In preparation for my own birth I asked around the closed loop & pregnancy facebook group for other ladies willing to share their stories. Here is a guest post from Gem (UK)
My resounding memory of my first diabetic labour with Nathan in 2014 (pumping with finger pricks) were my plans for an active yoga type birth being completely blown away by a drip of glucose, a drip of insulin, a drip of syntocinon, a drip of fluids, and the multiple wires & belt of the EFM. Lifting my gown to go to the loo and wipe my bottom was like trying to escape from Fort Knox so attempting to do yoga positions between the machinery and wires as the contractions changed was totally out of the question. Long story short it was a highly medicalised very long failed induction involving a lot of laying on the bed and cesarean. I vowed NEVER to do that again. I wanted a natural birth.
Fast forward to Millie’s labour in 2019 my first intention was to avoid an insulin drip at all costs….if you have a pump that doesn’t tangle up around your body in the same way as a drip why on earth not use it?! My diabetes team had got to know me a lot better and so there was a level of trust between us. At about 32 weeks we discussed my plans on the diabetes side and agreed as long as I was happy then my husband and I were to remain in control of my diabetes via pump & CGM using AndroidAPS. I could ask for the midwives to take over at any point, but on the understanding the midwives would not use the pump or AndroidAPS due to unfamiliarity so it would be a sliding scale via drips. This would also happen if an emergency resulted in general anaesthesia. Which seemed fair enough. This was written into a letter, that clearly stated their confidence in me managing my own diabetes with my own equipment, and was placed electronically on my file, and also in my paper notes so there were to be no doubts, especially if I ended up in another hospital over the Christmas period. I had also reviewed my birth plan with the G7 Midwife (Supervisor of Midwives post was vacant at that time) to ensure my plans of a less medical birth were understood by the team. The letter from the endo taking the diabetes care away from them made this conversation far easier.
In my birth plan (the non-diabetic side of things) I had declined CFM (continuous foetal monitoring) as a default unless baby was showing signs of distress. Usually for diabetics they are over cautious and use CFM from the beginning, but there is little evidence that this actually has a positive impact and so I chose to decline. The team understood this was coming from a well read and informed choice even if it went against their guidelines and so followed my desires without challenge bar the “we advise but you can choose to decline” statement. Having had these discussions in advance there wasn’t any debate or conflict ruining the atmosphere in the delivery suite.
So my hospital bag was set up with all the usual stuff, but also an electric socket extension and clearly labeled chargers with both my name & NHS number, and which item of diabetes electronics they were for. I wasn’t taking any chances in running out of power or not being able to reach a socket (the socket extension wasn’t used during labour but on the post-natal ward it was incredibly handy as the sockets were not placed in locations that cesarean mamas could reach easily!). I also had a tablet & stand to display my Nightscout page clearly for all who wanted to observe. The midwives were happy to quietly note blood glucose values from this periodically rather than interrupting me. Word obviously got round the staffroom as several came to visit me on the post-natal ward to have a nose.
My husband pretends to listen to me about my diabetes and can spot behavioural changes for a hypo/hyper, but isn’t an expert in looping or the maths and settings I use. So in the month before labour I tried to involve him in every dose I gave when in his presence, and ‘sports casted’ everything I was doing e.g. “oh crikey, that’s higher than I expected given my IOB, I wonder if I ate more than I thought, I’ll just do a correction dose using bolus calculator” to get him comfortable and up to speed. I encouraged him to bolus me at meals to get him familiar with the AndroidAPS interface. We agreed on the following tactic for him during labour:
• Actively keep an eye on numbers and direction.
• If nearing going out of range then start a temp target in the opposite direction. If this doesn’t nudge things then bring up bolus calculator and dose either insulin or carbs as it suggests. If you have to do that twice and it seems like it’s having little impact then do a profile switch of 20% smaller or greater than the current profile.
• don’t tell me my bloods unless I ask. If I ask tell me the data and not just “it’s fine”.
I had a sweep at 38+3/Friday as a compromise on my part for declining booking an induction for 38+6 in preference of awaiting a natural labour. My bloods were erratic that and the following day; a high of 13 mmol and low of 2.2 mmol at one point. I believe it was a mixture of my body saying “what the **** just happened?!” and the counter balance of me trying to be very active to help things along whilst also being exhausted and napping when I could. I used a lot of temp targets, profile switches (AndroidAPS’s version of an override in Loop) and just manual corrections using the bolus calculator. Contractions started at 6pm on 38+4/Saturday when bloods also returned to normality. I managed some sleep but also danced round the kitchen and bounced on the birthing ball. AndroidAPS kept bloods ticking over happily, a little dip low but no treatment needed. After breakfast on 38+5/Sunday we sent Nathan off to his grandpops’, my doula came round and we kept the curtains closed as I blissfully bounced round my dark cave-like comfort zone. The buzz I got from being just a normal person in early labour at home and not a highly medicalised hospitalised diabetic fuelled me with oxytocin. At 11am 38+5/Sunday contractions were lasting 1 minute and spaced less than 4 minutes apart so we took the 40min journey into hospital. The bright sunlight ripped me out of my zen like state, waiting in the florescently lit room to be assessed and having memories of the previous labour flood back dented my oxytocin stores more. My urine sample showed ketones because I’d only eaten protein for breakfast/snacks and not carbs, a long disagreement with the midwife ensued as she wanted to do a blood ketone sample but I declined; knowing that with my bloods being at 4.6mmol they were absolutely not DKA ketones and they did not need treating with insulin. My husband had to take the midwife out into the corridor to challenge her (he googled the difference between starvation ketones and DKA) and remind her I wanted to be in the zone not discussing things in detail. All that dented my oxytocin stores so much it took another 6 hours to get my contractions back to where they were before coming to hospital. I had been moved to the birthing pool room and spent my time wallowing with my sensor on my arm and my pump and phone both being waterproof. It had taken some persuasion to get this in my birth plan so to have achieved it was giving me warm fuzzy feelings, and having the tech working through it was golden.
