setting.

Perhaps you have questions about specific hospital policies, the most optimal delivery timing and strategy, labor induction practices, cesarean sections, and blood glucose management adjustments during and after birth, to name a few.

Educating yourself ahead of time and talking to your health care team about hospital policies, and their specific recommendations can help you feel more confident as you prepare to welcome your newborn.

Talk to Your Doctor Ahead of Time

Whether you are working with a high-risk (maternal-fetal medicine) team, or with a regular obstetrician, it’s important to be aware of standard protocols and your specific care approach. Here are some important questions to consider asking your healthcare team ahead of time:

What is your recommended schedule for third-trimester fetal monitoring?

Do you have a routine recommendation for delivery timing for women with diabetes? What are your recommendations based on (e.g., fetal monitoring results, maternal health parameters, etc.)?

If induction of labor is recommended, what specific options will be made available to me? What is the induction protocol and how is this adjusted/determined based on specific events?

Do you support expectant management (waiting for labor to start spontaneously) if blood glucose management is optimized and there are no complications or concerns? Why or why not?

Do you support a trial of labor/attempt at vaginal birth after cesarean section (VBAC)?

What are my options for pain management during labor and delivery?

What kind of resources will be available to me during labor (shower, bathtub, etc.)?

Can you describe the standard fetal monitoring procedure during labor? What conditions will prompt a recommendation for immediate intervention (e.g., cesarean section)?

Will I be able to freely walk/move around and under which circumstances?

Will I be able to eat and/or drink during labor?

What are the hospital policies on blood glucose management during and after labor and delivery? Is an insulin/dextrose drip standard procedure (and for how long)? If so, what can I do if I wish to manage my blood glucose levels independently?

Can I wear my continuous glucose monitor (CGM)/ insulin pump during labor and delivery? What about in the case of a Cesarean section?

Are “gentle cesarean sections” offered at this hospital?

If an emergency cesarean section is needed, what kind of anesthesia is generally used and in which circumstances (e.g., local vs. general)?

What are the protocols for infant monitoring after birth?

What type if infant care facilities does this hospital have (e.g., neonatal intensive care unit, NICU, and what level)?

What is the recommended length of hospital stay after delivery (for a vaginal birth without complications, for cesarean birth, etc.)?

What can I do ahead of time to ensure that I have control over my dietary orders and insulin dosing during my hospital stay?

There are probably even more questions that you could ask, but this list is a good starting point to making sure that you and your healthcare team are on the same page ahead of time. If there are conflicts that can be resolved, this will help to facilitate a smoother labor and delivery experience.

For example, if hospital policy dictates that you must adhere to an insulin sliding scale and “diabetic diet” during your stay, you should be able to file the appropriate paperwork to address this ahead of time. In some cases, a letter or directed order from an endocrinologist can go a long way to help the patient maintain their wish for blood glucose control during a hospital stay without conflict with the hospital staff. In some cases, women may choose to sign a medical waiver to receive the type of medical care that they feel is best.

Asking these questions well in advance is a good idea. If you find that your healthcare provider is not on the same page as you are when it comes to important issues, and furthermore, if their explanation of their recommendations does not appease you or make you comfortable, it is worthwhile to consider working with another provider or at least getting a second opinion.

Trust in your providers and hospital choice and having a comfortable relationship with your healthcare team will help facilitate a positive experience.

Delivery Timing

You may have heard that women with diabetes are more likely to deliver their babies early. This is true, but is not a given, and can sometimes be prevented, particularly via optimizing blood glucose control. Researchers summarize that

Preterm delivery is birth before 37-week gestation; prevalence varies between 21 and 37 % in T1DM compared to 5.1 % in controls. Risk factors for indicated preterm delivery include A1C > 7 %, worsening nephropathy, preeclampsia, and nulliparity. Increasing levels of third trimester A1C > 6.5 % are associated with increasing prevalence of preterm delivery.

Steroids Before Pre-Term Delivery

When early delivery is medically indicated, women often receive a course of steroids, which can help to mature the baby’s lungs and prevent breathing problems upon early birth. Steroids can increase insulin resistance and cause persistent hyperglycemia, so insulin adjustments are necessary if the mother is receiving steroids.

A recent review describes that

Treatment with antenatal steroids is associated with a decrease in neonatal morbidity and mortality. A recommended algorithm for insulin dosing to control glucose levels after betamethasone 12 mg IM and repeated at 24 h is as follows: increase from baseline total insulin dose of 27, 45, 40, 31, and 11 %, respectively, on days 1–5 from start of steroid therapy.

