Refusing 39w induction with Metformin-managed GD

[naranciata]

Consultant advised (very strongly) on induction at 39 weeks because of risk of stillbirth. No research I can find shows an increased risk of stillbirth for women with GD, just women with pre-existing type 1 or type 2. Other reason is that GD babies can be big - this baby is 55th-60th centile.

NICE guidelines (2015) suggest that women with well-managed GD can go to 40+6 at which point they should be induced.

I have brought this up with consultant and midwife and both have been quite dismissive. I know appointments are short but I feel quite strongly and now at 37 weeks I don't have a long time to make a proper plan and I feel really anxious.

Also really worried about things I've read saying that mothers with GD aren't given the same chance to establish early breastfeeding as others because of baby's blood sugar. MW and consultant both also very dismissive when I tried to discuss with them about expressing colostrum prior to delivery to freeze and use to supplement first feeds in case of blood sugar problems.

Does anyone have any experience of refusing induction in these or similar circumstances? Any advice for how to approach MW and consultant at next appts next week?

Do you have any other risk factors? eg are you over 40?

You don't need to be confrontational - just "that date doesn't work for me, can we do X instead?"
Have you had a growth scan?

No other risk factors. Had growth scan which indicated perfectly average baby.

Have you had an early induction before? If the body isn't ready to go into labour it can be an awful and drawn out experience. I'd recommend requesting a c-section instead, but that's just based on my own personal experiences.

It's better to be induced than have a stillborn baby, or an emergency CS because baby can't fit out of your pelvis. I am not saying these will happen, but I think it's good that the consultant is being cautious about it as baby is over 50th centile. However it's entirely up to you. But it's their job to tell you what the risks can be (stillbirth, shoulder dystocia, various) - there are, of course, various risks with induction as well. In your shoes I'd think 40 weeks is plenty. Some experts believe that everyone should be induced before 40 weeks even without GD but no it is not in the clinical guidance.

Look up fetal macrosomia (>4kg baby), shoulder dystocia and risks with GD. Sorry if I sound negative I don't mean to be. I was induced twice for other reasons and I hated the idea to start with and scared myself terribly about inductions but it turned out OK.

There's no harm in expressing or giving baby colostrum - presumably you can breastfeed for colostrum initially and also then supplement within the same feed if it is indicated.

I had gd. Induced at 38 weeks.
Scan at 37 weeks indicated baby was 8lb 13. Born weighing 7lb 3oz.
I was advised to express colostrum, took it with me. Never saw it again.
No one tested mine or baby's blood sugar.
I'm really not sure what their plan was. I would refuse induction again- it was pretty awful.

With regards to breastfeeding don't think that giving the baby one formula feed in hospital is going to be a huge issue it really isn't!

I gave DD one bottle just so we could go home and get a decent nights sleep so I could then face the battle to get her breastfeeding.

I was in your position GD, they wanted to induce at 39 weeks but they said baby was measuring large so I agreed. It took 5 days as my body and baby just weren't ready. Baby eventually arrived at bang on average weight (and on due date). If I had the same decision to make again I'd refuse an early induction, but want some monitoring during that time but probably agree at 40 weeks. Ultimately it's your decision and you don't have to agree to an early induction if you don't want to. Sounds like you've done some reading, can you push for another meeting with your consultant or a midwife to discuss your concerns?

I was induced at 38 weeks because of GD. I also hadon't signs that placenta was going to fail early. To me it just wasn't worth any risk and I actually had a positive induction experience and a healthy baby who I breastfed right away and we had no issues regarding blood sugars and were discharged next day and luckily for us breastfeeding was quite easy and she took to it right away. She was only tested for sugars every hour or 2 for 6 or 8 hours I think (memory hazy as 3 years ago and I was pretty exhausted!) and it didn't interrupt feeding at all.

Things to ask about / bear in mind
... induction procedure - blood sugar checks/ drips etc
... how long will you need to stay in afterwards.... 72 hrs here for baby sugars
... hospital food... waiting for induction to kick off etc do they have any suitable food that won't mess up your blood sugars

Thanks all. I have a long list of questions for appointments now and feel ready.

If your blood sugars are well controlled and baby is not macrosomic then waiting a bit longer is absolutely reasonable. Particularly when you don't have any other risk factors.
Just explain this to your midwife and consultant and suggest you would like to hold off on induction.. this will come alongside some closer monitoring perhaps, visiting the assessment unit every few days, an extra scan for placental function and growth.
Regarding feeding. Babies of diabetic mums are more likely to struggle with low blood sugars but if your antenatal sugars are controlled this shouldn't be much of a problem. However, baby will probably need some blood sugars monitoring for a period of time (24-72hr). I know our unit encourage antenatal expressing so you have a little store of colostrum, this also helps your milk supply to come in quickly. Ask for some syringes and start expressing, labelling and freezing. When you go in to labour or induction bring them with you in a cool bag and ask to put them in your milk fridge to defrost, always handy for everyone to have a bit of a supply.

Good luck with everything

I agree, I see a lot of people refusing inductions, yet wonder "would you prefer an awful birth with a healthy baby or a very natural easy birth with a stillbirth?" Sounds harsh but I know what I prefer!

