Dr. Rebecca Dekker – 00:00:00:
Hi everyone. On today’s podcast, we’re going to talk about the updated evidence on induction for gestational diabetes. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone and welcome to today’s episode of the Evidence Based Birth® podcast. Before we get started with this episode all about the updated evidence on induction for gestational diabetes I do have an important announcement for you. Today, February 25th, is the last day to register for the 2026 Evidence Based Birth® conference at the early bird rate before ticket prices go up. So if you want to join me, and 13 other expert speakers for sessions on respectful maternity care, the evidence on the hepatitis B vaccine for newborns, and pelvic floor health in the second stage of labor, be sure to grab your early bird ticket by midnight on Wednesday, February 25th. You can learn more about our conference, our speakers, and all of the topics, or go ahead and secure your spot now by visiting ebbirth.com/conference. And now let’s get started with today’s episode.

My co-host for today is Dr. Morgan Richardson Cayama, and I’m so excited that we are going to be talking together about this important topic that we get questions about all the time. And just as a side note, you will be able to access all of the information from this podcast, including scientific references, our updated full-length Signature Article that’s been peer-reviewed, as well as a free two-page handout about the evidence on inducing for diabetes by visiting ebbirth.com/inducingGDM. Also, as a content note, we will be talking about serious health issues and complications related to gestational diabetes. So today my co-host is Dr. Morgan. She has her PhD and master’s in public health and is a research associate here at Evidence Based Birth®. Dr. Morgan Richardson Cayama recently joined us in episode 370, where we reviewed the updated evidence on diagnosing gestational diabetes. And today she’s back with us here to talk about what she found around being induced if you’ve been diagnosed with gestational diabetes. So Morgan, we’re so happy to have you back.

Dr. Morgan Richardson Cayama – 00:02:40:
Thanks again. Yeah, I’m excited to be back and talk more about the research on gestational diabetes. And like you said, I know this topic touches a lot of families. And induction is something we commonly hear about at EBB.

Dr. Rebecca Dekker – 00:02:52:
Yeah. So again, a quick refresher about Dr. Morgan’s work. She’s been on Team EBB for about two years now, and there’s quite a few episodes you can go back to learn more about related subjects. So she taught all about the ARRIVE trial and elective induction at 39 weeks in episode 334. In episode 343, she talked about the evidence-based strategies for preventing a cesarean. In episode 369, she talked about preventing mistreatment in childbirth through her dissertation research. And the other big project she’s working on is for about the past year, we’ve been working together to update all of the evidence we’ve published on gestational diabetes, also known as GDM for gestational diabetes mellitus. And we originally published here at EBB the evidence on being induced for gestational diabetes back in 2012. And then it was updated in 2019. And so since that time, a few more studies have come out about whether or not you should be induced for GDM. And we’re excited to bring you some of this newer research. But if you haven’t already listened to it, I highly recommend checking out the accompanying podcast, episode 370, all about the evidence on diagnosing GDM. You can find the podcast and the full-length Signature Article at ebbirth.com/diagnosingGDM. So that gives you a lot more background information on what gestational diabetes is, the health risks, and why it’s important to be screened for it, and the evidence on the different methods for screening and diagnosis, including alternative screening methods. And then another topic you might want to educate yourself more about is the topic of big babies that has a little bit of overlap with gestational diabetes. And you can find more information about that in episode 190. We’ll put all of these links in the show notes. So for today, we’re going to be talking about two common questions we often hear from parents who’ve been diagnosed with gestational diabetes. The first, like most popular question we get is, should labor be induced if I’ve been diagnosed with gestational diabetes? And the second question that follows that, if I choose to be induced, when should that induction occur? So as you’re going to see throughout this episode, there are no really clear cut answers and there’s still some gaps in the research. So, let’s dive in. So Dr. Morgan, can you give us a quick refresher on gestational diabetes and tell us like how common is it to be induced if you have this diagnosis?

