Issues with diabetic home birth

[cranberry987]

Hi

I just had an email from the head of midwifery and wonder if anyone can help with the issues shes raised (in spoiler). Theres also a load of new complications mentioned which no one has ever told me before (and have not come up in any of my research). Wondering where theyve come from to be honest.... feeling very suspicious that theyre suddenly trying to scare me into a hospital birth so are bringing out the big guns.

Oh and I have my MW appointment tomorrow, aim was to talk about hb plans there... nice lot of notice theyve given me. Would have been nice if they had brought this up 18 fricking weeks ago when i first mentioned a home birth.

My daily blood sugars are perfect, hba1c 0-24w was 5.2 (will have it redone in 2w), baby measuring 50th% head and body, amniotic fluid and bp perfect, we are both healthy.

Would it be worth me contacting aims?

Thanks in advance

Spoiler

I have been trying to find a way forward with regard to looking at the possibility of monitoring your baby’s blood when it is born as it is a minimum requirement to ensure wellbeing of your baby.

I have spoken to several specialists in diabetes and neonatology and companies who make the monitors;

• No monitors will guarantee blood sugar recordings below 4mmol which is a problem as your baby is very likely to be below 4 mmols on occasions

The NICE and CMACE diabetes guidance advises no blood sugars need to be monitored before 4 hours post birth even in a baby of a diabetic mother and we would not be at your home realistically after 4 hours.

So I have looked at how else this could be done and drawn a blank once again.

I have spoken to our screening lead and the Trust legal team and whilst it is not illegal for you to test your own baby’s blood e.g. you draw the blood there are real issues with this;

• Damage can be caused to the heel or foot if not taken correctly at all times can result in bone deformity and walking issues at a later stage
• Infection
• Un-reliable results as discussed above
• Specialist training is required to perform this sampling and legally as midwives we are not allowed to teach you to do this having checked with our Trust legal team

One possible solution could be to birth at home and transfer in for the minimal time to allow reliable monitoring of the baby’s blood sugars although not ideal at least the birth experience would be as you would want and the safety of your baby and wellbeing could be closely monitored.


I have added below some thoughts and research the neonatal team have given me which may or may not be of interest to you

The first bit is there thoughts on the risk to your baby and the subsequent part is some research articles which they felt might be of use to you.

This information is in no way meant to frighten you merely ensure from a neonatal perspective you are aware of all the risks .I suspect you may be aware of many of these risks anyway.
Pulmonary disease
These infants are at an increased risk of respiratory distress syndrome and may present within the first few hours after birth with tachypnea, nasal flaring, intercostal retractions, and hypoxia. Operative delivery due to macrosomia also increases the risk for transient tachypnea of the newborn, whereas polycythemia predisposes the infant to persistent pulmonary hypertension of the newborn.
Initially, the differential diagnosis includes transient tachypnea of the newborn, respiratory distress syndrome, pneumonia, and persistent pulmonary hypertension.
Metabolic and electrolyte abnormalities
Hypoglycemia may present within the first few hours of life. Although the infant is generally asymptomatic, symptoms may include jitteriness, irritability, apathy, poor feeding, high-pitched or weak cry, hypotonia, or frank seizure activity. Hypoglycemia that requires intervention may persist for as long as 1 week.
Hypoglycemia is caused by hyperinsulinemia due to hyperplasia of fetal pancreatic beta cells consequent to maternal-fetal hyperglycemia. Because the continuous supply of glucose is stopped after birth, the neonate develops hypoglycemia because of insufficient substrate. Stimulation of fetal insulin release by maternal hyperglycemia during labor significantly increases the risk of early hypoglycemia in these infants. Perinatal stress may have an additive effect on hypoglycemia due to catecholamine release and glycogen depletion. The overall risk of hypoglycemia is anywhere from 25-40%, with LGA and preterm infants at highest risk.
Hypocalcemia or hypomagnesemia may also be apparent in the first few hours after birth. Symptoms may include jitteriness or seizure activity. Hypocalcaemia (levels < 7 mg/dL) is believed to be associated with a delay in parathyroid hormone synthesis after birth.
Sixty-five percent of all infants of diabetic mothers (IDMs) demonstrate abnormalities of iron metabolism at birth. Iron deficiency increases the infant's risk for neurodevelopmental abnormalities. Iron is redistributed to the iron-deficient tissues after birth, as the red blood cell (RBC) mass is postnatally broken down.

