Maternity
Introduction
If you have recently been for a glucose tolerance test (GTT) and have been told you now have gestational diabetes (GDM) firstly, do not worry. We have a specialist team of diabetes and obstetric consultants, diabetes nurses, dieticians and a team of midwives dedicated in supporting women with diabetes throughout their pregnancy, birth and postnatal period. This means you will see a health professional regularly, so please do not hesitate to approach us with any questions or concerns you may have.
I have been diagnosed with GDM what is it?
GDM is a form of diabetes that presents during pregnancy, usually going away after your baby is born. This means that the levels of sugar (glucose) in your blood are too high. A hormone called insulin, which is naturally produced by your body usually helps to lower this glucose level within the blood. However, with GDM, your body’s own insulin may not be enough, or you become more resistant to it, so your body is less able to control your high blood glucose levels.
Very rarely, it may be that you had diabetes before you became pregnant; meaning you have either type 1 or type 2 diabetes, but this may only have been detected during pregnancy.
You may have been referred for the test to detect GDM because it is more likely to occur in when:
Are there any risks to me and my baby?
Whilst being told you have diabetes can be an anxious time for you and your family, please be aware that with a healthy, balanced diet, light exercise, attendance of all clinic appointments and good control of your blood glucose levels, most women and babies remain healthy.
However, having gestational diabetes does require more medical input to minimise any potential risks to you and your baby. Therefore, you may be offered an induction of labour or elective caesarean section around your due date. This is dependent on a variety of factors, including your baby’s predicted birth weight, whether any previous children were born via caesarean section or by vaginal delivery. An individualised plan of care will be made with you and your diabetes and obstetric team.
Some of the risks to you and your baby can include
Will my pregnancy experience be any different?
As a pregnant woman with GDM, you will be considered at greater risk and so will be regularly invited to a joint clinic run by diabetes and obstetric doctors to look at the whole picture from both a diabetes and pregnancy point of view.
During these appointments, doctors will look at your pregnancy in general and the growth of your baby, alongside your blood glucose levels which you will record in an App or diary. These appointments will determine when you require further scans for your baby and appointments in the hospital. They may also determine if any medications are required to control your blood glucose levels.
How do I treat my gestational diabetes?
Once you have been diagnosed with gestational diabetes, you will be invited to a clinic appointment with specialist diabetes nurses and dieticians to discuss helpful changes to your diet and activity levels, to help you control your blood glucose levels.
You will also be taught how to monitor your blood glucose levels at home and be provided with a diary or given information on access to an app to record your blood glucose readings, a blood glucose meter and test strips; which you should always carry with you and use as instructed.
There are several ways in which gestational diabetes can be controlled:
Diet controlled: positive changes to your diet and the introduction of light, regular exercise can be enough to control your blood glucose levels so that they remain within the target range.
Metformin: if your blood glucose remains above your target range after changes to your diet, you may be given a tablet called metformin to take at certain mealtimes, which can further help to control your blood glucose levels alongside your diet.
Insulin: if, with both the above two measures, your blood glucose remains outside the target range, then you may be advised to start insulin either on its own or alongside metformin.
If you require insulin to control your diabetes, again, do not worry. You will be taught how to store and safely inject your insulin at home.
There are two types of insulin that we can use, ‘short-acting’ insulin and ‘long-acting’ insulin; you may require one or both of these.
‘Short-acting’ insulin is given at some or all mealtimes. ‘Long-acting’ insulin helps to control your blood glucose over a longer period and therefore may only be given once a day.
I am packing my hospital bag, what do I need?
Top tip: when you are packing your bag, it may be useful to use the checklist below so you know you have everything you need.
Generally, for anyone with GDM, you will remain in hospital for at least 24 hours after your baby is born. This is to ensure that both you and your baby are well, and that both of your blood glucose levels are stable. Therefore, it is important to bring along:
Visiting times
Please see link below for current visiting times
I am booked to have an elective caesarean section
Women who are booked for an elective caesarean section to deliver their baby and are treated with insulin may be invited into hospital the night before their planned caesarean section date. It will depend on the amount of insulin you are being treated with. If you are treated with diet and/or metformin or smaller amounts of insulin you will attend at 7.30am on the morning of your caesarean section.
Upon being admitted to the ward, the midwife looking after you will complete:
If you were admitted the night before then from 6.00am on the morning of your surgery, the midwife looking after you will start taking a blood glucose reading every hour to ensure your levels remain within the target range of 4.0mmols/L – 7.8mmols/L. If you are admitted on the morning of your caesarean section, you will have your blood glucose checked when admitted, and then hourly until you have your baby.
If you were admitted the night before then your midwife will start an insulin drip through your cannula at 6.00am (a variable rate insulin infusion – see separate section below). This is to help control your blood glucose levels before and during surgery.
However, even if you do not usually take insulin to control your blood glucose levels, this drip may also be needed in cases where your blood sugar is persistently outside of the normal target range.
Starting this drip to control your blood glucose levels is necessary to help you and your baby remain stable throughout the surgery. This drip will be stopped after surgery.
I am booked to have an induction of labour
The date for your induction of labour will usually be discussed with you at about 36 weeks of pregnancy. The date offered will be prior to 41 weeks.
On the day of your booked induction of labour, you should call the delivery suite at 10.00am on
01384 456111 ext. 3430
Please speak to the lead midwife who will give you a time to attend the unit to be admitted for your induction of labour. Your birthing partner can be with you throughout the induction process until after your baby’s birth, if you so wish.