Dr. Morgan Richardson Cayama – 00:05:34:
Yeah, absolutely. So as you said, gestational diabetes mellitus, often referred to as GDM, is high blood sugar that develops during pregnancy. It’s different from type 1 and type 2 diabetes and the cutoffs or the diagnostic thresholds for blood sugar levels are actually lower for gestational diabetes compared to type 1 diabetes. And the reason that we screen for GDM is because it can lead to issues like preeclampsia, preterm birth, low blood sugar in the baby, and newborn intensive care unit admission or NICU admission. But with proper high blood sugar management and treatment, we can lower the risk of these issues occurring. So that’s why, again, it is important to be screened for it and to be treated or have it managed if it does appear to be an issue. And people with GDM are also at increased risk for fetal microsomia or having a big baby, which is often defined as a baby weighing more than 4,000 grams or more than 8 pounds, 13 ounces. And they’re also at higher risk of their baby experiencing shoulder dystocia or getting their shoulders stuck during labor and birth, even if the baby isn’t big. So again, that’s also why we recommend checking out some of the big baby materials and resources that we have at EBB, again, because these topics do closely align. But because of these higher risks, that means that some care providers are even more likely to recommend an induction before 40 weeks for someone with GDM. Some providers might also be more likely to recommend a Cesarean if they suspect a big baby specifically. Even if we can’t accurately estimate the baby’s size, and I know we’ve talked at EBB a bit before about how ultrasounds only have about a 50% success rate at correctly identifying a big baby, although this is slightly better at predicting big babies in the cases of GDM. So again, check out those Big Baby resources at ebbbirth.com/bigbaby and that podcast episode 190 if you’re curious to learn a little bit more about that research. But because of all this, we do see higher rates of induction in people with GDM. Studies suggest that anywhere from 20 to 40% or more of people who are diagnosed with gestational diabetes get induced or are receive an induction. So for example, in Sweden, where induction isn’t really common, a large study found that about 21% of people with GDM are induced compared to only about 10% of people who don’t have GDM. And we don’t really have great data on induction here in the US for a few different reasons. It’s just not really captured accurately. But induction rates are generally higher here overall. They’re at least around 30 to 40% or more, depending on where you are regionally and who your care provider is. But it’s likely that people with GDM here in the US, are being induced at even higher rates than what we see in some of this international data. So even though it does seem like many people with GDM are being induced, we wanted to look further at the evidence to see, like, is induction always recommended or is it always beneficial? And do you want to talk more about this, Rebecca, and maybe touch on some of the challenges that we came across while we were reviewing this evidence?

Dr. Rebecca Dekker – 00:08:34:
Yeah, so I think one of the challenges we face is one you’ve already talked about and that we can’t really find accurate statistics on how often people with GDM are being induced, which is a little frustrating because it’s hard to talk about a problem if you can’t define the problem. But we do know that we’re hearing from birth workers in many places around the world, especially in the United States, that induction is commonly recommended and sometimes even suggested that it’s required for people with gestational diabetes. And because there are documented higher risks with pregnancy complications with gestational diabetes, it makes sense that we have more care providers encouraging everyone with GDM to plan to give birth earlier. So usually through an elective induction at or near term, so a little before or 40 weeks or by 40 weeks. On the other hand, we do see that some care providers are recommending induction on a case-by-case basis. And that recommendation usually depends on how well the blood sugars have been controlled throughout pregnancy. For example, if your blood sugars have been managed well simply by changing your diet, watching what you eat, and exercising, and you’re managing to keep your blood sugars in the appropriate range, then there’s going to be less pressure to be induced early. However, if your blood sugars do require taking medications to keep them under control, or if your blood sugars are not well controlled at all, then you might be told you need to give birth even earlier, like at 38 or 39 weeks. But it’s really important that we need to have evidence for these suggestions. What are the benefits? What are the risks of scheduling an earlier birth if you have GDM? So before I get into the research with you, I want to talk a little bit about kind of the state of the science on gestational diabetes induction and some of the limitations of the research. So one of the first things you need to know as a listener is that most of the research on this subject is going to compare being induced with expectant management. Expectant management is known as a wait and watch approach, which means you’re waiting for labor to start on its own. So you’re waiting for spontaneous labor is what we call that. But with expectant management, you still might choose to be induced later if you want an induction or if there are medical complications that call for an induction. So specifically studies on the topic of induction for GDM are comparing health outcomes between people with GDM who are induced at different weeks of pregnancy that are at or near term. And then they’re comparing those with people who received expectant management up until a certain time point. So as an example, maybe in one study, they are comparing people who were induced at 38 weeks, and they are compared with people who are not induced until the 39th week. In some of these studies, these people in the expectant management group might have given birth spontaneously during that week, or maybe they had an induction at the end of that week or went into spontaneous labor later. So this means that the research is complicated because it’s really hard to lump all the studies together and come up with a conclusion because the different studies are studying different time points, which makes it slightly harder to tease out, like, is there a generic recommendation? Another one of the key challenges with the research on inducing for gestational diabetes is that there are very few high-quality rigorous studies. So there are not that many randomized controlled trials. Most of the evidence on this topic comes from observational studies. In an observational study, the researchers are simply observing what happens when labor is induced or when the patient had expectant management. These studies are still important to look at, but they’re not as rigorous. And the groups are a little bit different because people who have an induction early or who choose expectant management might have slightly different baseline conditions or there might be more complications in one group or another. And with a randomized trial, you’re kind of controlling for that because it’s like flipping a coin and everybody settles into the two groups that are roughly equal, like have similar health profiles in both groups. But when you’re just observing what happens, the people that fall into the induction group and the expectant management group might be different to begin with. So that makes it trickier. Most of the studies also are not that large. So they don’t have enough participants to look at the impact of induction or expectant management on rare health outcomes, such as stillbirth or newborn death. They also typically don’t measure other factors that influence pregnancy and birth outcomes, like how well were the blood sugars controlled during pregnancy and what types of treatment were they receiving for their gestational diabetes. So they’re not tracking some of that important info. Also, most of these studies are only looking at pregnancies where you’re pregnant with a single head down baby with no serious health issues. So fairly healthy populations. So some of this data might not apply to people with complications. And in some of the studies that were observational, as I mentioned earlier, the groups were different at baseline. So to start, before they even gave birth, some of the induction group might have had a different profile than the expectant management group. Specifically, those who were induced earlier were more likely to be older in age, have a higher body mass index, require insulin treatment to manage their diabetes, and have hypertension or preeclampsia. So it makes sense that people with these health conditions were more likely to have an earlier induction. And a few studies tried to kind of account for these differences and isolate the impact of induction or expected management, but those methods are not perfect. So because the research has all of these limitations, professional organizations like the American College of Obstetricians and Gynecologists acknowledge up front that there really isn’t enough high-quality evidence to make a strong across-the-board recommendation around when birth should be timed with gestational diabetes. Now, they’re still going to provide clinical guidance and recommendations, which we’ll talk about later, but they’re pretty transparent about the lack of strong evidence, and so are we. So that gives you all kind of a background about the challenges of looking at this research. So Morgan, can you now share with us what you found specifically about the overall benefits and risks of induction versus expectant management for GDM?

