NOTE:
This post is a continuation of a series about managing my diabetes while trying to get pregnant and being pregnant. For more, you can check out these previous posts:
Diabetes Type 1.5/LADA
Diabetes & Miscarriage
Diabetes & Pregnancy: The 1st Trimester
Diabetes & Pregnancy: The 2nd Trimester
Diabetes & Pregnancy: The 3rd Trimester
As always, these posts are not meant to be taken as medical advice, and merely discuss my personal experience with my specific diabetes. Everybody's experiences are different, and I am only speaking about mine.
***
This post is a continuation of a series about managing my diabetes while trying to get pregnant and being pregnant. For more, you can check out these previous posts:
Diabetes Type 1.5/LADA
Diabetes & Miscarriage
Diabetes & Pregnancy: The 1st Trimester
Diabetes & Pregnancy: The 2nd Trimester
Diabetes & Pregnancy: The 3rd Trimester
As always, these posts are not meant to be taken as medical advice, and merely discuss my personal experience with my specific diabetes. Everybody's experiences are different, and I am only speaking about mine.
***
As I wrote in a previous post, my baby girl was born on New Year's day, January 1st, 2020, weighing 8 lbs 10 oz and measuring 20.5 inches long. That post delved into how I managed my diabetes during the last trimester of my pregnancy; this one will discuss a much shorter scope of time: the single week from Monday, December 30, 2019 - Monday January 6, 2020.
I was told to take half as much basal insulin (Levemir) as I usually did the morning of Monday, December 30 - the day I was scheduled to come in for induction - but to continue taking my full doses of mealtime insulin (Novolog), and to eat normally throughout the day until I came to the hospital birthing center at 3 pm to start the induction process. I had prepared a birthing plan ahead of time, and left space on the paper to write down my most recent insulin doses over the previous 24 hours, so the hospital staff would know how much insulin was in my system upon my arrival. I also made a note at the top of my plan of my usual end-of-pregnancy insulin doses (16 u. of Levemir - 10 u. in the morning + 6 u. at night; 12 u. of Novolog with breakfast, 5 u. with lunch, and 6 u. with dinner) and my pre-pregnancy daily insulin doses (12 u. Levemir - 5 u. in the morning + 7 u. at night; no mealtime insulin). And at the top of my birthing plan, I included a patient history, which listed my diabetes diagnosis, pregnancy A1C ranges (4.8-5.6%), the location of my Dexcom continuous glucose monitor (on my left arm), my daily medications (Levemir, Novolog, prenatal vitamins, calcium supplements, and baby aspirin, the last of which was discontinued at 36.5 weeks of pregnancy), allergies (amoxicilian and sulfatrim), and previous surgeries (the D&C I had after my miscarriage in September 2018, and an appendectomy in February 2001).
The plan itself included the following points:
- I would like to be consulted before any adjustments are made to my insulin or glucose IV, and any time treatments are suggested for high or low blood sugar. Please keep in mind that I tend to be very sensitive to insulin and can have frequent lows. If at any time during labor my blood sugar is consistently less than 70, my insulin drip should be decreased or temporarily turned off.
- I would like to be in charge of managing my own blood sugars after delivery, including the use of my own insulin pens and needles.
- I would prefer to walk around during labor. If fetal monitoring is necessary, I would prefer a wireless/mobile fetal monitor.
- I would like to labor without pain medication. I will ask if I would like something for pain; please do not ask me.
- I do not want an episiotomy, or for vacuum extractor or forceps to be used, unless there is a medical necessity.
- I would like to delay cord-clamping for 2 minutes or until the cord stops pulsing. After clamping, please use the provided kit to donate the cord and placenta to a public bank.
- I would like skin-to-skin contact as soon as possible and to breastfeed within an hour of delivery.
- I would prefer that any non-urgent procedures or assessments of my baby be done in the room with me, including any treatment of low blood sugar, if possible.