You can also read more about the effect of steroids on blood glucose management here.

Optimal Delivery Timing: Changing Perspectives

For many decades, the average maternal diabetes control was much poorer than it is today and complication rates were generally high. You can read more about the potential diabetes-related end-of-pregnancy complications here. For this reason, in previous years, early delivery for all women with diabetes was recommended. These guidelines have changed in recent years, although they vary considerably between countries and specific practices.

In the absence of complications and when blood glucose levels are well-controlled, many practitioners believe that the best practice is expectant management. This means that waiting for labor to begin on its own as long as the mother and child are doing well may be reasonable (although many practitioners may recommend inducing labor if the pregnancy progresses past the due date).

Experts explain that

Managing stable women with diabetes mellitus to 39 and 40 weeks is now commonplace as fetal surveillance tools such as nonstress testing and biophysical profiles have sufficiently low false-negative rates that providers can feel assured that expectantly managing these pregnancies close to term can be done with minimal risk. Without significant risk factors for adverse outcomes (vascular involvement, hydramnios, macrosomia) and reassuring fetal testing, a pregnancy with good glycemic control may be managed reasonably until 39 to 40 weeks when neonatal risks seem to be at their lowest.

So, today, many practitioners support continuing the pregnancy up to the due date, provided that diabetes is well-controlled, fetal testing is reassuring, and the mother is not experiencing any complications, such as preeclampsia.

Notably, recent research on nulliparous women undergoing a low-risk pregnancy indicated that labor induction at 39 weeks gestation may reduce the risk of cesarean birth and does not increase (or decrease) the odds of adverse fetal outcomes.

Talk to your healthcare team about your specific situation to learn what they recommend and why. You can also learn a lot more about third-trimester monitoring here.

Cesarean Section Delivery

Women with diabetes are more likely to require a cesarean section as compared to those without diabetes. A 2010 study reported that “45 per cent of women with pre-gestational diabetes are having C-sections compared with 37 per cent of women with gestational diabetes and 27 percent of women without diabetes.” This can be for a number of reasons, such as pre-term delivery (see above), macrosomia (large for gestational age baby), and fetal distress.

Although often a necessary and life-saving procedure, cesarean delivery generally carries more risks than vaginal delivery. Maintaining excellent glycemic control throughout the pregnancy can help to reduce the risk of complications that can necessitate a cesarean section delivery.

Blood Glucose Management and Insulin Adjustments

We all know that blood glucose control is paramount during pregnancy, and the weeks leading up to (and the day of) delivery are no exception. Maintaining optimal blood glucose levels in that final stretch can help prevent complications (like macrosomia and neonatal hypoglycemia) and will also help facilitate the healthiest healing environment for the new mom.

Insulin Requirements During the Last Weeks of Pregnancy

Note that insulin needs in the last few weeks of pregnancy may plateau or even decrease. While this may be one symptom of placental dysfunction, the phenomenon does not necessarily indicate a problem, as summarized in detail earlier:

Insulin requirements during pregnancy are governed by a complex system of many factors. For some women, insulin requirements may continue to climb leading up to delivery, while for others, they may plateau or even decrease. “Historically, a significant fall in insulin dose was attributed to failure of the feto-placental unit. However, there is no association between a fall in insulin requirement and adverse fetal outcome,” researchers describe. It has been estimated that “in most women with T1DM, insulin requirements show little change from 30 weeks gestation until delivery. Almost 10% of women had a significant fall in insulin requirements which did not correlate with adverse neonatal outcome.” “When [a fall in insulin requirements] occurs in late gestation, it often provokes concern regarding possible compromise of the feto-placental unit. In some centres, this is considered as an indication for delivery, including premature delivery. There are, however, many other factors that affect insulin requirements in pregnancy in women with type 1 diabetes mellitus and the decline in insulin requirements may represent a variant of normal pregnancy. If there is no underlying pathological process, expedited delivery in these women is not warranted and confers increased risks to the newborn,” experts summarized in a recent review. Thus, although it is important to be aware of falling insulin needs and informing your healthcare provider if this occurs, research shows that solely decreasing insulin needs do not indicate placental failure. However, your healthcare team may advise additional fetal monitoring to check on the relevant clinical parameters.

