1. Diabetes in pregnancy Timing and Mode of Delivery
Tan Lay Kok
Consultant
Department of Obstetrics & Gynaecology
Singapore General Hospital

2. Diabetic pregnancy & delivery
Best outcomes for mother & baby

3. What are the concerns
Stillbirth

4. What are the concerns
Stillbirth
Macrosmia

5. What are the concerns
Stillbirth
Macrosmia
Shoulder Dystocia

6. What are the concerns Stillbirth Macrosmia Timing of delivery
Shoulder Dystocia
Timing of delivery
Planned elective
versus
Expectant (spontaneous)

7. Literature Review
Overall quality is POOR

8. Fetal concerns

9. NICE guidelines 2015

10. NICE recommendations
Discuss the timing and mode of birth with pregnant women with diabetes during antenatal appointments, especially during the third trimester. [new 2015]

11. NICE recommendations
Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour, or by elective caesarean section if indicated, between 37+0 weeks and 38+6 weeks of pregnancy. [new 2015]
weeks

12. NICE recommnedations
Consider elective birth before weeks for women with type 1 or type 2 diabetes if there are metabolic or any other maternal or fetal complications. [new 2015]
weeks

13. NICE recommendations
Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. [new 2015]
NO LATER THAN
weeks

14. NICE recommendations BEFORE
Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015]
BEFORE
weeks

15. NICE recommendations
Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section. [2008]

16. NICE recommendations
weeks

17. NICE recommnedations
Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]

28. Informed consent & the standard of care
Patient autonomy & rights
Move away from medical paternalism
Patients are consumers making choices
Bolam may be inapplicable
Therapeutic exception may be inapplicable
Risk counselling with what patient meaningfully requires to make informed decision
Shoulder dystocia and sequelae are material risks the patient would want to know
Ensure patient aware of material risks in any recommended treatment, and provide reasonable alternatives and treatments
Inapposite
Material risks – attach signficane to the risk

29. NICE recommnedations
Explain to pregnant women with diabetes who have an ultrasound‑diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. [2008]

42. Conclusions
Timing & Mode of delivery is an important part of antepartum management
Factors to consider:
EDM versus GDM
Pharmacology versus diet/lifestyle alone
Degree of control
Concomitant maternal complications & risk factors
Fetal growth, size
Shared Decision Making
Important part
Devote time and energy
Medicolegally relevant part of management
Factos in timing
Shared