Hematologic problems
Polycythemia, caused by increased erythropoiesis triggered by chronic fetal hypoxia, may present as a clinically "ruddy" appearance, sluggish capillary refill, or respiratory distress. Hyper viscosity due to polycythemia increases the IDM’s risk for stroke, seizure, necrotizing enterocolitis, and renal vein thrombosis.
Thrombocytopenia
Thrombopoiesis may be inhibited because of an excess of RBC precursors within the bone marrow as a result of chronic in utero hypoxia and increased erythropoietin concentration.
Hyperbilirubinemia (Jaundice)
This is common, especially in association with polycythemia. The increased red cell mass results in increased number of RBCs that are taken out of circulation each day and increase the bilirubin burden presented to the liver.

References
1. Barnes-Powell LL. Infants of diabetic mothers: the effects of hyperglycemia on the fetus and neonate. Neonatal Netw. Sep-Oct 2007;26(5):283-90. [Medline].
2. Plagemann A. A matter of insulin: developmental programming of body weight regulation. J Matern Fetal Neonatal Med. Mar 2008;21(3):143-8. [Medline].
3. Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics. Mar 2005;115(3):e290-6. [Medline].
4. DeBoer T, Wewerka S, Bauer PJ, Georgieff MK, Nelson CA. Explicit memory performance in infants of diabetic mothers at 1 year of age. Dev Med Child Neurol. Aug 2005;47(8):525-31. [Medline]. [Full Text].
5. Bromiker R, Rachamim A, Hammerman C, Schimmel M, Kaplan M, Medoff-Cooper B. Immature sucking patterns in infants of mothers with diabetes. J Pediatr. Nov 2006;149(5):640-3. [Medline].
6. Rosenkrantz TS, Knox I, Zalneraitis EL, et al. Cerebral metabolism and electrocortical activity in the chronically hyperglycemic fetal lamb. Am J Physiol. Dec 1993;265(6 Pt 2):R1262-9. [Medline].
7. Stenninger E, Lindqvist A, Aman J, Ostlund I, Schvarcz E. Continuous Subcutaneous Glucose Monitoring System in diabetic mothers during labour and postnatal glucose adaptation of their infants. Diabet Med. Apr 2008;25(4):450-4. [Medline].
8. Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics. May 2000;105(5):1141-5. [Medline].

 

[Celesse]

How do you feel about thier suggestion to transfer in when baby is a few hours old for monitoring?

 

[lynnikins]

do you have a major objection to a trip up to hospital 4 hrs or so post birth for a blood test for baby? if you plan to breastfeed and have pre-expressed colustrum on hand to prevent your LO getting dehydrated etc and to boost their glucose then i dont see why they would have a fit about it.
Oh and i didnt think you were insulin dependant at this point which is the kind of mother they point to in the second part of the "research" an "IDM" which as far as i can read = Insulin dependant mother!

 

[cranberry987]

Not happy about transferring just for monitoring as it seems it's just a case of finding the right equipment. I don't know. I'm so confused now. Might have to tho.

 

[lynnikins]

when they were monitoring Nates bloods ( for jaundice not glucose ) they were doing 4-6 hrly blood tests and they were done on the SCBU and I had to go back there for it to be checked after coming home with him but we were down to tests 48hrly at that point

 

[cranberry987]

I've emailed aims. Every birth story of a diabetic woman says "we tested baby's sugar with a heel prick after an hour at home" etc. So there must be a way.

 

[Celesse]

If it's only inaccurate below 4, does that mean you could test baby at home and if above 4 stay at home, and if below 4 transfer in then for a more accurate reading? If your taking your own blood sugars I doubt the risks they mention of damage and infection are likely to happen.