- If my baby has to be separated from me for any reason, my husband will go with the baby and my doula will stay with me.
- After the placenta is delivered, I would like my insulin drip to be switched to my lower pre-pregnancy basal insulin dose, or shut off completely.
The plan was to take misoprostol pills overnight from December 30 into December 31st, and then start pitocin in the morning, as part of a gradual induction process. Until the pitocin started, I was able to eat normally; an insulin drip was not required. (But while the pitocin was in use, I was to be on a "clear liquid" diet only - water, ice chips, popsicles, broth, and juice.) I had been told that I would be able to use my own insulin pens and needles during those times when I wasn't restricted to that clear liquids diet - including early labor and after delivery. So I brought my pens with me to the hospital, and once I was out of triage and was assigned to an antepartum room, I gave my pens to the nurses to have them taken to the hospital pharmacy for verification. Once in the antepartum room, I was also given my first dose of misoprostol with dinner, and the nurses inserted a saline lock into my right hand, so they would be ready to quickly start the insulin drip (or IV fluid) whenever necessary.
I was hooked up to a non-mobile fetal and contraction monitor an hour before, during, and for one hour after each misoprostol dose. This was just like the NST (non-stress tests) I'd been doing once a week for the last several weeks of my pregnancy, with two small monitors that were strapped to my belly. Because this monitoring was happening overnight, I didn't request a mobile/wireless monitor - I would be lying in bed most of the time anyway. But it did mean I had to call the nurse anytime I needed to pee, so they could remove the monitors and hook me back up once I returned to bed. At arrival, I was 0 cm dilated, but having contractions (non-painful, barely-noticeable ones like most people have at the end of their pregnancy, as their body starts getting ready). The misoprostol regulated these contractions into a noticeable pattern, which I could watch on the monitor. Unfortunately, they were too close together (happening every 2 minutes when they wanted them closer to every 3 minutes) for where my body was in the process, and there was concern that my uterus would start tiring out too soon doing so many "unproductive" contractions. I was told to drink more water, and was also given some IV fluid, to try to space them out before they gave me the next dose of misoprostol. I was finally given the 2nd dose at 10:30 pm, and the 3rd dose at 3:15 am.
At 7 am on Tuesday, December 31, I got another cervical check, and they determined I was 2-3 cm dilated. I was given the chance to eat breakfast and take my usual mealtime insulin, and then was moved from my antepartum room into a labor/delivery room after I was finished eating. There, they placed another IV, this time in my left hand. The first attempt didn't work (my wrist was swelling up around the vein, where fluid was leaking in), and the second attempt was a particularly bloody affair that was gruesome to watch - but after ten minutes, I was set up with my second IV. My right hand was for IV fluid and insulin, and my left hand was for the pitocin for my induction, a glucose drip, and antibiotics (since I had tested positive for group B strep). This meant that at any given time, I had up to five bags to carry around with me on two different IV poles. Walking around the room and up and down the hallway, trying to go to the bathroom, and getting in and out of bed all required intricate choreography to keep the lines from tangling. Still, I wanted to walk around to try to get my labor going, so I requested the mobile fetal/contraction monitoring. It was another thing to keep track of, on top of so many other things - a heavy box that I could either wear around my neck or shoulder, or hang on one of my IV poles, and every hour or so I would have to end up back near my bed to recharge something (my IV monitors, or the fetal monitor), but at least it meant I could move around a bit and wasn't fully restricted to the bed.
