The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.
Other excellent resources about avoiding toxins during pregnancy
These are easy to read and understand and are beautifully presented.
I posted last week about a presentation about GDM testing; here is a summary of the presentation:
Presenter: Steven Gabbe, M.D. (for those of who don't know the name, he is the author of a respected OB textbook and generally a well-recognized academic and clinical OB.
To find those that need insulin, because they suffer the greatest perinatal mortality.
He presents a table from Cassady, G et al. Am J Obstet Gynecol 122:13 1979
124 Class A diabetics (diet controlled -- normal fasting and post prandial glucose)
Perinatal Mortality: 3 = 24.2/1000
24 diabetics labeled Class A who were actually Class A2 (needed insulin because their fasting and/or postprandials were elevated). He doesn't explain why these women were misdiagnosed and why their insulin requirement was overlooked.
Perinatal Mortality: 4 = 190.5/1000 (this is eight times higher than
the really truly Class A group)
Macrosomia: 38% (more than double)
This was his whole point of the presentation: that we should tighten up screening cutoffs, provide sound nutritional counseling to all GDMs, maintain strict home glucose monitoring, and provide insulin for those who's fasting is > 95mg/dl and/or who's 2 hour PP is > 120 mg/dl because this will reduce complications and lead to better outcomes
[Notetaker's Comments: I know that many midwives are angry that so many women get put into the category of GDM and protest putting women through an unpleasant series of tests, and therefore will be resistant to the notion that we should be MORE vigilant in identifying glucose intolerance in pregnancy.
However, IMHO we should not undertake greater surveillance so as to label more pregnant women as "high risk", because it is becoming clearer and clearer that when diet-control is sufficient (fasting and postprandials are normal) women and their babies have good outcomes. But as is evidenced by the study quoted above, when a woman is actually requiring insulin and for whatever reason her care providers don't know that she does, she and her baby are at very high risk of complications and we have a responsibility to find those few women in our obstetric populations and PREVENT fetal disability and death.
I understand the desire to avoid testing that has such a high false positive rate (only 15% of women with abnormal GCTs will have an abnormal GTT), and our clients can certainly opt to not test, IF they are fully informed as to the nature of the disease and it's subtle presentation and the potential risks. Heck, I have clients who won't do the metabolic screening of their kids. They know what it is for, they understand the prevalence of the diseases, the consequences if their child has one of them and it is not detected through screening. Can't tie the kid down and draw the blood, can I??? ]
59 Class A Controls (no home monitoring. he doesn't state whether or
not the provider was monitoring their glucose control, but it appears from
the results that they were, probably the recommended weekly fasting and
2 hour PP)
Rate of Macrosomia: 24% = 14 cases (does not detail definition of macrosomia)
Needed Insulin: 21% = 5 cases
58 Class A Treatment: unspecified number of daily glucometer readings
Rate of macrosomia: 9% = 5 cases
Needed Insulin: 50% = 29 cases
Intensified = 7 daily home glucose reading with meter. Conventional = 4 times daily visual. Conventional (n=1,316 women) Insulin requiring = 34% Macrosomia (>4000 gms) = 13.6% Primary Cesarean = 19% Shoulder Dystocia = 1.4% Intensified (n=1,145 women) Insulin requiring = 66% Macrosomia = 7.1% Primary Cesarean = 13% Shoulder Dystocia = 0.4% note: all results were significant to a p<.01Langer et al Am J Obset Gynecol 1994; 170:1036-47
Values for home monitors compared to plasma Capillary result Plasma result Accu-check II 160 135 Accu-check III 155 135 One Touch II 120 140
Jovanovic-Peterson L. et al Am J Obstet Gynecol 1989 161:415-419
Screening: (this was hand-written by me on the back of the syllabus, so I don't know if it was his opinion or an official ACOG criteria)
Women who do not need GCT screening:
I am very conflicted, as I am sure many of the midwives on this list are. My clients mostly hate the testing. I am horrified that I have to subject a pregnant woman to fasting and then a huge sugar load when only 15% of abnormal GCTs end up diagnosed GDM.
Then again, I buy the argument that some of those who truly are glucose intolerant are at higher obstetrical risk, but when we have to put a woman on insulin she can no longer give birth at the center, which is usually very upsetting news (thankfully we have privileges at the backup hospital and can still attend them, but the loss of the nice birth center birth dream is painful for many of our clients).
And I realise that midwifery is not just about people having a wonderful birth experience, it is also appropriately using knowledge and technology to wherever possible maximize the chances of a healthy outcome. So, it is too bad that women don't like the testing or that they get thrown out of the birthcenter if their sugars aren't well controlled -- it is better than a dead baby or an unnecessary cesarean, right? I still feel terribly conflicted.
And I also realize that these issues bear even more weight for homebirth
practitioners and non-legal midwives. If one of these practitioners identifies
a woman as GDM, she may have to leave the practice all together and then
might face all kinds of other complications at the hands of the mainstream
OBs (ie inappropriate induction, unnecessary cesarean, etc, etc), especially
if the OB knows or suspects the woman started her care with a non-licensed
practitioner or was planning a home-birth (or god-forbid thinks the woman
was irresponsible enough to get to 30 weeks with no prenatal care if she
doesn't disclose). ]
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