Insulin Requirements During Labor and Delivery

Insulin requirements during labor and delivery may vary considerably from woman to woman. This is because many factors may be at play, including pain, sleep deprivation, and varying degrees of food and/or liquid consumption. Depending on the specific labor process and whether pain management measures are used, women can have drastically different experiences when it comes to blood glucose management.

Some women may find it easier to allow the hospital staff to manage their blood glucose levels with the help of an insulin and dextrose drip, while others have great success managing their own blood glucose levels with an insulin pump, injections, and continuous glucose monitor and/or frequent blood glucose checks.

Insulin Requirements After Delivery

Unlike all the unpredictability of labor and delivery, it is well-established that insulin needs fall ubiquitously after the placenta is delivered. Experts summarize that

Insulin resistance drops rapidly with delivery of the placenta. Women become very insulin sensitive immediately following delivery and may initially require much less insulin than in the prepartum period.

More specifically:

After delivery, there is a significant increase in insulin sensitivity; so, a reduction of the dose of insulin to approximately 50 % of the preconception dose is advised. Women who breastfeed will likely have lower basal insulin needs than women who do not breastfeed.

It is imperative to be prepared to make these changes as soon as delivery occurs. This can require some planning in advance, especially for women who use insulin injections, so will have to consider how to best adjust their long-acting (basal) insulin strategy leading up to and following delivery.

Talk to your healthcare provider (preferably one who usually helps you with your diabetes management) ahead of time to determine the most appropriate medication adjustments for your particular situation.

Additional Resources

This resource discusses diabetes-specific considerations for labor and delivery, but it is no substitute for a comprehensive resource on the more general aspects of going through pregnancy and delivery. It is a good idea to get informed ahead of time to feel most prepared for what to expect during pregnancy, labor and delivery, and after birth, from diabetes, as well as from a general perspective.

Here is a list of some popular resources that you may want to look into as you prepare:

Books

Pregnancy, Childbirth, and the Newborn: The Complete Guide

What to Expect When You’re Expecting

Expecting Better: Why the Conventional Pregnancy Wisdom Is Wrong–and What You Really Need to Know

Balancing Pregnancy with Pre-existing Diabetes: Healthy Mom, Healthy Baby

Pregnancy with Type 1 Diabetes: Your Month-to-Month Guide to Blood Sugar Management

Real Food for Pregnancy: The Science and Wisdom of Optimal Prenatal Nutrition

Ina May’s Guide to Childbirth

Natural Childbirth the Bradley Way: Revised Edition

The Fourth Trimester: A Postpartum Guide to Healing Your Body, Balancing Your Emotions, and Restoring Your Vitality

Online Resources

Labor Induction

Cesarean Delivery (C-Section)

C-Section Recovery: What to Expect

Conclusions

Welcoming a child into the world can be overwhelming and stressful, and diabetes presents a unique set of considerations. Armed with the most up-to-date information, and with the appropriate planning and individualized, evidence-based care approach from an educated and trust-worthy health care team, women with diabetes can have very healthy and positive, full-term labor and delivery experiences.

References

American Diabetes Association; “Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2018” (2018) Diabetes Care 41(S1): S137-143. http://care.diabetesjournals.org/content/41/Supplement_1/S137

Feldman AZ and Brown FM; “Management of Type 1 Diabetes in Pregnancy” (2016) Current Diabetes Reports 16(76): 1-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919374/pdf/11892_2016_Article_765.pdf

Singh G, Sood R, Kaur K; “Association of biophysical profile with neonatal outcome: an observational study” (2017) International Journal of Contemporary Pediatrics 4(2): 421-425. http://ijpediatrics.com/index.php/ijcp/article/view/556/550

Thung SF and Landon MB; “Fetal Surveillance and Timing of Delivery in Pregnancy Complicated by Diabetes Mellitus” (2013) Clinical Obstetrics and Gynecology 56(4): 837-843. https://www.ncbi.nlm.nih.gov/pubmed/24071732

Vambergue A and Fajardy I; “Consequences of gestational and pregestational diabetes on placental function and birth weight” (2011) World Journal of Diabetes 2(11): 196-203. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215769/

Walsh MD; “The Biophysical Profile” (2008) The Global Library of Women’s Medicine http://www.glowm.com/section_view/heading/TheBiophysicalProfile/item/209#9051

Read more about blood glucose monitoring, diabetes management, pregnancy, pregnancy with type 1 diabetes, pregnancy with type 2 diabetes, type 1 diabetes, type 2 diabetes.