 

[booflebump]

I'm not sure what they mean about specialist training to do heel pricks - as a student midwife, we were just told what to do and watched over. Nothing was ever said that if we pricked in the wrong place it would affect their bones or ability to walk, so I'm not sure where that is being gleaned from x

 

[cranberry987]

Been looking into it and seems it's a case of them making a last ditch attempt to put me off hb. Aims have pointed me in the direction of a few resources. Have talked to an IM. Also asked a few diabetic home birthers in homebirth.org. They all say just self test as normal.

Also about monitors not being accurate under 4mmol that seems to be true. But more likely to be falsely low in which case we take him in, blood test, go home. Simple.

I found an internal Nhs memo (yey dr google) saying to make sure that the neonatal unit were using an approved meter as some aren't accurate. Meaning that they have some which are accurate enough for scbu. The one I have is a good one and uses the smallest amount of blood possible, might be that there's one which is better so will have a look

Also my doula is an ex mw and is going to talk to some old collegues

This is all just to double check tho really. I'm 99.999% confident about staying at home. And 100% about birthing at home.

The other issues they raise besides the testing, have had a look at the full Nhs guidance and they've picked the scary side of the info. The studies are either done on t1 diabetics (totally different from me) or are a minuscule chance or just aren't an issue. Yea babies get jaundiced, it's generally not a big deal.

Even if baby does go below 2.6 mmol, unless he's showing symptoms of being ill all they'll do is feed him, so either breast milk or formula if i cant produce. Genius idea. Watch a newborn and feed him. I was planning on putting him in a drawer for the first 24 hrs with no food to help him lose the baby fat.....

 

[diz]

Sorry.. I'm not really going to be able to contribute any useful advise but wanted to say its been an interesting read, and from the info that has been provided in the post, appears that it is very clever scare tactics. At the end of the day, part of the information the head of midwifery has provided does not apply to you as you are not insulin dependant, and then other factors such as the heal prick....? My Mum is a lead clinical nurse and apparently a heal prick is a heal prick... As long as you prick the heal of course and use the right equipment!

Hope you get the outcome you want cranberry x

 

[cranberry987]

So ive looked into the issues, wasnt hard tbh as if you look at the NICE guidelines you can see that the issues are not major ones to be concerned about in my case. Theyve picked the worst possible case in the women with the highest blood sugars tho it seems. Pissed off tbh to be given such a one sided story, but its all just arse covering on their part

The bold hasnt copied over, but the upshot is that the issues raised are v v unlikely, but if they do occur they have symptoms which we can look for - theyre not a case of baby dies on the spot, its a case of ooh thats a bit weird lets go to hospital.

Some of the issues arent even relevant, the low magnesium and calcium are just like oh they might be low, but probably doesnt mean anything.

The iron deficiency making baby stupid is caused antenatally (I think due to maternal iron, and mine is fine) and theres no treatment recommended anyway.

So its just low blood sugar which is v unlikely to happen anyway. We test him, along with observing his general wellbeing, and we feed him. If my levels are fine during labour theres actually no reason for him to have low sugars - high sugar in me causes high insulin in him, without high insulin levels in his body he wont have a hypo unless its due to some other unrelated issue.

Not sent this to the HoMw yet as I want to sit on it for a few days, have sent to doula tho who has also been looking into things for me.

All seems like a massive load of arse covering tbh and only serves to make me want to ignore their advice which isnt that useful if there actually IS a problem. Ive pointed that out to them in the past but they dont seem to give a shit.

Spoiler

Many thanks for your email last week, I have been looking into the issues raised, my comments are in bold.

No monitors will guarantee blood sugar recordings below 4mmol which is a problem as your baby is very likely to be below 4 mmols on occasions

I accept that this is true, however one study I read showed that monitors were more likely to produce a false negative.

A midwife my doula spoke to offered this opinion Everything does not need to hinge on the actual glucose measurements in isolation.
If baby comes out, feeds like gusto, is kept skin to skin and feeds at least 3 houry (more would be better) in the first 12 hours, then surely a community midwife can visit twice daily?
If all seems well, if he feeds well, shows no signs of hypoglycemia, is generally healthy, if my blood sugar levels during labour are well controlled, could we have visits at 12 and 24 hrs? Or if not visits then appointments at the local health centre.

