Not happy with the CNM...

[MomtoXane]

So I switched from an OB who pre-scheduled my c/s at my first visit to a natural birth friendly certified nurse midwife in the next county. I'm planning on a home birth with a CPM, however she doesn't do any prenatal testing or anything like that. She is perfectly comfortable with me seeing anyone I like for co-care.

At my first visit with the CNM (16wks) I expressed my concern with failing the GD screening at 10wks. She told me not to worry, that's not something she tests for until later. I brought it up again at my appointment last week (20wks) thinking I'd be doing the test soon. She said no not to worry, the screening isn't for two more months (28wks). I told her that during my last GD pregnancy I was on insulin by 26wks and her response was that if I needed insulin she could no longer see me as that puts me in the high risk group.

I felt my concerns were not addressed to my satisfaction. Her only recommendation was to avoid all carbs : So I decided to test with a borrowed monitor and a few strips I had on hand. My fasting level was 106 (supposed to be under 90) and my post-meal was 223 (supposed to be under 140). I called the nurse who had the on-call CNM get back with me. She consulted the on-call OB. They said my numbers are high enough that the 3hr glucose tolorance test might put me into a coma or something and I need to see the diabetic counselor ASAP. They also scheduled me to see the high risk OB within the week.

I'm frustrated that my midwife didn't suggest any testing, she didn't even do urine tests! I have no idea if I've been spilling ketones or glucose indicating possible GD. Also I just had my first fundal measurement, which is three weeks ahead of where I should be. With both my other pregnancies I always measured on target or behind. So maybe the baby is growing bigger or faster? I know I've gained most of my weight in the last few weeks. Am I freaking out for no reason? Should I take my cues from her laid back attitude and seemingly lack of concern? Or do I have a valid reason for being upset?

[leerypolyp]

I am the biggest midwifery supporter in the world, but I'm not sure this particular CNM is the best care provider for someone with your history and concerns. I don't know that I'd put too much stock in the fundal height issue, but the fact that you have a history of GD and don't feel your concerns were taken seriously suggests that closer monitoring might be what you want. Especially if you have a history of needing insulin.

I think you know that you're not overreacting here. It might be time to find a different practitioner for your co-care.

[MsBlack]

IMO, you did the testing that needed to be done. Home testing under normal fasting/eating conditions is going to give you far better info than anything that comes from the GTT or other forms of glucose challenge. Clearly, this is not the way your CNM practices; she is following 'usual prenatal routine' of doing the GTT after 24wks--it really is the most common med. maternity care routine. It is also routine for insulin-dependency to be considered high-risk and therefore outside the scope of CNM practice (not that all CNMs practice under just the same protocols--but what she said to you about insulin dependence is not unusual for CNMs).

It sounds like you expressed concerns, but did not ask for the GTT outright. It also sounds like she was unaware of your insulin dependence in prior pregnancy--something else that somehow did not get communicated to her. She has perhaps been a bit too laissez faire--and perhaps too busy to give you the personal attention you'd like...and yet, it also seems that you have not been as clear with her as might have been most helpful to you.

Most women with glucose control issues during pregnancy do very well with dietary changes and moderate exercise. However, some don't--and eventually will need insulin. If you were my hb client, I would probably get very serious with you about aiming for good blood glucose control via diet and exercise, while keeping daily tabs on your sugars w/home testing. This would include helping be sure that you knew how/what to eat, how often, things to avoid and so forth. I'm not so sure I would consider you low-enough risk for hb if you did become insulin dependent.

By the way--lots of med providers are no longer doing urine screening routinely anymore. It is just not that reliable a test. And also, neither glucose in the urine, nor ketones, indicates diabetes in a pregnant woman, whose biochemistry is different than a non pregnant woman. So doing urine testing would not have been helpful in the ways you might imagine.

In any event--maybe you need another med provider to do the testing and such that you want. Whatever you do about that, I strongly urge you to get very very well informed ASAP about diet and exercise to help maintain blood glucose control for pregnancy--and get on with the changes that are most likely to help your own and baby's health. No provider can do that for you; and you may be able to avoid insulin dependence again if you do it for yourself. It is not just the insulin that you should hope to avoid--it is the elevated risks for you and baby that are involved. There is so much you can do--and that only you can do--whoever your providers are.

[nashvillemidwife]

First on the little stuff... routine urine screening is not supported by evidence and many practices are getting away from it altogether. Fundal height measurements are considered to be normal within 4 cm from your weeks of pregnancy, but only AFTER 20 weeks, so I wouldn't even have been measuring you at all until now.

However, I would have been much more cautious with the diabetes screening. You say you already failed the test at 10 weeks? What treatment plan were you given then? You should have already had that endocrinologist consult.

[nashvillemidwife]

Originally Posted by MsBlack

Clearly, this is not the way your CNM practices; she is following 'usual prenatal routine' of doing the GTT after 24wks--it really is the most common med. maternity care routine.