Dr. Morgan Richardson Cayama – 00:15:36:
Yeah, of course. So in general, we do see different outcomes and risks really depending on that timing of birth that you kind of spoke about earlier, too. As well as whether labor was induced or expectantly managed. So researchers have found that inductions carry different risks depending on that gestational age or the week of pregnancy at birth. So again, both of these things are really important when we’re talking about the research. It’s not just the timing, but then there’s also this sort of induction compared to expectant management piece. And so looking at the timing of birth, the research frequently shows increased risks and poor health outcomes. So, you know, kind of worse outcomes for birthing people with GDM and their babies when birth happens before 39 weeks and zero days or after 41 weeks and zero days. So there’s really kind of that sweet spot that research sort of suggests of the ideal timing of birth being between 39 and 40 weeks. And so because of that, this is what many professional organizations recommend. So they recommend that most people with GDM do give birth between 39 and 40 weeks. Which can mean an induction of labor is recommended if labor hasn’t started on its own by that time. And again, someone might be advised to give birth earlier if there are other complications or if their blood sugars are not well managed. So when comparing induction with expectant management, the research suggests some possible benefits to induction, but there is conflicting and sometimes inconsistent evidence, especially when we look at some of these specific outcomes or health issues. And so this is probably, again, why so many professional organizations are being pretty transparent and candid about, you know, we just don’t have a ton of strong evidence. And so we looked at what individual studies had found regarding the impact on the birthing person or the mother. And then on the impact on the baby. So I can just talk through some of what we found with these individual studies around the impact on the birthing person. So for birthing people, most studies that we came across found no differences in Cesarean rates in people with GDM whose labors were either induced or expectantly managed at least between 37 and 39 weeks. Once we get to 40 weeks and after 40 weeks, the evidence actually suggests that the risk for Cesarean birth goes up kind of across the board for people with gestational diabetes, but that it might be higher or at least slightly higher for those who are induced. So that’s definitely something to consider. And we can kind of speculate on why that might be. For one, continuing a pregnancy past 40 weeks does leave more time for potential complications to develop. It could also be that care providers are maybe more quick to recommend Cesarean after 40 weeks because of those increased risks. They might also be less patient with labor progress and they might be quicker to label an induction if an induction is done and then proceed to a cesarean. So that’s just some reasons why we might see higher rates of cesareans, especially after 40 weeks for people with inductions. We also don’t see differences in rates of instrumental vaginal birth, like with forceps or vacuum-assisted births between people who are induced or expectantly managed with GDM. And we don’t see any differences in maternal deaths or serious maternal complications. The only difference that we’ve seen really when looking at these individual studies is in the risk of severe perineal tears, which are third or fourth degree lacerations that occur between the vagina and anus during birth. There is some evidence that inductions might lower that risk of severe tears. But the findings from across these studies are really inconsistent again. Some showed no differences between induction and expected management, while some did show kind of at least a slight decreased risk for perineal tears. And so that’s really what we found when we were looking specifically for birthing people or mothers. But do you want to talk about, Rebecca, what we found regarding the impact on babies between induction and expectant management?