Evidence shows that maintaining blood glucose in the range 4–7 mmol/litre during labour and birth reduces the incidence of neonatal hypoglycaemia and fetal distress. If I am unable to stick to these targets then we plan to transfer anyway.

The NICE and CMACE diabetes guidance advises no blood sugars need to be monitored before 4 hours post birth even in a baby of a diabetic mother and we would not be at your home realistically after 4 hours.

NICE guideline Neonatal care for babies of mothers with diabetes says that testing should be done between 2 and 4 hrs of birth. Additionally the full nice guidelines on diabetes in pregnancy (section 7) quotes one study showing ‘Nearly all the low blood glucose determinations (less than 1.7 mmol/litre) occurred in the first 90 minutes of life, which is the period of greatest risk of low blood glucose occurring in babies born to women with diabetes’

Another study says that operational thresholds were proposed by Cornblath et al.[8] They suggested that an infant with compromised metabolic adaptation (ie, IDM) undergo blood glucose measurements (1) as soon as possible after birth, (2) within 2-3 hours after birth and before feeding, and (3) at any time abnormal clinical signs are observed.

From this information it seems like the most conservative testing regime would be to test after birth (giving a reasonable period for skin to skin contact and possibly early feeding), at 90 mins (I assume the midwife would stay for at least 90 mins) and then we self test from then on all the time looking for any clinical signs.



Issues with self testing
• Damage can be caused to the heel or foot if not taken correctly at all times can result in bone deformity and walking issues at a later stage
• Infection
• Un-reliable results as discussed above
• Specialist training is required to perform this sampling and legally as midwives we are not allowed to teach you to do this having checked with our Trust legal team

I am confident that I am able to test correctly. I have sought advice from mothers of very young diabetic children who advise me its exactly the same as testing myself but the needle needs to be on a lower setting and also that toes are able to be used instead of heels. Is there anyone else who would be able to clarify this? A paediatrician maybe? If not then I will self test as I believe the risks to be minimal.
Pulmonary disease
These infants are at an increased risk of respiratory distress syndrome and may present within the first few hours after birth with tachypnea, nasal flaring, intercostal retractions, and hypoxia. Operative delivery due to macrosomia also increases the risk for transient tachypnea of the newborn (Ive had normal growth scans putting him at the 50th %), whereas polycythemia (see comments on polycythemia below) predisposes the infant to persistent pulmonary hypertension of the newborn.
Initially, the differential diagnosis includes transient tachypnea of the newborn (From NICE guidelines: While some of the morbidities listed above correct themselves within a period of few hours to a few weeks (e.g. transient tachypnoea normalises within 3 days of birth)respiratory distress syndrome, pneumonia, and persistent pulmonary hypertension (The midwife will be here initially for an assessment, we will also take advice as to what signs to look out for and transfer at the earliest sniff of a problem)

