"Speak English, Andrea."

Yes. Well. What the doctors are doing in the name of managing high risk type 1 diabetics does not actually decrease the risk at all. If you actually look at the studies. But the doctors do it anyway. I suspect most pregnant type 1 women don't actually go out and read the studies, so they likely assume that the doctors know what they're doing and are applying the latest and most up-to-date research and techniques, which is probably a less stressful way to live one's life.

Where I used to live, all diabetic pregnant patients were seen at the Diabetes portion of the High-Risk clinic in the local hospital. It was presented as a great convenience for patients: endos and obgyns all in the same place! Ultrasounds on site! Get it all over with at once! Actually it was terrifically inconvenient.

For one thing, all diabetic patients were seen Thursday mornings. Thursday mornings no good for you? Tough luck. Thursday morning it shall be, because that's the way the doctors like it. Redesign your entire life to accommodate our schedule, please.

For another, there were 8 obgyns in the clinic and one had no options about who one would see. One simply saw whoever was on rotation the day of one's next scheduled appointment. This meant that I never saw the same doctor twice in a row. And apparently they spent no time reviewing files beforehand, because they never seemed to know what was going on with me until they rushed through the office door, sat down, opened the file and skimmed the first sheet. Which means I often asked the very same question three visits in a row. And received three different answers, because I saw three different doctors.

For a third, they treated all of their patients the same way, regardless of blood sugar control. My very first appointment, I sat down with the nurse. I smiled at her, she smiled at me, and said, "The good thing about being diabetic is that we won't let you go overdue. You'll be induced at 40 weeks!"

And she really believed it was a good thing, too. I didn't, but it didn't matter; every time I brought it up with a doctor I would get a polite smile, a non-answer, and a firm commitment to induce at 40 weeks regardless of ultrasound results, blood sugar control, baby's size or the presence or absence of any signs indicating the onset of natural labour. As anyone who's done any reading on induction knows, if there are no signs that labour might be starting soon on its own (dilation or effacement of cervix, for example) then it often creates an incredibly painful labour that leads nowhere and results in a c-section.

Nothing was ever presented as a choice. "Your screening test will be at this office on this date." "You will have a level 2 ultrasound on this date. You will then have another level 2 ultrasound at the other clinic on that date."

And if I thought it was bad during the pregnancy, the actual delivery quickly put that in perspective, as the first thing they did was have me sign a form saying that they could do whatever they wanted and I couldn't object; then they strapped an electronic fetal monitor on me and refused to take it off, even for five minutes; which, as most of you will know, means you MUST be lying down to labour, which is incredibly painful and offers no options for relief, which almost invariably leads to epidurals, and so on.

I will never have to be in that hospital ever again, because last April we moved out of its area. I don't know that the new one is any better, but at least I don't have any negative associations with it. And let's not even talk about after the delivery, when they asked me if I wanted her finger-fed or bottle-fed and then bottle-fed her anyway even though I said I preferred finger-feeding.

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But isn't it all worth it if the outcome is better? Isn't it all about a healthier baby? I mean, it's pretty selfish of me to complain about this stuff if it could save my baby's life!

Except that there is no evidence that it does so. The downside of reading the research is that even as they are doing something to me I know that it is ineffective and that the distress it causes has no positive effects whatsoever, for anyone, except for the hospital's pocketbooks because they can charge OHIP more exorbitant fees for higher-tech tests and interventions. And I have no choice. I would love to have a midwife; but the laws governing midwives in Ontario prohibit them from providing primary care to high-risk patients.

Look at this abstract:

Med J Aust. 2005 Oct 3;183(7):373-7.

The Australasian Diabetes in Pregnancy Society consensus guidelines for the management of type 1 and type 2 diabetes in relation to pregnancy.

