Expectant management of the pregnancy involves nonintervention at any particular point in time and allowing the pregnancy to progress to a future gestational age. Women undergoing expectant management may go into spontaneous labor or may require indicated induction of labor at a future gestational age. In women with an unfavorable cervix, both expectant management and cervical ripening with prostaglandins or by mechanical methods, such as use of an intrauterine balloon followed by induction of labor, were traditionally proposed. Expectant management might be the preferred option in order to avoid a potentially prolonged labor and increased rate of Caesarean section following induction of labor, especially in women with an unfavorable cervix.
The choice between a policy of early elective delivery (either by induction of labor or by Caesarean section) and expectant management in diabetic women should take into consideration perinatal mortality and morbidity, shoulder dystocia (related to macrosomia), fetal distress and, conversely, respiratory morbidity related to prematurity. Regarding maternal morbidity, Caesarean section, instrumental delivery and women's views of their care need to be evaluated. Use of Caesarean sections, as well as induction of labor before the pregnancy has reached full term in order to prevent shoulder dystocia, are controversial issues. The main problem is that current methods of estimating fetal weight have inherent inaccuracies. Up to 50% of brachial plexus injuries occur in the absence of shoulder dystocia and may occur with a Caesarean section, which suggests that antenatal and intrapartum factors are also important etiological factors. Thus, it is presumptuous to advise the clinician on what the threshold for performing induction of labor or Caesarean section should be. Obviously, a past history of shoulder dystocia should influence the decision on the mode of delivery. However, although induction of labor earlier in pregnancy when EFW is significantly lower than the previous birthweight for the purpose of avoiding shoulder dystocia might seem appealing, it has no solid scientific basis. Certainly, unless obstetric complications dictate otherwise, with normal EFW, good metabolic control, good biophysical profile and monitoring of a normal amount of amniotic fluid, both pre-GDM and GDM might be left to enter into spontaneous delivery up to full term. Elective Caesarean section should be strongly considered if the EFW is more than 4000-4250 g. Induction of labor and planned vaginal birth after Caesarean has no greater risk than for nondiabetic patients and should be considered on an individual basis.
Expert Rev of Obstet Gynecol. 2009;4(5):547-554. © 2009 Expert Reviews Ltd.
Cite this: Managing Labor and Delivery of the Diabetic Mother - Medscape - Sep 01, 2009.