The nurses started my pitocin, antibiotics, and IV fluid at 9 am. They wanted to start the glucose and insulin drips at the same time, but I reminded them that I had just eaten breakfast and taken 10 units of Novolog an hour ago - and that it would make more sense to wait at least another hour, for my the fast acting insulin I'd taken with my meal to start working through my system. If they started me on an insulin drip on top of the insulin I'd just taken, I feared I'd go low. I also didn't see why I needed to be on glucose yet - I was contracting regularly, but they were not strong contractions; I was still in early labor. I had also JUST eaten breakfast. I was not in need of glucose for energy - nothing was happening yet! So they called in a doctor for consultation, and the doctor agreed that we could wait and see what my blood sugar was two hours eating first - if it was above 120 at that point, we'd start the insulin and glucose. Somehow this wasn't communicated fully to the nurses though - because though they didn't start me on the insulin yet, they did start me on glucose. I didn't realize this had happened until nearly an hour later, when I noticed my CGM saying I was at 145, and I took a closer look at what IVs were actually being pumped into my system. Two hours after eating, the hospital blood sugar check had me at 157 - because of course my sugar was high now that they'd given me glucose on top of my breakfast! I don't want to be cynical, but in that moment, I definitely was. They seemed very eager to switch me over to hospital insulin, so they could more closely manage how much insulin I was taking, and it made me wonder - had they started my glucose early just to ensure I would be above 120, prompting the insulin protocol into effect?
I'm sure they're used to diabetic patients that require a lot more insulin, making it more important to start the insulin drip sooner rather than later. In fact, it probably would've mattered more for me too - if I had actually transitioned into active labor and given birth that day. But that wasn't in the cards, and once they started me on the insulin drip it quickly became apparent that I really didn't need much of it at all. Following their own protocols based on what my blood sugar readings were every hour, I was on insulin for only three hours before they stopped it. They started me at a rate of 2 u./hour at 10:30 am. At 11:30, my blood sugar was measured at 109. At 12:30 it was down to 68, at which point they reduced my insulin drip to 0.5 u./hr. And an hour later, my blood sugar was at 65, prompting them to shut off the insulin drip altogether. They continued to check my blood sugars every hour, but as they stayed below 100 for the rest of the day, the insulin was not restarted. At 2:30 pm, I was at 89; at 3:30 pm, 90; at 4:30 pm, 96.
Meanwhile, they gradually increased my pitocin throughout the day, from 1 mu/min up to 8 mu/min by 3 pm, but nothing much was happening. (My husband and I watched a lot of Netflix and Disney+ on his laptop to pass the time.) A cervical check at 4:30 pm confirmed that there had been no progress since that morning - I was still only 2-3 cm dilated. It was decided that my baby wasn't ready to be born in 2019 after all. The pitocin, glucose, and antibiotic IVs were suspended. The plan was to repeat the cycle we'd already done - another night of taking misoprostol, and then restarting the pitocin in the morning. This meant my "clear liquid" diet restriction was lifted, and I was able to eat dinner and breakfast again.
This seems like a good time to point out how my meals and insulin pens worked in the hospital... I expected that once my insulin pens were verified, I would get them back and be able to use them - but I guess that was a naive assumption. In actuality, they were kept at the nursing station for the duration of my hospital stay, and anytime I wanted to use them I had to ask a nurse to get them for me, and wait for the dose to be verified by a doctor, before I was able to administer the medication. On the one hand, I understand why they do this (liability reasons), but on the other hand, it was beyond annoying. The doctors and nurses in the maternity ward were (obviously) often busy with more pressing matters than deciding how much insulin I was allowed to take. I would tell the nurses when I ordered a meal, and tell them again when my meal arrived, but still my meal would end up sitting in the room for an hour or so, getting cold, before I would finally be brought my insulin to take with my food. (Couldn't they have just had me sign a form promising I wouldn't sue them for any insulin mismanagement that happened on their premise, and then let me manage my own insulin instead? Seems like that would be less aggravating for everyone involved...)
