“What’s the Medical Indication?”

Or, Lily’s Continuing Misadventures in Gestating

I now have about two full weeks of watching my blood sugar numbers behind me. My fasting level stays consistently higher than the target, while my post-meal numbers stay consistently within target as long as I don’t have a lot of grain-based carbohydrates. Rather than following the diabetes center guidelines of whole grain carbs at every meal and snack (totaling more than I would normally eat in a day), I am basically on what high school Lily referred to as the “cave man” diet – not to be confused with the formal paleo diet, which cuts out all fruits, along with dairy milk, because paleo is a no-carbs-at-all diet. No, my caveman diet is more “Is it refined or grain-based? If so put it down.” The caveman food pyramid puts veggies and fruits on the bottom, then protein, then dairy and fats, then grain at the top. With a general avoidance of added sugars along the way, within reason, because total abstention is just not realistic every single day. So far I am keeping my numbers in line and hoping I don’t end up needing to go full paleo before this pregnancy is over.

That said, my doctor threw an unexpected loop at me when I finally had a visit with her post-test/diagnosis of GD. She looked over my numbers, said she wasn’t at all worried about them, and went on with the appointment. At the very end she added, “oh, and you know how I said I’d let you go to 42 weeks without pushing to induce? Yeah, with GD I can’t let you go past your due date because of the increased risk of stillbirth if you go over.”

Say…what?

I had by the time of my appointment read probably two dozen articles about GD, how to keep it in check, what the theories behind it are, what risks it presents to mother and baby both, and none of them mentioned any risk of stillbirth or had a discussion about induction at due date if spontaneous labor didn’t occur on its own (either as a true medical indication or even just SOP for doctors/hospitals). So her comment came as a surprise, even when I thought I was up on my information about the condition. I didn’t argue the point then, both because the appointment was essentially finished when she said that and because I wanted the chance to do my own research and have an assessment of my own before discussing it with her in more depth.

I used different search terms and found a lot of forums where women said their OB’s gave them that line and they agreed to induce (many of them at like 38 weeks instead of the full 40, many of them happily, because, of course, a healthy baby is not just an important thing, not just the most important thing, but the ONLY THING THAT MATTERS in obstetrical care right now, and us ignorant breeding cows should be GRATEFUL that the medical overlords can safely deliver us a child regardless of the harm to ourselves). What I didn’t find? Was an abundance of articles discussing the true risks of going overdue with mild/diet-controlled GD and the actual medical indication for induction either at or before the 40 week mark.

In fact, I didn’t find any articles that showed a true medical indication for why a mild GD patient must give birth at 40 weeks.

I found discussions on why insulin-controlled GD heightens the risk of placental failure (insulin apparently speeds up the natural degradation of the organ), and I found the increased risk rates for developing a secondary condition like pre-eclampsia after developing GD. Those were sobering findings, enough to make me take the whole diagnosis a little more seriously than I did at first. Keeping my blood sugar under control is a preventative measure for conditions that would utterly derail my pregnancy philosophy because they would inject *just enough* true risk for me to not ignore them.

I also found the two studies that most of the GD-outcome-assessments seem to be based on. One is a smaller study from 2002 that did seem to indicate an increased risk of stillbirth with GD. Something like 5% of the stillbirths in the study were correlated to GD rather than unrelated pregnancy complications…which ended up being something like 1 out of 500 births had a GD-related stillbirth, if I recall the math right. It was minuscule, statistically speaking, whatever the actual number. Moreover, that study did not differentiate (1) whether the GD was controlled or treated in any way and (2) did not differentiate which, if any, of the stillbirths happened in women who developed a secondary complication like pre-eclampsia. So the risk factor was both narrow and ill-defined in the published results. The second, much larger study (the HAPO study from 2012) found no correlation between diet-controlled GD and increased rates of stillbirth. Infant death was, in fact, so uncommon that it got bundled with several other adverse outcomes that were all on their own too statistically insignificant to mention.

Neither of these findings incline me toward accepting an induction at 40 weeks and 1 day if I’m not in that delivery room on my own.

Why am I so reluctant to induce? First, by current evidence-based definitions, a baby isn’t actually overdue until 42 weeks and 1 day (since full-term is the range from 37-42 weeks). Second, the average gestation for my statistical subgroup (Caucasian first pregnancy) is 41 + 1, not the 40 that is the average of ALL pregnancies. Third, both my mother’s first and my mother-in-law’s first were past the 40-week due date by a week and a half or more, so my little fella has the tendency from both sides of the family. Fourth, induced labors are longer, more painful, and more difficult than spontaneous labors. Fifth, induced labors have something like a 50% higher likelihood of ending in a C-section than a spontaneous labor. Or is it that 50% of inductions “fail” and end in a section? Either way the intervention of medical induction creates a much higher risk of fetal distress that results in a C-section than a spontaneous labor.

Why am I so paranoid about C-sections? First, it is a major surgery, and no matter how common a surgery it is, no such surgery is without risk. I believe the risk of adverse maternal complications in a C-section is significantly higher than that 1 in 500 risk (if that’s even the real risk) of strictly-GD-based-complications in delivery. Second, I do not want to spend my first few weeks with a newborn recovering from a major surgery, especially since I could easily end up functioning as a single mom with no real support network if my husband ends up offshore, since neither of us have family closer than 6 hours away and all of my friends also work full-time. I need to be able to take care of myself and my baby, period. Third, GD tends to happen in every subsequent pregnancy after it happens once, and often gets worse each time. Having a VBAC (vaginal birth after c-section) is already hard enough – another of those times the medical establishment wants to herd women into their preferred path by playing up the risks that come with VBAC rather than discussing them in comparative terms to normal complications – and with GD in the picture it would be even harder…especially if I were to go “past due” with my second pregnancy. See reason #2 why I do not want a section, compounded now by the fact that it would be caring for both a newborn and my other child(ren).