I'm actually having a induction on Saturday because of OC, I want a healthy baby, yes I may moan and say the labour was difficult but it's for my baby's arrival.

I'm sorry to put it this way, but this week my friend's daughter would have turned 8. She was stillborn on her due date, due to GD.

I had GD with all three of my pregnancies, and was induced at 38, 39, and 39 weeks. It's not a picnic. But I can't really imagine what the huge gain is in putting up such barriers, when the potential loss is so huge.

I feel some people refuse things medically for themselves as opposed to what is best for their baby.

Unfortunately google isn't your friend, you can't get a PhD from it either, its probably best to rely on the medical professionals & go with their advice on induction.

It may not be pleasant but neither is natural labour.

Don't put your baby at unnecessary risk.

I went to 41 weeks with GD and had a home birth with an independent midwife.

I had support in that decision from a consultant midwife at Kings but not from my doctor who was appalled.

In the end you have to make a decision that you feel comfortable with. As you can see from this thread - most people with GD feel that their baby is at significantly increased risk of a poor outcome and hence are willing to accept early induction. I looked at the evidence and came to the same conclusion as you and based my decision making on that.

Re: colostrum - just go ahead and do it. My local hospital invites all mums with GD to a special session to discuss this - they positively encourage it. I wouldn't bother discussing it with most people as they tend to not understand why you might prefer to give your milk as a first feed to your baby rather than formula, and you'll make yourself exceedingly unpopular explaining your rationale for doing this. The 'fed is best' propaganda doing its work...

I had GD with a plann d induction for 39+1

At 37+6 I had reduced fetal movement and went for a check up. They kept me in monitored until 38+4 where they felt the need to induce.

Do you have any reason to refuse an induction at 39 weeks? You say you can't find any evidence of risk but can you find any benefit in NOT being induced? I would be following the advice of highly qualified and experienced medics over a bit of a Google any day of the week

"I feel some people refuse things medically for themselves as opposed to what is best for their baby."

Colostrum is better for a newborn than formula. So you should ask yourself why all mothers with GD aren't expressing it and giving it to their baby, and all hospitals (rather than just some) aren't advising it? Good on the OP - she is trying to put her baby first in wanting to express her colostrum for a first feed if needed.

As for questioning induction - wise up. Some hospitals in the U.K. are currently inducing more than DOUBLE the numbers of mothers as others and there are huge variations across the board. This is because when it comes to an interpretation of the evidence there is a range of opinion among medics and midwives.

It would be easier for all of us if these things were set in stone, but they're not. There are risks and benefits to all interventions and we owe it to ourselves and our babies to understand what we are consenting to.

Thanks all for your input.

Spoke to consultant today and had another growth scan. The baby is still not macrosomic and sticking to 55-60th centile and consultant was happy that I could delay 39w induction to 40+4, while being adamant that baby should be here by 40+6. So now I'm booked in for 40+4 if I've not gone into spontaneous labour by then.

I don't feel like I've tried to get a Google Doctorate, it's more that in an 8 minute consultant appt, there's very little time to ask everything you want to ask, so to me it seemed wise to go away and do some of my own research and attend my next appointment better informed with a list of questions.

I think it's fair enough for the OP to ask why the doctor is not following the NICE guidelines. They are usually evidence based and the doctor should be able to explain why they feel earlier induction is beneficial

I linked to some NHS leaflets on antenatal colostrum expressing in a previous thread, definitely worth doing if you have gestational dm. It's still relatively unknown as a recommendation but looking at the evidence it's a really good idea with basically no drawbacks.

I don't know what risks /benefits are for induction for gdm as I haven't looked into it, but, I have looked at risks /benefits for induction for baby being late, and there are definite risks to the mother (higher rates interventions such as instrumental deliveries and c sections) so for people implying that inductions are always good - I think that's not true. Of course we should be doing everything we can to prevent stillbirths, I just think it's not that simple to say induction is the magic answer.

I was induced at 40w both times with GD. No blood sugars were taken from me or the DCs and breastfeeding was fine. Both inductions were fine too - cheeky dc1 was back to back which added a bit of stress but it was absolutely fine. First pessary at 4pm, gentle contractions started around 6am the next day, baby here at 6pm. Dc2 was similar, first pessary 4pm, contractions started at 5.30am, but then it went from 0-60 in about 10 mins and dc2 arrived at 7.10am. I breastfed them both fine, no problems generally. DC1 was a bit slow to get started and got a bottle feed in the middle of the first night but I put that down to both of us being a bit dopey from the pethedine.

Is it the induction that you have a problem with, or that it's at 39 wks? My view is reflected by what I wrote in my birth plan - a long list of what I'd like to happen over the course of my labour but the last line was 'but ultimately I want a healthy mum and baby and I'll do whatever necessary to achieve that'. They must have a reason for suggesting this - think hard about what aspect of it is concerning to you and then discuss it with them. But if I were you, I'd be taking the advice of the people who deal with this every day and have a better handle on the risks than you do.

Best of luck!