Being Induced because Type 1 Diabetic - Can I have a c-section?

[LisaClapham]

I am 17 weeks pregnant and have type 1 diabetes. The hospital (St Thomas in London) have told me I must be induced at 38 weeks - which I understand the reasons why. However I have requested an elective c-section which they have refused. Does anyone have a similar experience. I am scared about being induced and having a long difficult labour resulting in intervention (highly likely I hear) and would prefer to have a c-section - at least I can mentally prepare for that and know what will happen. Any advice?

Ask St Thomas's what their rates of failed inductions for first timers are - or you may find this information on the internet.

You're right that early inductions have a higher rate of intervention, and specifically emergency c-section, and for first time mothers the rate is significantly higher. At my local hospital the rate of failed inductions for first births is 50%. However, some early inductions proceed smoothly with no problems, and the problem is you just won't know how yours will go until it happens.

My SIL had an induction at 36 weeks for pre-eclampsia, and it was a totally straightforward natural birth taking 8 hours in total - which most women would prefer to a c-section.

I have no experience of arguing for a c-section on your grounds, so don't know how likely it is that St Thomas's will grant your request (not very likely, I would have thought). All I can suggest is that you do as much research as possible so you know all the risks and likely outcome, whichever way things turn out.

Hi,

I'm a type 1 and had my ds at St Mary's (where they let you go up to 39 weeks before induction). I was told that they preferred to do it this way rather than an elective because firstly there is a chance that you may deliver vaginally (which is usually better for both you and the baby) and even if you don't the process of labour is still beneficial for the baby and helps develop its lungs or something like that. For these reasons in addition to the added risks for diabetics of surgery they prefer you to have the chance of a vaginal birth.

I was mentally prepared for a c-sec both in the sense that I firstly expected them to go straight to an elective (had forgotten when they said baby must come out by 39 weeks that you could induce - thought that just meant cut) and then when they explained it more fully many weeks later still knew rationally that the dice were loaded against a vaginal birth because of the need for insulin drip and therefore cfm as well as inducing at that stage. Although it did end up in a c-sec I did not have the same shock as other people I knew who had never considered that their baby might come out through the sun-roof. Saying which it was still not my ideal end and when I work up the nerve to go through pregnancy and childbirth again I'll do my best to have a vbac.

The way to consider what to do is assess risks and benefits of both methods of delivery to you and the baby. Childbirth is not predictable and even though one route might look easier things can happen on the day to change that.

If you decide to try for a vaginal birth, ask your consultants about

1. do they require you to have continuous monitoring from the time the insulin drip is in.
2. if yes, do they have a telemetric monitoring system and will it be available on the day. this would allow you to move around somewhat while still being monitored and assists your chance of a vaginal delivery.
3. why is there a difference between 38 and 39 weeks? The reason given for early induction is that the placenta starts to fail earlier for diabetics and there are unexplained stillbirths. But why are there perfectly respectable London hospitals allowing induction a week later if there is not a valid reason?
4. Do they impose a time limit on you labouring - either directly or by reference to the insulin drip?

All these things will affect your chances of success.

There are threads here on how inductions can work and also check out this one mumsnet.com/Talk/1365/371630?ts=1211889188108 which you may want to revive.

If you do decide you want an elective try and find the threads about women who want electives and see the reasons they use to convince consultants. The fact that you have diabetes and the care proposed just mean you would have a stronger argument as you can show that your risk of ending up in a c-sec is higher than most.

inductions are usually shorter.
i was induced at 39 weeks due to gestational diabetes.
my cm said that you could request a cs but i think you can only do that if you have problems in previous labours.
i hope someone has more advice for you.

Bethoo - inductions are only shorter in the sense that they closely monitor your reaction to the drugs and up them if they don't believe they are working fast enough. These forced contractions can have the effect of distressing the baby leading to a c-sec or if they do not work then you end up with a c-sec for failure to progress.

My "short" induction was 18 hours of labour by their reckoning (21 by mine) and I had a c-sec 24 hours after they started the induction.

