Labor induction may be attempted when the fetus is not excessively large and the cervix is considered favorable (Chap. 26, p. 503). Little and colleagues (2015) analyzed term singleton births from 2005 to 201r1 and showed a higher percentage of diabetic women were delivered each year before 39 weeks compared with the entire cohort-37 versus 29 percent. Cesarean delivery at or near term has frequently been used to avoid traumatic birth of a large fetus in a woman with diabetes. In women with more advanced diabetes, especially those with vascular disease, the reduced likelihood of successful labor induction remote from term has also contributed to an incre�sed cesarean delivery rate. In an analysis of pregnancy outcomes of diabetic women from University of labama at Birmingham according to the White classiication, the rate of cesarean delivery and preeclampsia escalated with White class (Bennett, 2015). In another study, a HbA,c level >6.4 percent at delivery was independently associated with urgent cesarean delivery. This suggests that tighter glycemic control during the third trimester might reduce late fetal compromise and cesarean delivery for fetal indications (Miailhe, 2013). The cesarean delivery rate for women with overt diabetes has remained at approximately 80 percent for the past 40 years at Parkland Hospital.
Reducing or withholding the dose of long-acting insulin to be given on the day of delivery is recommended. Regular insulin should be used to meet most or all of the insulin needs of the mother during this time, because insulin requirements typically drop markedly after delivery. We have found that continuous insulin infusion by calibrated intravenous pump is most satisfactory (Table 57-10). Throughout labor and after delivery, the woman should be adequately hydrated intravenously and given glucose in suicient amounts to maintain normoglycemia. Capillary or plasma glucose levels are checked frequently, especially during active labor, and regular insulin is administered accordingly.
Often, women may require virtually no insulin for the irst 24 hours or so postpartum. Subsequently, insulin requirements may luctuate markedly during the next few days. Infection must be promptly detected and treated. When appropriate, oral agents can be restarted.
Counseling in the puerperium should include a discussion of birth control. Efective contraception is especially important in women with overt diabetes to allow optimal glucose control before subsequent conception.
In the United States in 2010, almost 5 percent of gravidas were afected by gestational diabetes (DeSisto, 2014). W orldwide, its prevalence difers according to race, ethnicity, age, and body composition and by screening and diagnostic criteria. There continue to be several controversies pertaining to the diagnosis and treatment of gestational diabetes. A National Institutes of Health (NIH) Consensus Development Conference (2013) was convened to study this. he American College of Obstetricians and Gynecologists (2017a) has also updated its recommendations. These two authoritative sources provide an analysis of the issues surrounding the diagnosis and bolster the approach to identiying and treating women with gestational diabetes.
The word gestational implies that diabetes is induced by pregnancy-ostensibly because of exaggerated physiological changes in glucose metabolism (Chap. 4, p. 56). Gestational diabetes is deined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy (American College of Obstetricians and Gynecologists, 2017a). This deinition applies whether or not insulin is used for treatment and undoubtedly includes some women with previously unrecognized overt diabetes.
Use of the term gestational diabetes has been encouraged to communicate the need for enhanced surveillance and to
TABLE 57-1 0. Insulin Management During Labor and Delivery
Usual dose of intermediate-acting insulin is given at bedtime.
Morning dose of insulin is withheld.