After doing this for dinner on December 30 and breakfast on December 31, I was rather fed up with the whole procedure. I assumed (again, perhaps naively) that the problem was that I had insisted on bringing and using my own insulin pens, instead of the hospital insulin. So for dinner on December 31, I acquiesced and told the nurses that I would take the hospital insulin instead of requiring them to find my Novolog pen at the nurses station and get it re-approved. Unfortunately, using their Humalog syringes didn't go any faster; I still had to wait until a nurse was available to check my blood sugar, put it into the system to see what insulin dose was recommended for me, get a doctor (and myself) to sign off on that assessment, go get the Humalog, and wait for another nurse to be available to administer it - all while I sat there staring at a plate of food I wasn't able to eat until all those steps had been completed. The first two times, it was annoying; this time - after a day of not being allowed to eat anything solid - it was even more so.
That second night, December 31st, I had my first misoprostol dose at 8 pm. My next dose was at midnight, to the sounds of nurses shouting "Happy New Year!" to each other in the hall. My husband and I did nothing to acknowledge the new year (the new decade!); our room was dark, and we were both trying to rest up for what would be a long, tiring day to follow (assuming my labor finally started progressing). That first night in the antepartum room we'd both been too excited at the thought of meeting our baby soon that we hadn't gotten much sleep, but after a rather boring day of waiting for things to happen, we were both able to get more sleep the second night. (No small feat, as I was woken up frequently for blood sugar and blood pressure checks, fetal and contraction monitoring to assess whether my body was ready for the next misoprostol pill, and being woken up to take said pills.)
My last dose of misoprostol was at 4:30 am on January 1st. I was given hospital Humalog with my breakfast at 8 am, given another cervical check (still 2-3 cm dilated, with no further progress overnight), and the pitocin and my antibiotics were resumed at 9:30 am. This time, they didn't begin the glucose or insulin right away - as a result, my glucose two hours after eating was only 87, and it wasn't until around noon, when my blood sugar was at 113, that my glucose and insulin drips were restarted - the insulin at a rate of 1 u./hr.
The pitocin was increased more quickly on January 1st than it had been on December 31st, and I was up to 6 mu/min by about 1:30 pm. By 3 or 4 pm, I started getting consistently painful contractions for the first time. A cervical check put me at 4 cm dilated - finally some progress! We called our childbirth doula to join us at the hospital, and she recommended positions and breathing exercises that helped me manage my pain without requiring medication. (I already had so many IVs pumping medication through me - I really didn't want any more!) As my contractions grew more painful, my blood sugars also started to climb. I wasn't eating anything - at one point some chicken broth was ordered from the cafeteria for me, but I wasn't able to concentrate on drinking much of it - and as far as I know my glucose IV was kept at a similar level throughout the day (though honestly I never really looked at it, so I have no idea); the increase in my blood sugars then, was mostly (if not completely) due just to stress and the exertion of the labor process.
By 6:30 pm, my blood sugar was at 115 and the insulin drip was increased to 1.5 u./hr, by 7:30 my blood sugar was 131 and it was increased again to 2 u./hr, and at 8:30 my blood sugar was at 144, and the insulin drip was dialed up to 3 u./hr. At this point, I was given another cervical check; I was at 8 cm dilated. My blood sugars briefly evened out a bit (at 9:30 pm, they were back down to 131), but around 10 pm I started pushing, and this again raised my blood sugars. At 10:30, the glucometer tested me at 156, and my insulin drip was increased to 4 u./hr... And at 11:09 pm, our daughter was born!
You may wonder how I remember what my blood sugars were doing during all of this, or what my insulin was adjusted to. But the answer is - I don't remember. Before going to the hospital, when I thought about the labor/delivery process, it was SO important to me that I be aware of what was going on and how my diabetes was being managed by hospital staff - but when it was all happening, it was often the last thing on my mind. The nurses would tell me they were increasing my insulin, and I would just nod; I no longer cared what they did. I was too busy concentrating on getting through the next contraction. But my husband and our doula helped me keep track of what was happening, and they wrote down notes for me so that I'm able to refer back to them now and piece together what happened, which I'm so grateful for.