Metabolic and electrolyte abnormalities
Hypoglycemia may present within the first few hours of life. Although the infant is generally asymptomatic, symptoms may include jitteriness, irritability, apathy, poor feeding, high-pitched or weak cry, hypotonia, or frank seizure activity. Hypoglycemia that requires intervention may persist for as long as 1 week.
Hypoglycemia is caused by hyperinsulinemia due to hyperplasia of fetal pancreatic beta cells consequent to maternal-fetal hyperglycemia. Because the continuous supply of glucose is stopped after birth, the neonate develops hypoglycemia because of insufficient substrate. Stimulation of fetal insulin release by maternal hyperglycemia during labor significantly increases the risk of early hypoglycemia in these infants. Perinatal stress may have an additive effect on hypoglycemia due to catecholamine release and glycogen depletion. The overall risk of hypoglycemia is anywhere from 25-40%, with LGA and preterm infants at highest risk. (This only applies if my blood sugar levels arent controlled during labour and if baby is in distress during labour, in which case we would transfer anyway)
Hypocalcemia or hypomagnesemia may also be apparent in the first few hours after birth. Symptoms may include jitteriness or seizure activity. Hypocalcaemia (levels < 7 mg/dL) is believed to be associated with a delay in parathyroid hormone synthesis after birth. Hypomagnesemia is related to younger maternal age (unfortunately does not apply to me), severity of maternal diabetes (my levels are near perfect) , and prematurity (we wouldn’t birth at home if he was premature). Neonatal magnesium levels are also related to maternal serum magnesium, neonatal calcium and phosphorus levels, and neonatal parathyroid function. The clinical significance of low magnesium levels in these infants remains controversial and uncertain.
Low serum calcium levels in IDMs are common. They are speculated to be caused by a functional hypoparathyroidism; however, their clinical relevance remains uncertain and controversial.
Sixty-five percent of all infants of diabetic mothers (IDMs) demonstrate abnormalities of iron metabolism at birth. Iron deficiency increases the infant's risk for neurodevelopmental abnormalities. Iron is redistributed to the iron-deficient tissues after birth, as the red blood cell (RBC) mass is postnatally broken down.
From what I found in the one study referenced which I could actually access (#4) it seems that the iron deficency stems from the prenatal period. “the infants were iron deficient in the pre- but not postnatal period.” “prenatal iron status may be an important risk factor associated with cognitive outcome in the myriad factors related to the diabetic pregnancy.” I would be interested to know how this is assessed/treated if I was in hospital as it does not seem to be something which is relevant to the issue where to birth but more to the general risks of a diabetic woman having a baby.
Hematologic problems
Polycythemia, caused by increased erythropoiesis triggered by chronic fetal hypoxia, may present as a clinically "ruddy" appearance, sluggish capillary refill, or respiratory distress. Hyper viscosity due to polycythemia increases the IDM’s risk for stroke, seizure, necrotizing enterocolitis, and renal vein thrombosis. Maternal-fetal hyperglycemia and fetal hypoxia is a strong stimulus for fetal erythropoietin production and subsequent increase in fetal hemoglobin concentration. – again, in either of these situations we would transfer.
Thrombocytopenia
Thrombopoiesis may be inhibited because of an excess of RBC precursors within the bone marrow as a result of chronic in utero hypoxia and increased erythropoietin concentration. . Given that maternal-fetal hyperglycemia and fetal hypoxia are a strong stimulus for fetal erythropoietin, and given that we would transfer in either of these situations, I don’t feel this is relevant. How would this be assessed if I was in hospital?


Hyperbilirubinemia (Jaundice)
This is common, especially in association with polycythemia. The increased red cell mass results in increased number of RBCs that are taken out of circulation each day and increase the bilirubin burden presented to the liver.
From NICE guidelines :Where there has been lethargy, delayed feeding, polycythaemia and birth trauma, bilirubin levels should be monitored.
So my conclusion is

Yes handheld monitors do not seem to be accurate, I suggest we take the information given along with all other information ie my levels during labour, his general appearance, feeding, signs of hypoglycaemia and also have the midwife test at birth and 90 mins then we self test from then on.

Hypoglycemia – This is very unlikely if my levels are controlled during labour, if I am unable to control them we will transfer. I have been told that its more likely that my levels will be low/middling rather than high.

Pulmonary disease – the midwife would be looking out for signs of this initially, please could you forward symptoms for us to look out for specifically as well.

Hypocalcemia or hypomagnesemia – seems that there is no consensus as to whether this is actually even an issue. I would welcome information on what signs to look out for but I really see this as a non issue. How would this be assessed differently if I was in hospital?

The issue with iron seems to be caused antenatally. Would this be tested for in hospital?
Polycythemia and Thrombocytopenia seem to be caused by high maternal blood glucose levels and, in the case of Polycythemia, hypoxia – in either of these situations we would transfer
Jaundice – we would transfer if we observed symptoms such as lethargy, delayed feeding, polycythaemia and birth trauma

Im not a medical professional and a lot of the references given were not accessible to me (need to have an account to read the full studies). If I have got any of the information wrong then I am happy to be corrected but it seems that if my levels during birth are fine that negates a lot of the issues. If they aren’t fine then we would transfer. The issues raised do seem to present with symptoms which we would be able to look out for, in which case we would transfer.

Please could you ask the specialists you talked to to compile a list of symptoms which we should be on the lookout for, or forward me their details so I can contact them myself.
Could you also send me information as to how these issues would be assessed if I was to birth in hospital. Would all diabetic mums have their babies routinely tested for such problems if they were asymptomatic?