This is not meant to discourage you Lisa but as you are aware, the risk of an induction particularly when the baby is not ready is it can lead to a long difficult labour making it more likely that you'll need an epidural and therefore more likely that you'll need intervention of some variety at the end. Saying which that is the worst case scenario and women do have successful early inductions.

thanks for all the advice tigger. I definitely need to do some further research and ask some questions of my hospital.
This is my first pregnancy and was only diagnosed diabetic last year, so it's all been very new to me.
I am really worried about having an emergency c-section (and being total under) so am looking at what is the best think for me to prevent that happening as I want to be conscious when the baby is born. With all the other potential complications I thought elective c would be the best route for me.
I will do some more reading and get my case together to put forward.
Anything else I should know about being diabetic and pregnant? (aside from tight blood sugar control)

also thanks for the other thread - some really useful insights on here

Lisa,

Just because it is an emergency csec does not automatically mean that you will be under GA. The vast majority are done under spinal/regional anaesthetic which means that you will be awake. The exception is the crash section where it is really urgent to get the baby out. Most c-secs are not like that and even in cases of distress there are different levels of it. They prefer not to do c-secs under GA as it passes to the baby.

Have a look at that thread that I linked to before as it was experiences of birth and pregnancy and aftercare from type 1s and others on insulin.

Only other thing I can think of apart from tight sugars is that pregnancy can have very funny effects on your sugars (ie drastic lows). Anything else I'm happy for you to CAT me if you want.

A baby delivered by elective cs at 38 weeks has a higher risk of being born with breathing difficulties than those who have been through labour, even if the labour ends in emergency cs. The risk is lower (although still exists) at 39 weeks. Might be why your hospital is reluctant to do elective cs at 38 weeks. If you google you should be able to find numbers for those risks - might help you with your decision making.

Tigger i was lucky then as my labour was only 2.5 hours once the gel started working as i fully dilated within an hour. very painful though!

Hi Lisa.
Firstly, congratulations on your pregnancy .

I can't really help with this question, but have already learnt stuff from this thread which I find useful, and plan to have a good read through the thread that Tigger has linked.

Just thought I would let you know that there is a support thread in pregnancy for those with gestational diabetes. Although I appreciate that type 1 is more severe (my brother has it), you may like to join us there, for chat and moral support if nothing else. Many of the ladies there are having to take insulin during their pregnancies. There are a couple of other type 1s who pop in too.

Hi, thanks for all the messages on this. I have been reasearching further and am now considering induction - althought tigger, looking at your experience I think I would still have to be prepared for c-sec. (Which I am as I wanted one all along)
However I am concerned being diabetic about being on an insulin drip, having a very painful labour and obviously the feeling that I did it all for nothing if I have a c-sec that could have been an elective and less painful experience had I pushed for it.
My primary worry is the baby's health so i will do whatever is the best thing for the baby - some research I have done suggest that there may be breathing difficulties (as advised by LiegeandLief) if I have an elective at 38 weeks.
I am going to look at some more threads and see what other advice is offered, but please let me know if anyopne has any further thoughts.
This forum has proved far more useful (and i have just joined!) than any discussion with my (frankly useless) midwives - So thank you.

I wouldn't worry too much about breathing difficulties. In the grander sceme of things that can go wrong breathing difficulties is very minor. DS was born at 38 weeks. I thought he had breathing difficulties, but the paed kept saying Oh that's nothing we don't need to do anything about that. If they were worried about it they would inject you with that hormone that they give to mums who are about to have babies pre 35 weeks.

If you refuse to be induced they will have to give you a section.

You should do what you want of course. But, if it was me, induction would be out of the questions, especially since it's likely to end in emergency section. And believe you me, a planned section is MUCH better than an emergency.

Why can't you have a setion at 39 weeks? Or 40 weeks? I think they get babies of diabetic mother out at 38 weeks so they won't be too big. (not sure if that's right though so feel free to correct me). Wouldn't the baby be better off staying in another week or two and coming out the sun roof?

Thanks Athene, I really am against being induced - but other than c-sec I don't have any options - unless I can get baby to come early (this is my first pregnancy, so unsure on how or if I can make that happen).
I much prefer a planned c than an emergency c. I will ask the hospital about 39 or even 40 weeks. I have no idea what my chances are of having no intervention (which would be my ideal). I suppose I am also very scared too so looking at what will be least stressful for me (and also best for baby)

Athene - 40 weeks is only for mothers with GD not type 1.

The other thing to consider with sections is the recovery time. Although many women recover quickly others do not. I was amongst those who didn't and I'm not sure how much of that was linked to diabetes. It has never impeded my healing before but this was the first major surgery I'd ever had. In addition, I found post-natal blood sugars absolutely appalling to manage and when I spoke to other people discovered that this was quite common. It doesn't help that in addition to that every movement you make hurts.