Strict control of blood glucose levels should be pursued before conception and maintained throughout the pregnancy (glycohaemoglobin [HbA(1c)] level as close as possible to the reference range). Before conception: high-dose (5 mg daily) folate supplementation should be commenced; oral hypoglycaemic agents should be ceased; and diabetes complications screening should take place. Management should be by a multidisciplinary team experienced in the management of diabetes in pregnancy. Blood glucose monitoring is mandatory during pregnancy, and targets are: fasting 4.0-5.5 mmol/L; postprandial < 8.0 mmol/L at 1 hour; < 7 mmol/L at 2 hours. A first trimester nuchal translucency (possibly with first trimester biochemical screening with pregnancy-associated plasma protein A and beta-human chorionic gonadotropin) should be offered. Ultrasound should be performed for fetal morphology at 18-20 weeks, if required, for cardiac views at 24 weeks and for fetal growth at 28-30 and 34-36 weeks. Induction of labour or operative delivery should be based on obstetric and/or fetal indications. Level 3 neonatal nursing facilities may be required and should be anticipated when birth occurs before 36 weeks, or if there has been poor glycaemic control. Insulin requirements fall rapidly during labour and in the puerperium. At this time, close monitoring and adjustment of insulin therapy is necessary.

Did you catch that? Labour induction and/or operative delivery should be based on obstetric and/or fetal indications. In other words: don't just induce at 38 or 40 weeks because the patient is diabetic, for crying out loud.

I had to go back to 1993 to find an abstract supporting early induction of labour in insulin-dependant diabetics:

Am J Obstet Gynecol. 1993 Sep;169(3):611-5.

OBJECTIVE: Our purpose was to assess whether a program of expectant management of uncomplicated pregnancies in mothers with insulin-requiring gestational or pregestational class B reduces the incidence of cesarean birth. STUDY DESIGN: Two hundred women with uncomplicated, insulin-requiring diabetes at 38 weeks' gestation who were compliant with care and whose infants were judged appropriate for gestational age were randomly assigned to (1) active induction of labor within 5 days or (2) expectant management. The expectant management group was monitored with weekly physical examination and twice-weekly nonstress tests and amniotic fluid volume estimation until delivery. RESULTS: Expectant management increased the gestational age at delivery by 1 week. Approximately half (49%) of the mothers in the expectant management group required induction of labor for obstetric indications. The cesarean delivery rate was not significantly different in the expectant management group (31%) from the active induction group (25%). The mean birth weight (3672 +/- 407 gm) and percentage large for gestational age, as defined by birth weight > or = 90th percentile, of infants in the expectantly managed group (23%) was greater than those in the active induction group (3466 +/- 372 gm, p < 0.0001, 10% large for gestational age). This difference persisted after controlling for gestational age and maternal age and body weight (p < 0.01). CONCLUSION: In women with uncomplicated insulin-requiring gestational or class B pregestational diabetes, expectant management of pregnancy after 38 weeks' gestation did not reduce the incidence of cesarean delivery. Moreover, there was an increased prevalence of large-for-gestational-age infants (23% vs 10%) and shoulder dystocia (3% vs 0%). Because of these risks, delivery should be contemplated at 38 weeks and, if not pursued, careful monitoring of fetal growth must be performed.

The difference in birth weight between induction at 38 weeks and expectant management, if you're not into reading that closely, was about 200 grams or less than half a pound. It was half a pound that pushed approximately 13% of the babies over the magic "LGA" line; but it was still only half a pound.

This, more recent, review demonstrates no difference between expectant management (i.e. waiting for labour) or induction/c-section:

Cochrane Database Syst Rev. 2001;(2):CD001997.

