Last month, we sat down with Ginger Vieira to chat about her recent pregnancy while living with diabetes. This month, we have the pleasure of sitting with Jennifer Smith, CDE, who along with Ginger, co-authored Pregnancy with Type 1 Diabetes, which is available for purchase here.
Jenny, you’ve coached so many women with type 1 diabetes through pregnancy...with so much knowledge on what to expect, what surprised you the most during your own pregnancies?
Jenny: Coaching women with diabetes through pregnancy teaches you the simple fact that everyone is a bit different and that you can achieve anything once you know that you are taking care of the beginning of life for this little person you carry within you. I feel like I didn’t have the same expectations for my second pregnancy as I did for my first. I controlled and watched things the same way, but knew that things could shift and change differently. I found benefit from looking at the records that I kept for my 1st pregnancy and I had a better idea of when a shift could likely take place, but wasn’t worried when insulin needs didn’t change the same way. I think I was most surprised by the differences in pregnancy itself - not so much by the diabetes piece...although that plays a role in the pregnancy, right, so I guess all-in-all each pregnancy is different and you have to work through it as it is happening. That’s why it is helpful to have a great care team to help you along!!
We talked a lot about type 1 diabetes during pregnancy in our first Q&A with Ginger...let’s talk about delivery and postpartum. Can you describe briefly why women with type 1 are more likely to have a c-section?
Jenny: In general, women with diabetes are more likely to have a c-section from statistical evaluation of births. There are several reasons why it might be encouraged more or occur more even when a birth starts out naturally (natural labor or induction). Some women elect to have a c-section for fear of natural delivery not progressing and not wanting it to end in a c-section after the long labor. A c-section might be advised if the growth scans/Ultrasounds close to delivery date show a large baby and the OB team feels that vaginal delivery wouldn’t be possible for safety of mother and baby. It might be advised for someone who has previously had a c-section due to issues with natural delivery or for someone who has other risks that natural birth would create further problems for such as unstable eye disease or blood pressure, or other health risks. Diabetes should not be the only factor for a c-section vs natural delivery. As long as the mother is healthy near the due date, the baby isn’t too large and there are no other risk factors then a natural labor and delivery should be the first option. If natural labor starts, as long as there are no issues with progression a woman is typically able to have a vaginal delivery. With diabetes, so many extra things are being considered and the monitoring is much more intense during labor so these extras can sometimes bring additional reason that they might encourage a c-section at some point in the labor. Monitoring of the baby and changes in fetal heart rate that don’t normalize can be a common reason for c-section delivery. Lack of progression in the mother is another reason for a c-section delivery - at some point the team will advise a c-section to avoid trauma to the infant and mother.
Can a woman, if she wanted, elect to not be induced or have a ceserean at 39 weeks and just wait for the baby to come on its own?
Jenny: While the answer to this is yes, it isn’t something I’d advise. As much as we all want that perfect birth day for our baby, the health of you and the baby is most important. Most OB or High risk OB (MFM - maternal fetal medicine) teams will advise against this and will also possibly discharge you from their service if you decide to go AMA (against medical advice). If you have a healthy pregnancy with diabetes start the discussion early on to see what they will allow for the time close to your due date (40 weeks). Some practices will allow you to go to 40 weeks (but not longer) as long as you come in for more evaluation after 38 weeks. Some practices have a specific “do not go past 38 or 39 weeks” protocol and it is important to know this upfront so you can prepare for the possibility of at least an induction around that time if you do not go into labor naturally. From working with the number of women I’ve coached through pregnancy I’d estimate the natural birth (natural labor or induction) vs c-section is about 50/50 honestly. Every delivery is unique and individual, kind of like diabetes management - you have to be ready to let go of the idea of a perfect delivery and let things unfold at that time. You have worked really hard to keep things healthy up to this point and when the day comes to meet your little one it will be beautiful whether it is a vaginal delivery or a c-section.
In a nutshell (which I know you describe much more complexly in your book), what happens to a woman’s insulin needs during the days after she gives birth?
Jenny: Insulin needs decrease dramatically after delivery. Most women find a drop in insulin of about 50% right after delivery of baby/placenta. This includes basal rate/dose as well as ratios used for meal and correction dosing. Many women find that the 72 hours after delivery may also be a bit more drastic cut in insulin need - up to 60 or 70% less overall. Things even out at a lower level for a few weeks and then by about 4-6 weeks after delivery and milk comes in and nursing has been more of a pattern things go back up to about where insulin needs were pre-pregnancy.
We advise women in a post partum basal rate/dose as well as adjustments to the insulin to carb ratio and correction factor to prevent continued lows. This should be enabled or started as soon as the baby is delivered.
And then...breastfeeding! Some people seem to go low constantly and others say they don’t experience many lows with breastfeeding. Do you have one piece of wisdom for readers in addition to guidance in the book on juggling the blood sugar challenges of breastfeeding?
Jenny: For the most part, the early weeks post partum will be the most challenging with nursing and blood sugar regulation. The 4-6 weeks after delivery will usually be when lower BG can occur after nursing and if you are pumping it will be the same. Having a source of glucose near where you plan to nurse in the house is most helpful (in the nursery, by the rocking chair, in the kitchen, near the couch in the living room, etc). If you find a pattern to nursing and lows, then adjustment to insulin can help prevent having to eat more than you want to avoid or treat a low BG. Overnight can be a time for many lows for women who are nursing and it can help to adjust basal insulin back to avoid having to eat too much at night. If you find you go low after a meal when nursing follows the meal time, then cut the calculated meal time bolus back by 10-20%. If you have added activity back to your plan then lower BG may also be related to nursing as well as the increase in movement and timing of insulin adjustment may need to be made here as well.
Okay, one more question: with the intensity of a new baby, what advice would you give to new moms when it comes to blood sugar goals, burnout, etc. during those first few postpartum months?
Jenny: It will be an intense time of change. Whether it is a new first baby, or adding a baby to a family with another child (or children), time becomes tight to manage. Blood sugar goals can be loosened up compared to pregnancy. Aim for 80-180 (with post meals going no higher than 160-180 and returning to target by the next meal time). If you use a CGM, reset the alert parameters so you don’t get nuisance alarms and create more to worry about. If you have maternity leave from a job - ASK FOR HELP while you are on leave. Give some recipes to a family member or friend who is willing to cook some things for you and have them prep and bring food over. This way you’ll have the carb info for the meal which makes it easier. People want to help when they get a chance to see a new baby (yes, you become the forgotten person - the baby is what holds interest!!) so let people know what they can do. A friend or a grandparent may be willing to come over while the baby is sleeping and this can allow you to have 30-60 min to get out and enjoy some fresh air for exercise or even meet up with a friend. Set reminders on your phone for things like pump site change so that you keep up with diabetes management which will help you stay healthy and ensure you feel good while learning to be a Mommy!
One of the best things I did was to prep some meals for dinner in the last month of pregnancy. I planned some soups and mixed slow-cooker type meals, cooked them and put them in labeled containers in the freezer with the contents and carb count per portion. I even pre-portioned many of them so that I could just take out a labeled bowl and thaw/heat and eat without worrying about meal prep or counting the carbs.
Thank you, Jennifer, for continuing this conversation this month. Next month, we will be having this conversation LIVE at our Weekend for Women Conference in Alexandria, VA. Be sure to check out the weekend's activities and agenda - then REGISTER and join us!