I was trending lower (4s) and we were keeping an eye on it, watching IOB and speed of fall. It all seemed fine. Husband went out to the car to grab something and I leant on the side of the birthing pool creating a compression low. He came rushing back into the room and fed me glucose without checking the next reading due to recieving the low alarm in the car park. As soon as we noticed it was a compression low we used the bolus wizard to dose. We notified the midwife that bloods may go a bit out of range but we knew exactly why and had taken corrective action so planned to ride it out as there wasn’t much more we could do. Bloods did dance along the top of target for a while but my midwife eloquently explained why to the supervising midwife when she popped in to say hello and my bloods were displaying 8.2mmol. It was beyond reassuring to know they were on board and we didn’t need to justify everything.
My waters broke at midnight and there was meconium so I had to jump out of the pool for the dreaded monitoring. Pain management became harder (baby was back to back). Epidural followed. We had previously done a +10% profile switch at 7am and again at 6pm but needed an extra +20% profile switch around the time of the epidural. Suspect this was due to lying down on the bed, though it could equally be pain management or stress. During pushing Millie’s heart rate kept dipping and not recovering so a cesarean was decided upon.
When the anaesthetist came to discuss the cesarean plans we offered he could take the tablet with Nightscout page into the operating theatre but the midwives had already shared their trust in the system with him and he was happy to not have sight as long as my husband had it on his phone and alerted him if necessary (which of course AndroidAPS kept me in range so no altering was needed). Occasionally he asked my husband for a blood reading to record in my notes, but generally left the diabetes and looping to us.
As agreed with my endo, as soon as the placenta was out we did a profile switch to my pre-pregnancy profile. The ease of doing this in AndroidAPS was perfect and just what was needed after all the sleep deprivation. However, fighting a lot of highs later it seems in wasn’t until my milk came in on day 2 post partum that the reduction in basal & ratios was actually needed.
I planned to co-sleep and get as much skin to skin as possible and noticed that the UNICEF guidelines for this discouraged it for diabetic mums due to the risk of nocturnal hypo being undetected. My endochronologist agreed that with both the alarms on my CGM and AndroidAPS suspending insulin if a low was predicted then the risks for me were incredibly low and so it was recorded in my notes to actively facilitate co-sleeping. Skin to skin is a far more effective method of preserving baby’s heat to prevent hypo from unnecessary energy exertion from temperature regulation in an isolated crib. Baby had no hypos, despite the compression low fuelled dance in the 8s six hours before being born.
• Set alarms to something more gentle sounding. Wind chimes etc rather than beeps that’ll jolt you out of serenity and make you shout at your husband “snooze the damn alarm!! Swipe right, swipe right!”
• When considering sensor placement take account of potential water blocking signal but also any objects you may lean your body on. Make sure everyone in the room (or car park!) knows how to identify a compression low.
• I found it invaluable having a doula. Those times when my husband had to take the conversation out into the corridor to stop disturbing my zen she was there rubbing my back, or vice versa, and I knew I was not alone. I had two people there for me so one could focus on my diabetes while the other focused on my natural oxytocin. In my discussions of my birthplan the midwife was delighted at the prospect of a doula and had said they wished resources would allow a midwife for the diabetes side of labour and a midwife for the birthing side of labour.
• All the research out there is based on poorly controlled diabetics. Having read Milli Hill’s Positive Birth Book I learned that guidelines are based on varying qualities of research or opinion and can and should be challenged and not always followed blindly.
If you take nothing else away from my long ramblings it’s that most of what I’ve written about is mainly labour, or the practical gubbins of diabetes. I’ve barely had to cover looping, and that’s because looping just works merrily in the background doing its own thing keeping things stable and calm. It did need a few nudges but they were minor and easy enough for my husband to do. I had a cesarean again but that was because of meconium in the waters. I wanted a normal non-diabetic birth and I did get what I wished for….sometimes the grass isn’t greener on the other side
• G4 Dexcom with parakeet and xdrip
• DanaR pump (waterproof)
• Contour next blood test kit for automatic calibrations with xdrip
• Samsung A3 waterproof phone running AndroidAPS and xdrip and uploading to Nightscout
• tablet showing nightscout website and husband’s android phone following using NSClient