Within an hour of our daughter's birth, it was no longer January 1st. At midnight at the beginning of January 2nd, my blood sugar was 142, and my insulin and glucose drips were both cut in half. Again, I didn't really care what they did to my IVs at this point; I was barely paying attention. I was holding my new baby and trying to breastfeed for the first time, while my ob/gyn worked on some repairs. At 1:30 am, my insulin drip was cut in half again, and my husband and I were presented with a tray of food in case we wanted a snack before the cafeteria opened up again for breakfast at 6 am. I assume it was the same sort of tray they gave every family - there was nothing diabetic-specific about it, and all of the options (sandwiches, chips, juice) were full of carbs. I ended up eating half of a turkey sandwich, and a protein bar that I'd brought from home. I wasn't really hungry, but felt like I should probably eat something. At 2:30 am, they were finally ready to move us from our labor and delivery room into a postpartum room; my blood sugar was down to 115 at this point, and the insulin drip was shut off.
I got maybe two hours of sleep that night, in little chunks, once we were in the postpartum room. I was also, understandably, a bit distracted with my new baby still. So I wasn't really paying attention when, at 6:30 am, a nurse came to check my blood sugar for a "fasting" number. (I put "fasting" in quotation marks because usually to be considered fasting, it has to be at least 7-8 hours since last eating - but I'd eaten that half a turkey sandwich and protein bar sometime around 2 am, only 4.5 hours earlier.) My blood sugar was high - 193. The nurse put this into their system and got back the recommendation to give me a corrective dose of 2 u. of Humalog - a fast acting insulin I usually only take with meals. She administered the insulin; distracted and half asleep, I wrongly assumed she was giving me my morning Levemir dose, which I usually took when I checked my fasting blood sugar. This caused a lot of confusion at 8:30 am when my breakfast arrived and we started going through the process of checking my blood sugar and figuring out how much mealtime insulin I needed to take with my breakfast. The nurse was trying to tell me I needed to take my morning Levemir, which I thought I'd already been given; and I was trying to tell her that I didn't need to take any insulin with breakfast, since my blood sugar was at 101 and I'd been told weeks ago by MFM not to worry about taking mealtime insulin right away after delivery. (MFM had recommended that after delivery I go down to 4 u. Levemir in the morning + 6 u. Levemir at night, for a total of 10 u. - close to the 12 u. I'd been at pre-pregnancy. They also suggested that I not take mealtime Novolog (or the hospital's Humalog equivalent) with my meal, waiting instead to see how the meal affected my blood sugar, and then giving myself a corrective 1-2 u. dose if needed. It wasn't as important to keep my blood sugars down now that I was no longer pregnant - in fact, they told me it was better to be slightly high than to be too low.)... Eventually, we sorted it out and I took my 4 u. Levemir with breakfast, with no additional mealtime insulin. Three hours later, my blood sugar was at 197; at which point I took a corrective dose of 1 u. Humalog.
The nurses were also repeatedly checking our daughter's blood sugars throughout the day. One of the potential problems caused by diabetic pregnancies is low blood sugar (hypoglycemia) in the baby. Because the baby spent the last 9 months in a sugary womb, their pancreas got used to producing more insulin to manage that extra sugar - and now that they're on their own and no longer exposed to as much sugar anymore, their pancreas is producing too much insulin, which can cause hypoglycemia - until their pancreas readjusts to the new levels of insulin they now need. Our daughter's initial blood sugar soon after delivery had been within normal ranges, but by 12:30 pm - about 13 hours after her birth - they were too low, and we had to give her glucose gel, which the nurses rubbed into her gums. Perhaps her blood sugars would have been low anyway, just because of my diabetes and how high my blood sugars were at the moment of her delivery - but it definitely didn't help that she was congested and having trouble breastfeeding, and couldn't get her blood sugars raised from my breastmilk either. An hour later, her blood sugar was still a bit low, despite the glucose gel, so she was also given a bit of formula in an oral syringe. Her blood sugars did not dip so low again that she required more glucose gel - but she was given formula a few more times over the next several days, mainly because she was having trouble breastfeeding.