Beyond all my rational reasons I also have visceral fears of both induction (due to a friend with a pretty horrific worst-case-scenario outcome when hers failed) and section (due to my absolute terror at having no control over the outcome of a situation).

So with all of that said, I am obviously not going to let my OB railroad me into “SOP for that condition” without her being able to prove to me why it is medically indicated. Those are the magic words. SOP is not good enough – I am not a statistic, I am a human being, and the circular argument of “we need to treat you this way because that is just how we treat that condition you have” essentially tries to wipe out my own agency and individual circumstances/beliefs. The associative argument of “But don’t you want a healthy baby?” is not compelling enough for me to surrender every piece of my own agency and ability to draw my own risk assessments, rather than letting a doctor decide that the 1/500 chance of an adverse fetal outcome trumps the 1/50 chance that the surgery will injure me.

No, at my next appointment we are going to talk about why, exactly, she feels compelled to get that baby out right at 40 weeks, and if she can point me to the study or medical journal listing the actual statistical risks then I will be more than happy to take them into consideration, along with her medical opinion. But from everything I’ve been able to find for myself on the public web, I don’t expect her to be able to conjure an actual medical indication for treating my pregnancy any differently than we initially planned on.

And I am pissed off all over again that I am having to go to such lengths to protect myself and my baby from what I view as unnecessary and unjustified medical interventions. What the fuck is wrong with prenatal care in this country?!

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4 Comments

Filed under Ramblings, Rants and Storms

4 responses to ““What’s the Medical Indication?”

  1. The ‘medical model’ of pregnancy tries to ensure a healthy baby – but don’t they remember maternal stress (which they cause) is the worst thing you can do for the baby?

    With you in spirit – hoping you can get this doctor a bit out of her comfort zone. They all worry too much about being sued – if they don’t use some guideline or other. Their statistics are not well examined – they don’t have the time for it.

    Take your time, do your research, consider whether, even at this late stage, this is the best person for you. I found it important to read how large a sample of people the medical studies were based on: there are a lot of papers out there written by graduate students as a thesis. Make sure you feel safe with the doctors/midwives you’ve chosen.

    • In my view the “medical model” aims for a healthy baby no matter what the consequences to the mother, be they physical or psychological. It’s another face of the Cult of the Sacred Child that this country belongs to, where the argument of “it’s for the children”/”if it saves one child” is expected to trump any other consideration.

      And yes, that model is creating a ridiculous amount of stress for me that should not be there, that would not be there if I were receiving no prenatal care at all (not that I am advocating that but it’s kind of sad that I’d be the happy pregger i’m supposed to be absent any of their interference or advice vs a mostly zen pregger who goes through occasional but regular bouts of despair, terror, and hysterical tears because of their interference/advice).

      RE the sample sizes on the studies, I did look at those. The earlier study was around 3000; the larger study – the newer one that showed no link to mild GD and stillbirth – was I think around 20,000. Its findings were a little more compelling to me.

      RE the OB, I really don’t know how the conversation will go, whether she will be willing to work with me on this. I was surprised at her attitude, because she is a very “it’s a natural-process” minded doctor who just seems to let things roll and told me from the beginning she only induces in strict circumstances. Because of that reassurance I have expressed to her that I want a natural (pain-med and intervention-free birth) but not my fears about induction/section because I thought those were just…not in the picture for me barring some really serious complication that would convince me that really was the best course of action. I am certain she has no idea that I have broken down sobbing on the phone with my mom trying to explain all of this. I think I should aim for doing that in her office if she tries to insist on her way even if she can’t provide evidence to back it up. Sometimes what logic can’t get for you emotional outbursts can. 🙂

      • Best of luck with that – and with the doctor – but I worry about doctors (male AND female) who turn paternalistic and ‘protective’ when women turn emotional. Follow your gut instincts.

        It seems like a complete lack of concern for the incubator part of the equation, doesn’t it? And yet there will be no help and no sympathy if you can’t take care of the baby because they made you ill/weak/disabled, because of course it’s all about the healthy child.

        The part I hated about the situation was that there were so many of them, and only one of me, and I was the one in pain. It should be the other way around – and I hope you get that feeling of loving support all the way.

      • The main reason I think bursting into tears with her would work is that i’ve heard from another of her patients that the moment which finally spurred a “heart to heart” cnnversation was that kind of break-down. But that’s kind of the last resort…hopefully she’ll just talk to me rationally. 🙂

        What’s funny is i don’t even care about a feeling of loving support. i just want them to stay out of my way and not make me feel threatened or pushed toward paths i’m not comfortable with when there’s not a good reason to medicalize. But i certainly hope the staff i am with will understand and support my birth plan and goals. Since, barring any *actual* high risk factors creeping in during these last few weeks, i’ll be at a birthing center attached to a hospital, rather than standard L&D ward, I SHOULD have sympathetic assistance.

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