Actually, for women who are at high risk for GD the standard of care is to perform the test early in pregnancy. If I understand correctly, she had already failed the test at 10 weeks - there was no call for waiting to repeat the test at the usual time, it should have already been taken seriously and dealt with.

[MsBlack]

I agree totally, Nashvillemw--but it seems that the OP was seeing someone else (OB) at time of 10wk test; apparently CNM had not noted the earlier test or prior-pregnancy GD issues...or so it seems, anyway. All I meant was that most med providers, in most 'normal' pregnancies, don't do GD screening until late 2nd trimester or so. Hard to say how the CNM missed the news about this mom's history--whether records hadn't yet been transferred, hadn't yet been read by CNM, she never knew about the early OB visit at all....or what. Not so uncommon for med providers to ignore client input, really--to assume they are just worrying, don't know what they are talking about, etc (in the absence of med records, anyway).

MomtoXane said in her original post:

"At my first visit with the CNM (16wks) I expressed my concern with failing the GD screening at 10wks."

That statement is what I was going on. But I do agree with you--certainly, any mom with a history of insulin dependence in pregnancy needs earlier screening and generally more attention to blood sugars. I think it was very wise of OP to start looking at her own sugars at home!

[MomtoXane]

When I failed the 1hr I declined the 3hr. My OB instead had me do a fasting draw at every appointment. I was seeing him every two weeks. They sent me to the nutritionist, who gave me a food pyramid to follow. I was never told to test at home.

I told my midwife all of this and she just looked confused. I know the dietary guidelines for GD, I followed them very strictly with my last pregnancy. But sometimes even if you eat what you're supposed to (my 223 was after a bean salad) sometimes you can't control your blood sugars all that well. Now I don't even have any test strips left so I'm just guessing what my BG might be...

[MsBlack]

"I told my midwife all of this and she just looked confused. "

Assuming you mean the CNM here? Well, whichever one it was, this is not a good sign at all--at least, not a good sign of a knowlegeable, competent practitioner. Seems if you want medical co-care, then you ought to look eslewhere--perhaps particularly for someone who has already worked with GD moms like you (insulin dependent, as could occur for you again).

So--it seems that you are one of the few who cannot maintain good bs control with diet alone. I'm sorry to hear that--it does happen for some women. Is your hb mw aware of this? Is there a plan in place to account for your GD--I mean, besides your having med co-care? has she worked with moms like you before?

Sorry--I guess I'm being nosy here. You do sound very well-informed and activated concerning your own care. But it is concerning to me that you are planning a homebirth--although I probably should not consider it to be out of the question, with or without insulin, for a mom who IS so self-responsible and as long as her sugars are well controlled by whatever means. Just not something that I am comfortable with myself at this time.

In any event, back to your original frustration--I think I have a better picture now, thanks for adding details. I think I would be similarly frustrated; this CNM does not sound like the one for you for various reasons.

[logcabinmomma]

IMO, if you risk out of a homebirth, you pretty much risk out of a CNM's care also. I would see if you can find a mw friendly or holistic minded OB to use as backup instead. Any medical finding or emergency that brings you from home will either be a high risk complication of pregnancy OR an outright emergency, and CNMs aren't allowed to manage either.

-Kristi

[nashvillemidwife]

Many CNMs work in direct collaboration with physicians who can co-manage high-risk situations.

[logcabinmomma]

Originally Posted by nashvillemidwife

Many CNMs work in direct collaboration with physicians who can co-manage high-risk situations.

Oh, I know, I've used some great collaborative practices, but I would think that your backup should be the OB, not the CNM? I mean, if you want a relationship with the person who would deliver... I have had every birth imaginable, and anything that would have risked me out of a CNM homebirth or a CPM homebirth would have risked me out of a CNM hospital birth as well.

-Kristi

[MomtoXane]

Thank you for all the input. My home birth midwife is someone I consulted with during my last GD pregnancy and she is confident that I will still be able to birth at home. I have a fairly complex prenatal history, so I won't go into all the details. My first pregnancy my OB did not take my concerns about pre-eclampsia seriously and I ended up with an emergency c/s at 27wks. My second pregnancy I had significant hyperemesis and was in/out of the hospital for months. Then I struggled with the GD diagnosis. I had a very supportive OB. She was not happy with the endocrinologist who put me on insulin without attempting to manage with diet and exercise. Once I was relieved of the stress of 3x daily shots and 8x daily finger pricks, my levels were completely normal. I was able to have a successful VBAC, perfectly healthy 7lb 40wkr with no issues at all.

