By Elaine Lawson
I'm an insulin dependent diabetic. Eight years ago I gave birth to my first son Benjamin in hospital at UCH in London. It was the kind of birth that most diabetic mothers are led to expect - glucose/insulin drip, epidural and finally forceps because "things are not progressing as they should". It was not the kind of birth I would have chosen and I believe that many of the procedures were "standard issue" rather than specific to my needs during labour.
Last year I gave birth to my second son, Ruben, at home happily, safely and much against the wishes of my local hospital, The Royal Sussex County Hospital in Brighton. I wanted to write about my experiences so that any other diabetic woman who wants to explore the possibility of a home birth will know that it can be done safely.
I knew from the beginning of the pregnancy that I wanted to do things differently. I didn't want to be put on a glucose/insulin drip unless it was absolutely necessary. I had read transcripts of correspondence in The Lancet from 1992 where Professor John Yudkin and Anna Knopfler had discussed successful deliveries using multiple subcutaneous insulin injections instead of drips, so I knew it was possible.
When I put this to my diabetic nurse specialist she was interested but pointed out that it all depended on what the consultant would "allow" me to do. Not wanting to spend the rest of my pregnancy doing battle with my consultant I decided to carry on with my own research and decide for myself what would be safe for me and my baby.
Thanks to a helpful midwife friend, I was able to access the MIDIRS database and found the most up to date research on diabetes management in labour. Among the papers was a survey of 77 insulin dependent diabetics over a 12-year period to 1994 in Canada. Although these women had given birth in hospital, using saline drips, the conclusions of the authors gave me a firm basis to believe that my plan was likely to succeed.
They had found that 60 % of the pregestationally diabetic mothers needed neither insulin nor dextrose during labour and that the outcome for mothers and babies had been better than expected for diabetic women. They furthermore stated that as labour is a "highly aerobic and intense form of exercise" it was logical to expect women to remain euglycemic.
Through the Independent Midwives Association I finally tracked down a midwife who had helped an insulin-using diabetic to deliver at home. The mother was a gestational diabetic but as far as I was concerned the basic idea was the same (and as an insulin user of 10 years experience I felt that I might be more in tune with my diabetes),
This mother's blood sugar levels had stayed well within normal throughout labour, the baby had been monitored with Sonicaid every 15 minutes and the mother had used fresh orange juice for energy. They had taken the precaution of having donated early breastmilk on hand in case the mother could not feed in the first hour which might have caused the baby's blood sugar levels to drop. In the event it wasn't needed.
So my plan was beginning to seem more and more feasible. I presented my research to Julia Montgomery, the consultant obstetrician at the hospital. She wasn't very interested. She replied that it was "not our policy to allow diabetic mums to have a home birth nor to stay at home in labour". No discussion of research, just a statement of policy.
Knowing that policy in matters diabetic is always changing and as I felt convinced by my research that my plan was possible, I didn't take her pronouncement too seriously. I knew that it was my legal right to give birth wherever I chose and I felt that my decision was an informed one.
By this time (about 7 months into my pregnancy) I had the community midwife on my side. After an initial "no way" when I had mooted the possibility of a home delivery, she had taken the trouble to read my research, presented it to her manager and been given the green light.
Now we needed to establish procedures to follow during labour to keep it as safe as possible. Although I had asked the consultant obstetrician and the diabetic consultant for specific information on this, none was forthcoming. They seemed unable to see beyond hospital policy. Luckily my diabetic nurse specialist was more pragmatic.
She gave me the phone number of the consultant neonatologist at the hospital who, although bemused by my intentions, was able to give me clear information on possible problems that the baby might face, how to recognise them , how to deal with them and at what point hospital would be necessary. He advised me to have some Hypostop on hand to smear on the baby's gums in case of hypoglycaemia.
He also told me that the baby had a 50/50 chance of further intervention after birth in hospital which made me wonder why it was being presented to me as the only safe option. I had already read in some papers that there was a possible link between neo-natal hypoglycaemia and inaccurate dosages in the mother's insulin/glucose drip.
The only piece of the puzzle now missing was the amount of insulin to give myself in each dose through the labour and how much food/drink I would need to balance it so that my blood sugars stayed on an even keel. I was used to giving myself 3 injections a day before meals and wasn't quite sure how to break that down into smaller, more frequent injections as I wasn't expecting to be eating meals during labour !
Again I asked the diabetic team at the hospital for help to work out a safe regime. None was forthcoming so I was left to figure it out myself. I had contacted Professor John Yudkin for information and was able to use his general pointers to put together a system. I made sure we had plenty of juice in the house in case of hypos during labour.
I felt as ready as I could be. When labour started with a show at about 9 pm the evening before my due date I did my usual nightly injection of long acting insulin. For the next few hours I tested my blood sugar every hour and it stayed well within the range of normal. As things really got going around 1am my blood sugar dipped but a good slug of orange juice seemed to sort that out.
I had a pool which I used throughout the labour but we were too distracted to keep the water warm enough and Ruben was born as I stood over the water at 3.45am. His blood sugar was tested an hour after birth and was normal. It remained normal through the next few tests and, as far as I know has been normal ever since. He is a strong, healthy baby without any of the problems his brother suffered from being delivered by forceps.
While I understand the hospital's concern to prevent any possible problems during the pregnancy and labour of diabetics, I was very disappointed at their lack of interest in (or indeed, knowledge of) the most recent research. As in most things diabetic, it seems that present policy is based on old information and many women are suffering unnecessary interventions due to medical inertia.
In my own case you might think that the hospital diabetic department would have been interested in my safe experience of a home birth as an addition to their knowledge of the subject. Sadly not. Even though they were fully aware of the outcome of my unusual labour, none of them contacted me afterwards. They were probably just relieved that they wouldn't have to deal with a diabetic who had stepped out of line any more.
Reading back through this account of my pregnancy I feel that I may be giving the impression that I sailed through the whole experience with a bit of research here and a few skirmishes with consultants there. I'm more distanced from my feelings of the time as I'm writing this one year on.
Thinking back, the battle to get the hospital to take my research on board and to give me the help which I needed on specific points of diabetic management during labour was exhausting and depressing. I was left to find out the specific information on my own.
Luckily I was able to call on various independent midwives who gave their time generously even though I was calling them out of the blue. Pat Thomas of AIMS was a pillar of strength, giving me the support I needed to deal with the unwillingness of the hospital to take my plan seriously (even though I had always made it clear that I would come into hospital if it proved necessary and that the hospital is 5 minutes from our house). It would have been a long and lonely battle without them.
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