Dr. Rebecca Dekker – 00:19:26:
Yeah. So several studies looked at the risk of having a big baby if you have gestational diabetes, which you defined earlier as a baby weighing at least 4,000 grams or 8 pounds 13 ounces. And this research that we have on GDM suggests that the risk of your baby being born big is probably lower if you’re induced compared to expectant management, which would make sense because there’s less time for the baby to grow in utero, so they’re less likely to grow larger. There was one meta-analysis where they combined multiple research studies. They found that those with GDM who were induced had a one-third to one-half lower chance of having a big baby. On the other hand, research on the risk of having a large for gestational age baby, it’s a slightly different measurement, but it’s defined as a baby weighing more than 90% of all other babies born at the same gestational age suggests that there’s no difference in large for gestational age babies when you’re looking at induction and expectant management for GDM. When we’re talking about serious health complications, so the research on the impact of induction versus expectant management suggests that the risks really depend on the timing of birth. So there are higher rates of infant health issues with GDM when the induction is done pretty early, before 39 weeks and zero days. Once you get to 39 weeks, zero days, up through 40 weeks, six days, studies showed really no difference in serious health issues or any lower risks with induction compared to expectant management. So either of those options, if you go into labor on your own, that’s great. If you’re induced, that’s great. There’s similar outcomes between 39 weeks, zero days, and 40 weeks, six days with GDM. The research on the risk of stillbirth or perinatal death, which includes stillbirth and early newborn death, suggests that there’s a possible lower risk of perinatal death when babies are born between 39 and 40 weeks. But higher risks of death when they are born earlier before 39 weeks. These lower risks were found in two studies, while other studies, including a meta-analysis, found no differences in the risk. So just to recap, some of the benefits of induction that the research on GDM suggests include a lower risk of having a severe perineal tear, a lower risk of having a big baby, and a lower risk of stillbirth or perinatal death with inductions between 39 weeks and 40 weeks. And induction also, some of the other kind of more intangible benefits include that it may be convenient for some families. It may help them accommodate scheduling needs for themselves or for loved ones or for their preferred care provider if they want a specific care provider to be present during the birth. On the other hand, if we look at the risks of induction with GDM, the risks include a higher risk of Cesarean if you’re being induced after 40 weeks. And a potentially higher risk of serious issues for the baby if you are being induced early before 39 weeks and zero days. So if your provider is recommending a 37 or 38 week induction, we do know that there are higher health risks at those time for babies. And that’s pretty much across the board. That’s consistent with other populations that they’ve studied induction with. There’s also a potentially higher risk of stillbirth or perinatal death if the induction occurs early before 39 weeks and zero days, although this risk is very low overall because this is a very rare outcome. And other kind of more intangible risks or drawbacks to induction include that you tend to spend more time in labor and you also will experience more medical interventions throughout your labor because inductions by their very nature include interventions. And because medically induced contractions may increase pain, it can make it more difficult to avoid pain medications if you are hoping to avoid pain medicine. So that’s kind of an overview of the research on the benefits and risks of induction versus expectant management for gestational diabetes. And as you mentioned, and we’re just going to keep hammering home, the timing does matter, the timing of birth and the risks and benefits kind of change depending on where you are at in your pregnancy. So. Morgan, we’ve kind of given an overview of the research. And if you want details, we have tons of details in the full-length Signature Article where you can even go and look through kind of a summary of each study and what it found. But what are the professional organizations around the world saying about being induced for this reason?