The reason I switched from the OB to the CNM for co-care is the VBAC issue. He wanted to schedule me for a repeat c/s at 38 weeks, no exceptions. I wasn't comfortable with that and I didn't want to be pressured into attempting to go into labor on my own before I was full term. The local hospital has banned VBACs and according to the OB "No one does VBACs anymore", even though mine was only 2yrs ago. I wasn't comfortable doing a HBAC last time because I had never been in labor before and I didn't know how I would handle it. Plus my OB at the time was so supportive, she had a successful VBAC herself. Unfortunately she retired last year. This time I'm more confident of my ability to HBAC given that I had a complication-free vaginal delivery last time. However I know have people telling me I should just submit to the scheduled c/s and not worry about anything else. If I was one of the poor uninformed masses, I probably would be blindly led into the medically unnecessary surgery. On the other hand I know better than to expect the risk of complications is non-existant, at the hospital or at home. I'm just trying to do the best thing for my baby and my body and it seems like there isn't really a clear answer either way...

[MsBlack]

Wow--yet more enlightening information, thanks! which really changes the picture, I can totally see why you would want an HBAC, and why your hb mw is agreeable.

And by the way--not sure you realize how very awesome you are for coming through so much, and learning through all of it rather than just resigning yourself to Hi Risk status with all that that entails. I'm sure it hasn't been easy.....you have some lucky kids, to have such a devoted, strong mama.

I hope you find a way better backup person for your med stuff. You definitely need someone else, someone special considering not just your med history but your way of self-managing pro-actively.

[caedmyn]

Have you considered trying a truly low carb diet? Even type one diabetics generally control their blood sugars much better on a low carb diet than any other type (although they're still insulin dependent), so it seems likely that it would work well for GD, too. Beans might be on the recommended list to eat, but they aren't exactly low carb. Just a thought...

[mwherbs]

Originally Posted by MomtoXane

So I switched from an OB who pre-scheduled my c/s at my first visit to a natural birth friendly certified nurse midwife in the next county. I'm planning on a home birth with a CPM, however she doesn't do any prenatal testing or anything like that. She is perfectly comfortable with me seeing anyone I like for co-care.

At my first visit with the CNM (16wks) I expressed my concern with failing the GD screening at 10wks. She told me not to worry, that's not something she tests for until later. I brought it up again at my appointment last week (20wks) thinking I'd be doing the test soon. She said no not to worry, the screening isn't for two more months (28wks). I told her that during my last GD pregnancy I was on insulin by 26wks and her response was that if I needed insulin she could no longer see me as that puts me in the high risk group.

I felt my concerns were not addressed to my satisfaction. Her only recommendation was to avoid all carbs : So I decided to test with a borrowed monitor and a few strips I had on hand. My fasting level was 106 (supposed to be under 90) and my post-meal was 223 (supposed to be under 140). I called the nurse who had the on-call CNM get back with me. She consulted the on-call OB. They said my numbers are high enough that the 3hr glucose tolorance test might put me into a coma or something and I need to see the diabetic counselor ASAP. They also scheduled me to see the high risk OB within the week.

I'm frustrated that my midwife didn't suggest any testing, she didn't even do urine tests! I have no idea if I've been spilling ketones or glucose indicating possible GD. Also I just had my first fundal measurement, which is three weeks ahead of where I should be. With both my other pregnancies I always measured on target or behind. So maybe the baby is growing bigger or faster? I know I've gained most of my weight in the last few weeks. Am I freaking out for no reason? Should I take my cues from her laid back attitude and seemingly lack of concern? Or do I have a valid reason for being upset?

OK so I am going to play the bad cop here-- my expectation as a homebirth midwife is that CLIENTS take care of themselves. I give guidance and do some routine testing but it is up to you to be as healthy as you can be- insulin would risk you out of a home birth in my book- and if you have had a very early test- a test pre-placental lactogen altering blood sugars then you are not just a gestational diabetic but most likely a diabetic (probably type 2, but I don't know your whole history could be type 1) in any case the OB you transfered from has the right of it-- the at risk group of infants who die at term- and they still don't know why are born to moms who are diabetics- not gestational diabetics(although since some women are only tested in pregnancy- it messed with the stats for a long time) but diabetics type 1 or 2.- so early induction or even birth by c-section is a conservative way to manage and increase the chances of having a live baby-- that you are also a VBAC makes this an even greater challenge because most of the routes of induction are not acceptable at all any more because of the increased risk of uterine rupture- perhaps a foley cath induction-- or you could get very very serious about what you can control as far as blood sugar goes--
- and I can agree with MSBlack about diet and exercise- and that you should know that pre-glucose tolerance testing- carb loading with an extra 100 grams of sugar/day for at least 3 days ahead of when you fast for the test to be sure that the test is accurate-- in any case past the GGTT very very low carb eating- as well as paying attention to the glycemic index of foods - so if you were going to eat a carb then blueberries over a piece of toast- whole grains over white bread-- veggies you can eat tons of most veggies, meat yes - chips little to none- an apple over apple juice -- no sodas-- forget the fries and forget pizza, unbreaded chicken not breaded chicken certainly season it but you don't need the breading--
at this point the only way that this is going to stay in the normal- moderate risk category is if blood sugars are controlled without insulin -
oops forgot to mention exercise- walking even 20-30 minutes a day- or how about a water exercise class? belly dancing...

take care