It is not uncommon for babies to have some congestion after birth, given all the fluid they're exposed to both in the uterus and during the birthing process - but our daughter's excess fluid was sticking around longer than usual. Given that it was interfering with her ability to successfully breastfeed, and given that I had tested positive for group B strep during pregnancy and had been on antibiotics during labor, there was some concern that it wasn't just "normal" fluid build-up after all, but a sign of infection. My antibiotics were supposed to be administered every 12 hours during labor, but my last dose hadn't been given, as I'd been in the middle of pushing when it was due. As a result, 12.5 hours had lapsed between my last dose and when our daughter was born, which was considered "inadequate." To top it off, my group B strep had been resistant to the most effective antibiotic, and I had an allergy to the second choice (amoxicilian), meaning that I'd been given their third choice antibiotic, which was considered not as effective. All of this led to our baby being taken to the NICU for three days to monitor her breathing and administer antibiotics (just in case), while we awaited the test results to see if she actually had an infection. During that time, her congestion got a lot better, and we slowly were able to see some success breastfeeding. She was also treated for jaundice while she was there. Eventually, her results came back infection-free, and she was finally discharged on Monday, January 6, 2020 - exactly one week after my husband and I had arrived at the hospital to start my induction.
Later, talking to (of all people) my lactation consultant, it was brought up that maybe our baby had so much excess fluid in her nasal passages and lungs because of all the IVs I had for the 14 hours immediately leading up to her birth, and for 7 hours the previous day. All that extra fluid could've also accounted for her size at birth - 8 lbs 10 oz, about 10 oz more than I was expecting her to be, given my growth ultrasounds at the end of my pregnancy. At the hospital, doctors and nurses at shift changes kept asking me what kind of labor/delivery experience I'd had, and whether there was anything abnormal about it. I never really knew how to answer that question, and ended up saying, "I mean, I was induced? So it took awhile to get started, but once it did, I think it progressed pretty normally?" I assumed they wanted to know if she'd gotten stuck at all on the way out, if my labor had momentarily stalled, if the doctor had needed to use tools to help her get out, if her heartrate or my blood pressure had ever been too low or too high, etc. - all things that hadn't happened. But maybe I should've brought up all the different fluids I had pumped through my veins during labor and delivery - the IV fluid, the glucose, the insulin drip, the pitocin, and the antibiotics. Of course, those things should have been listed in my chart; I shouldn't have HAD to tell them - but clearly not everyone looks carefully at the notes the previous doctors and nurses have written from a day or two earlier. Maybe they would've been less concerned about my daughter's congestion and difficulty breathing if they'd considered that aspect of her delivery; maybe it would've been more obvious that it was "normal" fluid that she just needed a bit more time than the average baby to work out of her system, and not an infection.
In any case, it was actually kind of nice having her in the NICU for a few days - the worries about her health notwithstanding. It meant we got to spend a few extra days in the hospital, which meant more opportunities to talk to lactation consultants and nurses. The nurses in the NICU were especially helpful with tips on how to help our daughter latch and suck and figure out how to breastfeed, working around her congestion and showing me how to pump to help my milk supply come in faster. I was discharged earlier than our baby was - on Saturday, January 4. Thankfully, the hospital let us continue boarding there, in another room (our 4th different hospital room since our arrival) closer to the NICU, while our daughter was there. Even better - once I was discharged, I no longer had to wait for nurses to bring me my insulin anytime I wanted to eat. My insulin pens were returned to me, and I was able to fully go back to managing my blood sugars on my own.
I have more to say about what my blood sugars looked like in those first few days, weeks, and months after giving birth, as I readjusted back to non-pregnancy target ranges and much lower doses of insulin - but as this one is already quite long, I'll save all that for another entry, which I'll write and post here soon!