I believe taht the reason they recommend induction is partly the breathing problems risk, but more the risk to you of infection. Also since all future pregnancies would also have to be ended at a similar date, if you give an elective csec for the first then you are nearly automatically deciding that all future births will be by csec with increased risks with each one.

Personally I want the next one by vbac as I foudn the pain debilitating and pretty horrific post-op and also they keep you in longer in hospital which causes problems with control as you have to often fight them for the right to control diet and insulin.

What are you concerned about regarding the drip? Try and get the consultant to talk about it with you. I got mine to agree that once I was able to inject mine could come out but I know other people had to keep it in for longer with bad results.

Mind if I ask where you are? What hospital? What do you mean whenyou say they refused? Is it really out of the question, or did they just manage to talk you out of it?

"if you give an elective csec for the first then you are nearly automatically deciding that all future births will be by csec with increased risks with each one. " just to clarify - once you've had a c-sec it is unwise to induce so unless the baby comes early you are most likely to have a c-sec.

Just curious, why does type one have to get the baby out earlier than GD?

Yes, but if you actually want a c-sec than that is a good thing because it is less likely to be refused the next time you ask for one.

I am with St Thomas hospital in waterloo. They have advised me that I will be induced at 38 weeks and that they will not perform an elective c sec without good reason (me wanting one is not good reason enough). They advise that the csec carries big risks for me and the baby.

My GP has advised that if I keep on pushing for the elctive c-sec and do not back down then I should get my way, but that it may be a tough slog - everytime I have brought this up they have massively pushed back. I am only 18 weeks, so have time to convince them, but it will be tough.

Tigger - from your experience do you think I should try the induction route?

I also have no idea about recovery as have never had any type of sugery before, and no idea of my pain threshold either

You do know that an induction is considerably more painful than a natural delivery?

If you are sure you want a section (and that is of course your chaoice not mine so don't let me persuade you if it is not what you want), I would:
1- Write this preference all over your maternity notes. Copy them, Tell them you have copied them.
2- Raise the issue again. When they ask you why you want a sections put the question back to them and give them an opportunity to talk you out of it. Tell them you still want one and if they choose not to give you one any complications that may arise will be a result of their actions, not yours. (that will scare the lawyers)
Make it clear in writing that your preference is for an elective section. Write a letter if you have to.
Gather medical evidence to support your desire for a section. For example, if your baby is big (at diabetic mother babies tend to be) then obviously that reduces the changes of you being able to push baby down the birth canal. Tell them you want to avoid an emergency section.
4- If they are still not convinced, refuse the induction. Write them a letter and tell them that you do not want an induction for any reason. If natural vaginal birth is not medically advise, please give me a section.

If you are strong and determined and stand your ground, they will give in.

I had an emergency section with my first child. I wanted an elective section for the second. I had to put my case forward and do some convincing, but they gave it to me without too much fuss.

And remember that it is their job to offer their medical expertise and advise you. But the medcal treatment you receive is you decision, not theirs. They can not tell you you are being induced at at 38 weeks. They can recommend it, and you can say "no thank you".

This may or may not be helpful. I haven't read it.

www.nice.org.uk/nicemedia/pdf/CG063FullGuidance.pdf

Lisa--I was induced at 38 weeks due to high blood pressure and it was a beautiful experience. I was put in on a Friday night to have prostaglandins overnight. Saturday morning (8am) they broke my waters and started a drip. At 2pm I felt a small contraction. At 8pm ds1 was born.

I'm one of those that can stand here and say that having an induction with a with baby does NOT mean you will have a C-section and does NOT mean you will have any other interventions. I used no pain relief and there was never any talk of forceps or vacuum extraction. I like to think that I didn't have a natural labor, but I did have a natural birth. I can also say that my induction was no more painful than my natural labor with ds2. In fact they were pretty much the same as far as progression and pain.

Go into an induction knowing that a C-section is an option, but also knowing that it can be a beautiful experience.

Athene - thank you for your advice, you make some very sensible points and a logical way for me to push forward and thanks for the link, I am going to take a good look through it.

MKG - I would love to have an experience like yours, but fear you are in a minority. However, I am still considering the possibility of going the induction route and hearing experiences like yours do give hope.