BACKGROUND: In pregnancies complicated by diabetes the major concerns during the third trimester are fetal distress and the potential for birth trauma associated with fetal macrosomia. OBJECTIVES: The objective of this review was to assess the effect of a policy of elective delivery, as compared to expectant management, in term diabetic pregnant women, on maternal and perinatal mortality and morbidity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (last searched February 2001). SELECTION CRITERIA: All available randomized controlled trials of elective delivery, either by induction of labour or by elective caesarean section, compared to expectant management in diabetic pregnant women at term. DATA COLLECTION AND ANALYSIS: The reports of the only available trial were analysed independently by the three co-reviewers to retrieve data on maternal and perinatal outcomes. Results are expressed as relative risks (RR) and 95% confidence intervals (CI). MAIN RESULTS: The participants in the one trial included in this review were 200 insulin-requiring diabetic women. Most had gestational diabetes, except 13 women with type 2 pre-existing diabetes (class B). The trial compared a policy of active induction of labour at 38 completed weeks of pregnancy, to expectant management until 42 weeks. The risk of caesarean section was not statistically different between groups (relative risk (RR) 0.81, 95% confidence interval (CI) 0.52 - 1.26). The risk of macrosomia was reduced in the active induction group (RR 0.56, 95% CI 0.32 - 0.98) and three cases of mild shoulder dystocia were reported in the expectant management group. No other perinatal morbidity was reported. REVIEWER'S CONCLUSIONS: There is very little evidence to support either elective delivery or expectant management at term in pregnant women with insulin-requiring diabetes. Limited data from a single randomized controlled trial suggest that induction of labour in women with gestational diabetes treated with insulin reduces the risk of macrosomia. Although the small sample size does not permit one to draw conclusions, the risk of maternal or neonatal morbidity was not modified. Women's views on elective delivery and on prolonged surveillance and treatment with insulin should be assessed in future trials.

Or, in other words, babies delivered early were smaller (duh) but the risks of morbidity and mortality were the same. Of course, doctors do it anyway. They do it anyway because they believe it is safer and because they believe it will look better in a courtroom if, god forbid, anything were to go wrong.

The doctors were very good about picking up new research when it suited them, however; for instance, my skin reacts very badly to pregnancy. I look like a fourteen-year-old boy on steroids. I did some research on my options. I printed abstracts. I called Motherrisk to find out what the known effects and risks were. I decided that I wanted to try a topical antibiotic cream to at least mitigate or manage it (being very fair and thin-skinned, I also scar easily). I waited until the third trimester and then asked the doctor.

She said no. Why did she say no? Because a single study had just been released saying that infants who received too much oral antibiotics had an increased risk of asthma later in childhood. Was there the slightest evidence that the use of a topical antibiotic cream by a mother during the third trimester had any chance of even being absorbed, let alone crossing the placenta in sufficient quantities so as to increase asthma risk? No. This was the same obgyn who at a later appointment advised me not to write a birth plan, as I wouldn't get what I wanted anyway.

That was the attitude of the office: current medical research would be used when it enhanced the doctors' control over the patients. Otherwise, it was disregarded. They didn't have to pretend to listen to their diabetic patients because we had no other choices for care: midwives are legally barred from us, and family doctors refuse to take the high risk patients on.

Since my experience with them ended I've been known to say that I would rather give birth in the Ganges River than subject myself to their care again.

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So one thing I was happy about on Wednesday when I saw the new doctor was that it's her own practice. It's not an office of eight where there is never one person to follow your care. I can get to know one doctor, who can get to know me; there can be discussions from week to week. Things can develop. I don't need to worry about sitting on an important question until I have an appointment with the one doctor in a large practice who isn't an asshole.

And there were other signs that I took to be positive, too. The pregnant women in the waiting room seemed relaxed. There were three teenagers, one girl there with her mother. I thought it was a good sign that she is seeing patients from a diversity of situations; and teenagers are frequently treated as high-risk, too.

I'm not letting myself get too settled in. Even if we are successful, maybe she'll want to refer me to someone else for my care. Maybe she didn't flinch because she has no intention of caring for a diabetic. I can only tell when the time comes. And she might be a complete jerk. Just as patronizing and controlling and rigid as the old practice.

But at least right now, I can imagine it otherwise.

Sometimes ignorance is bliss.