I want to be that mother who can stand up and say I am a strong confident mother and I know what is best for my children. We breastfeed and co sleep, We listen, We include, We eat chocolate and snot smoothies, we trampoline and grow frogs, we sling, we carry and we try and understand and work with our children without resorting to punishments, threats or coercion.

Sunday, 26 February 2012

Another chance for me to be informed about birthy stuff whilst pregnant - Gestational Diabetes

I realise I launched into my thoughts on my experience with gestational diabetes quite late on in the journey without actually talking about the whole GD thing from the beginning.

The main reason for that, is that once again I found myself in the midst of having to deal with yet another pregnancy and birth related 'problem' whilst being pregnant.  I don't deal brilliantly with stress at the best of times but whilst pregnant well thats a whole nother level.  I felt optimistic that having an independent midwife this time round would make things less stressy than having to deal with a multitude of NHS staff.  I was visualising my homebirth more and more frequently now we had settled into our new home and not once did it have NHS intervention or any issues attached to it.

"Gestational diabetes mellitus (GDM) is a (usually) temporary form of diabetes that occurs during pregnancy. It happens when the hormones made by the placenta during pregnancy make it harder for insulin to work. Insulin is a hormone that helps process your food and keeps your blood glucose level stable. If you can’t make enough insulin your blood glucose levels will rise. High blood glucose levels can cause the baby to put on too much weight. This can impact on the baby’s well being and your delivery and can affect the baby’s health later in its life"Understanding Diabetes - Natasha Leader

During my 18week midwife appointment, my sugar levels from peeing on a stick were very high.  We put it down to the fact that it had been Halloween the night before and we had all eaten a tremendous amount of sweeties!!  I had been given a blood test a few weeks before, which luckily (since we hadn't asked for it), showed my sugar levels as being within the normal limits.  I was advised to cut out refined sugar.  It had been on my mind to at least cut down.

Then at my 27week midwife appointment, my sugar levels were once again raised.  This time and for some unknown reason, except that I am possibly an idiot, I had a bowl of coco pops and raw milk just before she arrived.  I had a major craving for this childhood cereal because I was loving enjoying milk again after stopping whilst breastfeeding.  I have not had sugary cereal like this for at least 4 years.  We cut down gradually by calling it weekend cereal and only having at weekend for a while, until I stopped it altogether.  There was clearly some subconscious voodoo wake up call type thing going on.  I also think it was a last blow out as me and the girls were stopping ALL refined sugar that week after a particularly crazy December of sweets and chocolate.

Then at 30weeks more sugar showed in my urine so this time it was decided I should get a glucose Tolerance Test.  I also fell into a lot of risk categories for possibly having gestational diabetes: older mama, overweight, previous big baby and two family members with late onset type 2 diabetes.

The main concern with gestational diabetes is the size of the baby, a large baby at full term can in some cases cause shoulder dystocia, something my IM has had no experience with either.  Other issues are hypoglycaemia in the newborn who is used to having large amounts in utero.  This can also be due to stress after birth, so skin to skin straight away and establishing breastfeeding are of the utmost importance.  To this end, I am sorting out expressing colostrum and organising donor milk just in case there are problems and my baby needs milk before my own milk comes in.  (video for expressing)

So a week later after researching as much as I could about 'consuming a phenomenal amount of sugar after eating nothing and testing my sugar levels' that's where I found myself.  I was not keen on doing the test since a lot of articles I read seem to question the validity of it.  Michel Odent talks about the discrepancies in diagnosis and whether this is a disease or a diagnosis.

We made the decision based on my other risk factors and the fact that our IM midwife had never had a client with GD before, so she was unclear yet of protocols and risks.  It is also good to have a more clear answer than the peeing on a stick test.