Upon being admitted to the delivery suite to start your induction of labour, the midwife looking after you will
During this time and until active labour starts, you should continue your regular medications, including any insulin you may be on.
When the lead midwife has given the go-ahead to start your induction of labour (this can sometimes be in the middle of the night, when it is considered safest to start your induction), then the midwife looking after you will
If your cervix is dilated, anterior and thin:
If your cervix is closed/ posterior and thick:
A further method of inducing labour which has been shown to be effective is the insertion of ‘Dilapan rods’. These are thin, tubular sticks that are inserted into the cervix at the beginning of the induction process during a vaginal examination. They remain inside the cervical opening for 12-24 hours, during which time they swell, manually dilating the cervix enough to be able to artificially break your waters, without the use of drugs/ chemicals. This method of induction can be particularly useful for women who have had previous caesarean sections, or those who have shown to be sensitive to the pessary/ Prostin gel.
Top tip: spend time considering your pain relief options before coming to hospital – we have numerous options available both before and during active labour. Before active labour starts, we recommend Paracetamol, Codeine or a dose of Pethidine as the most appropriate forms of pain relief for these early stages. We can also offer the use of a bath, birth ball and TENS machine when available. When active labour starts however, we then have other forms of pain relief, including Entonox (gas and air), further Pethidine or an Epidural.
Active labour
In active labour (when the cervix is at least 4cm dilated and you are experiencing strong, regular contractions)
Hint: this drip will be started on some women who use insulin to control their diabetes at the beginning of active labour. However, it may also be needed for women who control their diabetes with diet and/or metformin, if their blood glucose levels become unstable.
What is a variable rate insulin infusion (VRII)?
A variable rate insulin infusion (also known as ‘sliding scale’) is a continuous drip that is delivered into the blood circulation via a cannula. It is made up of one part insulin, and another part fluid containing potassium chloride mixed with either dextrose (a form of sugar), or sodium chloride (salt), dependant on how high your blood glucose is.
Hint: during the time that this drip is in place, you should still receive any long-acting insulin you have been prescribed.
The VRII is designed to stabilise your blood glucose levels in cases where your body may be using a lot of energy (for example, in labour), or because you are not taking your current medications that you usually use to control your blood glucose (for example, in cases of surgery).
The midwife looking after you will ask to take a blood glucose reading from you every hour. This is to ensure that your levels are stable and to help adjust the rate of the scale as needed, to ensure your blood glucose levels remain within the optimum levels of between 4.0mmols/L and 7.8mmols/L.
If a VRII is started for you, then the midwife will also ask to take a blood sample every twelve hours. This is to check your blood potassium levels, to ensure they are not getting too low or high, in which case a different concentration of the fluid may be needed within the VRII.
When will the VRII be stopped?
When your baby is delivered.
Top tip: it is a good idea, regardless of how your baby was born, to try to eat and drink something after birth. This will help to build your energy stores back up and stabilise your blood glucose levels after birth. Tea and toast will always be offered post-birth to any new mums who wish to have some.
What happens to me after my baby is born?
After delivery, all medications used to control your blood glucose in pregnancy are stopped. However, it is important to ensure your blood glucose levels remain stable for a minimum of twelve hours post-birth, and before you are discharged home. We do this by asking to check your blood glucose level before meals and before bed.
After this, if your blood glucose levels remain stable, we will then stop checking them. Your GP should follow you up around 6 weeks after delivery with a repeat blood test to ensure your diabetes has resolved. You should then be offered a yearly blood test to check for diabetes.
In some rare cases, it can take a little longer to fully stabilise your blood glucose levels, but do not worry, because we can involve the specialist diabetes nurses and doctors in these cases to review your individual blood glucose readings and create a plan for you.
What happens to my baby after birth?
After birth, it is important to make sure your baby’s blood glucose levels are stable before being discharged home, along with their other observations, including general colour, heart rate, temperature and respiratory rate.
We do this by monitoring your baby for a total of 24 hours. These observations are designed to regularly measure your baby’s wellbeing and can promptly and easily alert us if there are any issues which need a paediatrician’s input.
We also ask to measure your baby’s blood glucose levels from the heel of their foot:
This means that your baby should have both of their blood glucose readings at or above this level. If not, we will need to monitor your baby more often to ensure your baby is safe and able to stabilise their own blood glucose levels before going home.
However, do not panic, as there can be numerous, correctable, reasons why your baby may have a low blood glucose level, for example:
Top Tips:
Please speak to your community midwife or a midwife at the hospital if you would like any information about expressing breast milk in pregnancy.
If these blood glucose readings and observations are all stable after 24 hours, then your baby will have the hearing screen and the full top-to-toe examination before being considered fit for discharge home.
Important contacts
It is completely normal to feel a little overwhelmed if reading this guide in one sitting. We instead advise you to keep it with you during your pregnancy and refer to it as much as you need; to help direct you through your journey into meeting your new baby. However, if you do have any questions, please do not hesitate to approach your community midwife, clinic midwives or diabetes antenatal team.
Alternatively, if there are any further pressing matters, or if you have any worries/ concerns, for example:
Then please call triage immediately on 01384456111 ext. 3053.
We really hope this guide is useful in guiding you through what to expect during your pregnancy with gestational diabetes.
If you have any questions, or if there is anything you do not understand, please contact the Russells Hall Hospital switchboard number on (01384) 456111 and ask for the relevant department who issued this leaflet.
This leaflet can be made available in large print, audio version and in other languages, please call 0800 073 0510.