Dr. Morgan Richardson Cayama – 00:24:27:
Yeah. So, again, because of that lack of strong evidence and so much of the inconsistency that we see across studies, the guidelines and practices do vary around the world. So in the United States, the American College of Obstetricians and Gynecologists, or ACOG, we mentioned earlier, provides recommendations that, again, depend on how well your blood sugar levels are controlled. For people whose blood sugar levels are adequately controlled with diet and exercise, they recommend expectant management up to 40 weeks and six days. So, again, you can go almost all the way up to 41 weeks before they recommend that these people who can control or whose blood sugar levels are controlled with diet and exercise need to be induced. They really advise against an induction before 39 weeks for those people specifically as well. So again, probably citing some of those risks with higher health issues for babies and that higher risk of stillbirth and perinatal death for babies before 39 weeks. They make that recommendation to not induce anyone whose blood sugar levels are controlled with diet and exercise before that 39-week mark. But in contrast, if you do need medication to help control your blood sugar levels, they recommend that you be induced or give birth sometime during that 39th week. So 39 weeks and zero days up to 39 weeks and six days. And ACOG really states that there is no clear guidance on the timing of induction or birth. For people whose blood sugar levels are not well controlled. They state that delivery between 37 and 38 weeks might be justified in these cases, maybe even earlier if there are other complications. But again, that risk is really sort of weighed with what we see of these other risks, especially, again, for babies born earlier. So that’s really kind of an individual case-by-case basis, something that can be done if there are other complications present. Now, in the United Kingdom, the National Institute for Health and Care Excellence, or NICE, recommends that care providers offer induction to people with GDM who have not given birth by 40 weeks and six days. If there are other complications, they recommend an earlier elective birth, which could be either an induction or a cesarean, again, before 40 weeks and six days. They don’t really tease out as much some of the other issues in terms of how well your blood sugar levels are controlled. There’s this kind of more of just a blanket recommendation that someone with GDM give birth by 40 weeks and six days. Meanwhile, in Canada, the Society of Obstetricians and Gynecologists of Canada, or SOGC, recommends that pregnant people with GDM be offered an induction between 38 to 40 weeks. And that exact timing, again, depends on how well your blood sugar is controlled and if there are any other risk factors. So that’s what we kind of see, at least from those big professional organizations around the world.

Dr. Rebecca Dekker – 00:27:14:
I also wanted to add that in 2025 the Perinatal Services of British Columbia, also known as PSBC, updated their clinical care guidance for GDM and their guidance was based on a review of the current evidence and it’s published on their perinatal and newborn health hub. So, in these guidelines the authors state recommendations for pregnant people with GDM to be based on number one blood sugar management, including whether its with diet or nutrition, exercise or medication. Number two, the blood sugar levels whether these levels are at target or above target levels and number three, the presence of any other pregnancy complications or health issues with the fetus. The hub also provides recommendations on both fetal monitoring throughout pregnancy and near term at 36 weeks and beyond and the timing of birth. So based on their review of the evidence in the hub they recommend that people be treated as normal if their blood sugar meets target levels using diet and exercise alone. That is they would receive the same induction and delivery protocol after 40 weeks as the general population without GDM. For people whose blood sugar meets target levels using medication, then they recommend induction or birth between 39 weeks and 0 days and 39 weeks and 6 days. And for people whose blood sugar is not at target levels they recommend induction or birth beginning at 38 weeks. And something else we cover in the full length Signature Article at ebbirth.com/inducingGDM are some of the most frequently asked questions that we get on this topic specifically. And so we’re going to cover two of those FAQs, but you can find more of them at the full length Signature Article. So one of the questions that I found really interesting and that we hear a lot at EBB is about extra fetal monitoring in the third trimester if you’ve been diagnosed with GDM. And that’s because people who are diagnosed with GDM often face additional testing and monitoring, particularly as their pregnancy gets closer to term. Now, the reason for this extra monitoring is because of the increased risk of complications and poor health outcomes with GDM around the time of birth. So extra monitoring and testing can include things like non-stress tests to check the baby’s heart rate, Doppler ultrasounds to check the blood flow and umbilical artery and comprehensive ultrasounds to check amniotic fluids, the baby’s growth, and their biophysical profile, like their breathing movements and their muscle tone. But there is no international consensus around extra fetal monitoring for gestational diabetes, and it can sometimes be controversial. Here in the U.S., ACOG states that extra monitoring is usually started around 32 weeks of pregnancy for those whose blood sugars are either not well-controlled or they have to be controlled with diabetes medication. They also state that extra monitoring might not be necessary if your blood sugar is controlled with diet and exercise, because research does not strongly show any higher risk of stillbirth in that population. ACOG also does not provide specific guidance on which types of testing should specifically be done. Now, we do see that many care providers are recommending that all of their patients with GDM or gestational diabetes get an ultrasound sometime between the 36th week and the 39th week to estimate the baby’s size. Some care providers report conducting regular non-stress tests and checking the amniotic fluid on patients with medication-controlled or poorly controlled blood sugar levels starting at 32 weeks. So in 2024, a group of researchers conducted an international review looking at eight different guidelines and 17 different studies to develop their own recommendation on fetal surveillance, which is what we sometimes call extra-fetal monitoring for people with GDM. Based on the existing evidence, they recommend ultrasounds to check fetal growth and amniotic fluid in everyone with diabetes, whether it’s gestational or type 1 or type 2 diabetes, beginning between 28 and 32 weeks. And if these results are normal, they recommend repeating the measurement every two to four weeks just to check in. In cases of other complications or uncontrolled blood sugar levels, it seemed like most guidelines were recommending ultrasounds every one to two weeks. And if potential issues were identified in these ultrasounds, like the baby is growth restricted and not growing, or the opposite, they’re a large for gestational age baby, then they recommend increasing fetal monitoring to twice a week. So this increased fetal monitoring could include checking the amniotic fluid levels, doing a Doppler ultrasound, and doing a non-stress test or a biophysical profile test. So as you can, I think the summary of the fetal monitoring in the third trimester with gestational diabetes is that it really depends on which guidelines your practitioner is following, how well your blood sugar has been controlled, and whether you’re experiencing any other complications. So that’s one of the FAQs. Another one that I think is really fascinating is how can someone handle if they’re feeling pressure to be induced or to have other interventions during pregnancy and birth? So can you take that one, Dr. Morgan?

