Labour and birth, for women with type 1 diabetes
Planning for labour and delivery
Your diabetes in pregnancy team will work with you towards the ultimate goal of having a healthy baby. They will discuss what to expect during labour and birth, including a plan for insulin adjustment, blood glucose management and who to contact if you go into labour earlier than expected.
Your diabetes in pregnancy team will work with you to aim for a natural birth close to your due date. It is usually recommended, that a woman with diabetes, has her baby at around 37–38 weeks’ gestation (for some women, close to, but before 39 weeks may be considered). If you do not come into spontaneous labour by then, your labour will be ‘induced’, or possibly an elective caesarean section will be suggested. The obstetrician in your diabetes in pregnancy team will discuss delivery options with you, with the goal usually being a vaginal birth. It is important that you feel comfortable discussing these birthing options with your team of health professionals.
If you go into labour spontaneously, it is best to go to hospital early for close monitoring of your diabetes and the baby’s well-being.
Sometimes, an earlier birth may be recommended if there are concerns during your pregnancy, such as:
- high blood pressure
- your baby becoming too big or not growing enough
- a substantial fall in your insulin requirements
- change in your baby’s patterns of movements.
If you need to have your baby early, you are likely to be given a cortisone-like medication (betamethasone, Celestone) to help mature your baby’s lungs before birth. These medications usually increase blood glucose levels for several days. In this situation, your doctor would usually recommend a hospital admission to monitor you and your baby and manage your blood glucose levels. An intravenous insulin infusion or intensive insulin therapy would be used to help keep your blood glucose levels in the target range at this important time before your baby is born.
Induction of labour
Depending on how your pregnancy is progressing, you may need to have an induction, which means helping your body to start labour. An induction can be performed in several ways and sometimes a combination of two or more methods will be used. These include:
- Gel insertion—this involves inserting a prostaglandin pessary or gel into your vagina, to help the cervix to soften and open. This, in turn, tells your uterus to start contracting. Some women need two or three doses of gel before labour begins.
- Balloon induction—this involves a catheter being inserted into your vagina. Water is then pumped into the device, which gently puts pressure on your cervix, assisting dilation and encouraging your uterus to start contracting.
- Rupture of membranes (breaking waters)—this method involves rupturing the membrane, or bag of fluid, around your baby. Your membrane is gently broken using an ‘amnihook’, which looks like a long crochet hook, and the gush of fluid may encourage your uterus to start contracting and bring on labour.
- Oxytocin drip—this method involves an intravenous (IV) line (or drip) being inserted into a vein in your arm, and the oxytocin hormone being slowly delivered into your blood to help your uterus start contracting. The drip may be used alone or with a gel insertion.
When an induction is planned, your diabetes in pregnancy team will discuss with you a plan for managing your diabetes. This will include adjustment of your insulin doses/pump rates or changing the way insulin will be delivered.
Managing diabetes during labour
Your own blood glucose levels in the time leading up to the birth have an important effect on your baby’s blood glucose levels. The higher your blood glucose is, the greater risk of hypoglycaemia in your newborn baby. Keeping blood glucose levels close to the target range during labour, helps reduce the risk of your baby having low blood glucose levels at birth.
When you are in labour, you will be under the care of your diabetes in pregnancy team including your midwife, obstetrician and endocrinologist/diabetes specialist. Your blood glucose levels will usually be monitored frequently (usually hourly) and there will be regular contact with your diabetes team, who will make adjustments to the amount of insulin you are being given to keep your blood glucose in the target range.
If you are using continuous glucose monitoring (CGM), this may be continued throughout labour if you wish. CGM however does not replace finger-prick blood glucose monitoring at this time, but can be helpful to show glucose trends and offer reassurance about glucose levels during labour and birth.
An intravenous (IV) insulin infusion and IV glucose (sugar) are often used throughout labour, which allows small amounts of insulin and glucose to run into your blood continuously. Alternatively, rapid-acting insulin injections every two hours may be used during labour to manage your blood glucose levels.
If you use an insulin pump, talk to your diabetes in pregnancy team in advance about how to best manage your pump during labour and delivery. This will involve modified basal rates and smaller bolus doses, as well as ensuring your infusion site is away from the abdominal area. If you have a planned delivery date, change your cannula the day before. Be sure to have a spare infusion set when you go to the hospital. Not all hospitals are familiar with pumps. It may be recommended that you have an intravenous insulin infusion or frequent small doses of subcutaneous insulin.
From around 35–36 weeks, your doctor will discuss a plan for your baby’s birth. If your doctor is concerned about you not being able to have a vaginal birth (for example, if they suspect your baby is too large, is breech (bottom first) or there are other obstetric problems), they will discuss with you the possibility of a planned caesarean section.
If a caesarean section is advised, it will be according to your obstetric needs, not because you have diabetes. Birth by caesarean section is not a decision taken lightly, as there are risks involved with such major surgery. The medical decision to perform a caesarean section should be discussed with you in detail, so your doctor can explain the risks and benefits involved.
If you are having a caesarean section, you will usually have to fast for about six hours beforehand, so you should discuss with your diabetes in pregnancy team the options for managing your blood glucose levels and insulin doses during this time.
It is a good idea to make a management plan with your diabetes in pregnancy team well before the birth.
In some circumstances, a caesarean section is undertaken as an ‘emergency’. This might happen if there are problems with you or your baby, or because the labour is not progressing the way it should.