Managing Labor and Delivery of the Diabetic Mother

Hen Y. Sela, MD; Itamar Raz, MD; Uriel Elchalal, MD

Disclosures

Expert Rev of Obstet Gynecol. 2009;4(5):547-554. 

In This Article

Mode & Timing of Labor & Delivery

Labor and delivery management of women with GDM can affect neonatal and maternal outcomes in millions of women. The presence of GDM is not a sole indicator for Caesarean delivery. GDM is not an indication for delivery before 38 weeks' gestation in well-glycemic-controlled GDM patients without suspected fetal compromise.

Several factors are crucial for the management of labor and delivery in this setting. Estimated fetal weight (EFW), both clinical and measured by ultrasound, maternal glucose control and gestational age are factors of particular importance in such pregnancies.

Management options include expectant management, induction of labor and Caesarean delivery. Individual providers and medical institutions have traditionally developed protocols for labor and delivery management in women with GDM by incorporating published literature, anecdotal experience and recommendations ofexisting guidelines. Variations in practice also may exist, since patients and providers have different perceptions of the potential benefits and risks of management approaches.

Elective Caesarean Delivery

Elective Caesarean delivery defined as a planned Caesarean delivery for a wide range of maternal and fetal indications is one of the suggested options for mode of delivery of the suspected macrosomic fetus.[42]

However, the best strategy for avoiding brachial plexus injury is a controversial topic. Although brachial plexus injury after Caesarean delivery has been described,[43,44] it is a remarkably rare event.[45] This debate is related to maternal versus fetal risks. On the one hand, there is the chance of surgical complications to the mother with GDM following Caesarean delivery, and on the other hand, there is the possibility of severe damage to her fetus from a shoulder dystocia and brachial plexus injury following traumatic birth. The risk of brachial plexus injury (at least transient) when a macrosomic infant (>4000 g) is delivered vaginally by a diabetic woman is 2-5% and is increased further for delivery of babies weighing more then 4500 g.[33,46,47]

It is widely assumed that Caesarean delivery results in higher rates of maternal morbidity and mortality compared with vaginal delivery. Additional evidence exists for a two- to four-fold greater risk of maternal death in women who delivered by Caesarean delivery compared with vaginal delivery.[48] However, women with various medical complications have an increased risk for maternal death and serious morbidities who often deliver by Caesarean section, making it difficult to single out the risk attributable to the operative intervention itself. Conversely, it is difficult to find data indicating that an elective prelabor Caesarean delivery at term carries a higher maternal risk than vaginal delivery. Information from the Washington State Birth Events Records Database from 1990 indicates that women delivering a macrosomic infant by prelabor Caesarean section have a threefold greater risk of postpartum infection and an 11-fold greater risk of wound complications. Overall, rates of each complication were low in both groups.[45] Moreover, the increasing risk of repeated Caesarean deliveries also needs to be considered and factored into clinical decision-making. It is well known that there is an increased risk of placenta previa and accreta after repeated Caesarean deliveries,[49] as well as an increased risk for stillbirth in subsequent pregnancies.[50]

Thus, it seems that avoiding vaginal delivery favors the infant who may be destined to suffer shoulder dystocia and brachial plexus injury, while elective prelabor Caesarean delivery poses a relatively minor risk to mothers. It has been calculated that, in diabetic women, 489 babies (estimated birthweight > 4000 g) or 443 babies (estimated birthweight > 4500 g) would have to be delivered by elective Caesarean delivery to prevent one permanent brachial plexus injury.[51] This would have then cost US$930,000 or $880,000, respectively, for each case prevented.[51] For an individual patient with a permanent brachial plexus injury, a planned Caesarean could have made a large difference in quality of life. However, for the population at large, the advantages are less clear.

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