I had also begun my diet change.  After discussing it with my CC mothers group, most of whom are incredibly knowledgeable with regards to healthy dietary habits, I formulated a nominal can and can't have list based on low and high GI.  Basically, the foods with a lot of carbohydrates.  The can have is much larger so I have not included it, but it contains many many vegetables, black eyed beans, quinoa and brown rice instead of white forms of pasta.  I will right more about my diet at a later stage as in midst of it at moment!

white potato – sweet potato instead
white pasta – wholemeal instead
white bread
white cous cous
white rice -wholemeal instead
fruit juice
honey (have small amounts occasionally)
bananas (can have half) -  
all sugar (had already stopped this a month or so before)

the fruit one is a hard one since I ate tons before, now half an apple or two tangerines or half a banana are my allowance probably not all at once!

I also bought a blood glucose monitor and started checking my levels first thing in the morning.  I would recommend starting to monitor 2hrs after eating and keeping a food diary as soon as possible, but for me, it was a lot to take in, a lot of changes being made and a lot of information being researched that I was just not ready to incorporate that regime if I didn't HAVE to. I managed the food diary.

[A very important issue to note regarding blood glucose monitors are that they have a discrepancy rate of 10% which means that if I get a reading of 6.5mmol it could mean 7.15 or 5.85 which, when one is trying to keep levels below a certain criteria, can make a massive difference.  The other issue with the monitor is that the way the blood is taken can also affect the reading.  Fingers should be clean since there is glucose on so many things from paper to the counter or food that may have been touched hours before.  Also, the way the blood comes out makes a difference.  The finger pricker is meant to cause enough blood to appear to be sucked onto the strip but often it doesn't and squeezing can cause plasma to come out which affects the reading.  All of these together often leaves me feeling very frustrated and upset and quite often makes me think that the whole thing is a waste of time, completely impossible to monitor and means nothing]

I can tell you I was crying whilst I ingested the 75g of lucozade plus into my body, because not only did it have caffeine (which I don't normally have) but it had various other colourings and additives that I don't want my children going near, especially my unborn ones.  I let the midwife know in no uncertain terms how appalling it was that this was their drink of choice.  Being there also felt to me as the start of a whole NHS invasion into my life which we had chosen to avoid this time around and this was even more upsetting.

Blood Sugar Levels for pregnant - non pregnant

Unfortunately, the result were not up to standards.  6mmol at fasting and 9.3mmol at 2hours.  This is where I have my issues.   Different levels from different sources, different doctors using different numbers.  The interpretations all depend on which protocol whichever particular hospital is using.  For ours, it was the SIGN guidelines, Scotland specific. <5.1mmol at fasting and <8.5mmol at 2hours.

Whatever way we looked at, I had gestational diabetes and a complete overhaul of my diet was required.  I was given an appointment at the clinic for 3days time and sent on my not so merry way, flying as high as a kite and wired to the moon on sugar.  The effect lasted most of the day and was not pleasant.

The day before my first clinic appointment, my midwife came for another check up and we found ketones in my urine.  I still do not understand fully what this meant, neither did she but made it clear I was to let them know at my appointment the next day.  There are studies regarding the long term effects of GD and of ketones on my child but I decided it is not the best place (35weeks, emotional, stressed and generally peeved) to be reading about that kind of thing.  I will at some point, when I am feeling stronger.  Informed is the key but overwhelmed is inadvisable, i know my limits!

The diabetic clinic appointment was actually not as invasive or threatening as I had worried it might be.  We were seen by a very informed and friendly diabetic nurse who answered all my questions and allowed me to follow her into the testing room and stand talking with her whilst she checked my urine and ketones.  I was given the all clear on both counts, no infection, no ketones.  My blood glucose level that day was 6.4mmol and I was informed that they were very happy with the results and I was to keep my levels between 5mmol and 8mmol.  We spoke with a dietician who looked at the diet I had been keeping since 23rd January and told me the reason I may have ketones, is that there was just not enough carbohydrates in my diet and so I had begun using fat as an energy source instead of carbohydrate or sugar.  Ordinarily this would have pleased me greatly..burning fat YAY! (akin to atkins diet)  Unfortunately, she was unable to tell me, as were most of the doctors I spoke to, the risk for my baby of having ketones in my body.  I was simply told it was not a great state to be in for the baby.  This dietician basically told me to eat more carbohydrates in my diet.  I decided not to discuss with her my views on wheat and dairy, as it seemed her basis for discussion was for people with a completely different diet than mine.  I was thoroughly confused with her advice to eat more carbohydrates (bread, potato, pasta) as I knew that would increase my blood glucose levels.  I already did not eat the white forms of these anyway and rarely if ever ate bread any more.

As it turns out,  my downfall and major error was really my portion sizes.  I followed her advice for a few days and soon realised that even though brown rice or basmati rice or even quinoa are low in carbohydrates compared to their white counterparts, eating a huge portion is still going to push my glucose level through the roof!!

During this appointment I also made sure I had a very important test called the HBA1C.  During my initial phone call with the Dr regarding my appointment, he seemed very non-committal over the importance of this test, so I was relieved I would not have to fight to have it done.  Basically, this test shows the average blood glucose levels over the past 8-12weeks since our amazing bodies store this information for us!!  It lets you know, how long the sugar issue has been going on.  Mine was within normal limits which shows that this was a relatively new problem and had not simply been missed.

I left that appointment feeling pleased with all my results and optimistic about my abilities to control my blood glucose levels with my diet.

13days later I met with the big guns at the obstetric diabetic clinic.  It was quite a full waiting room.  I had been pre-warned that there could be at least 6 people in the room and not to freak out at this, it was not a reflection on my progress but merely a way of seeing all relevant people at the one time and place.  Still, it was overwhelming to walk into a roomful of unrecognisable faces.  Faces of NHS staff who could potentially scupper my homebirth plans.

Did you know that within the NHS, there is ONE woman who has gestational diabetes and this is how they deal with it?  Same measures for everyone, all treated as that one clinical patient.  These are my husbands words on one problem with NHS being involved in pregnancy

"The real problem with the nhs being involved in a pregnancy is everything is reduced to risk and risk management.  Of course the NHS provides an important and valuable service when needed.  But the NHS views risk factors as the start of the road to maximum intervention.  Everything becomes an exercise in monitoring and assessing risk based on current studies and statistics.  
Mothers are removed from deciding what they want, from knowing what they need, or choosing how they want the birth to be… unless they are prepared to battle.  The mother’s focus shifts from preparing for the birth to dealing with the NHS.  The power of a woman to take control of her birth experience is undermined at the very moment that she needs to be connecting with her capabilities and strength"

They basically wanted to start me on insulin straight away and outlined their protocols for this outcome, which is full time monitoring and attached to machines.  Not the community midwife unit, not at home but in their medicalised labour ward.  It was handed to me as the only option but unusually he did say it was still my decision at the moment. For some reason, they also changed their own bracket for my blood levels to 5mmol-7mmol, a total difference to two weeks previous which  upset me greatly as it makes controlling with diet even harder.

I also declined the scan and my midwife was quite surprised to note that there was no palpation of the baby or any hands on checking whatsoever.  They made another appointment for two weeks later.  I doubt it even occurred to them that I was not accepting outright and would make a decision later regarding the scan.

I came away from the meeting with the following thoughts:

"Processing the info and crapness of info, But as of right now I am screaming NOOOoooo
No placetal function cord doppler sizing
No hospital labour hooked up to iv machines
No monitoring
No progressing police

They asked me to keep them informed of my blood levels by calling in with my numbers, which brings me to my other post which were my first thoughts on the whole GD experience.

This has been my journey so far....I have decided to have the scan on Wednesday, my midwife would feel more comfortable knowing a rough size estimate although by her calculations I have been consistently 2cm more than my week with no major increases.  Also, it helps to appease the NHS, not that it should be a major factor, I just do not want to have another battle and fight with them.  I fully expect the placental and cord function to be normal and the baby's growth to be slightly high (growth scans are still notoriously inaccurate)but I think it will be manageable.  After all I have done this twice before!!

Meltdowns - minimal
Losing the Plot - intermittent
Breastfeeding - got the colostrum bottles, now waiting to pump at 36weeks!

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