Dr. Morgan Richardson Cayama – 00:32:49:
Yes, yeah, absolutely. And this is an issue that is really near and dear to my heart with my own interest in respectful maternity care. And so I just want to say that right off the bat, no matter what health issues you might be experiencing in your pregnancy, you always have the right to say yes or no to any intervention, including an induction. You also have the right to inform choice and consent and to ask questions and to have those questions answered with accurate, comprehensive, and unbiased information. So an induction can be both medically necessary and still violate patient rights when it is pushed on a patient without their complete information or without being given complete information or without their full informed consent. So that’s just something that’s very important to keep in mind. Even if you are diagnosed with gestational diabetes, you still have the right to ask questions, to get additional information, and to make these decisions for yourself. And as we discussed, inductions carry both risks and benefits for people with gestational diabetes. And it’s important to discuss these with your care provider. So in general, inductions can impact the delivery of care. As Rebecca mentioned earlier, they do come with more medical interventions just by their very nature. And that can impact how someone perceives their birth experience. Also keep in mind, as we talked about throughout this episode and throughout our conversation, that benefits and risks and timing of induction really depend on how well your blood sugar levels are managed and whether there are any other health issues or concerns. So we do see, again, those different benefits and risks, depending on these different factors like blood sugar control, other complications. And then again, you still have the right to make decisions for yourself and speak with these things about risk. Also keep in mind that benefits and risks and the timing of induction can depend on how well your blood sugar levels are managed and whether there are any other health issues or concerns. The research, again, suggests that inductions carry different benefits and risks at those different weeks of pregnancy. And you may want to consider those when you’re talking with your care provider and, you know, to decide what’s best for you and your individual situation. So definitely something that’s important to keep in mind, as we’ve talked about over the course of today’s episode. I also really recommend checking out some of the other podcast episodes that touch on rights during care and respectful maternity care. Again, the issue that is near and dear to my heart. That includes podcast episode number 338 on Respectful Maternity Care, where we talk with Dr. Jessica Brumley, who is a certified nurse midwife and has some really great recommendations and discussion around respectful care. As well as EBB episode number 369 – What is Mistreatment in Childbirth? where I talk more about pressure and consent and what we see in terms of mistreatment and even how you can help advocate for yourself if you find yourself in that situation. And we include a free two-page handout on Respectful Care as part of that conversation as well.

Dr. Rebecca Dekker – 00:35:41:
Yeah, you can get that free handout at ebbirth.com/369. And Dr. Jessica Brumley is actually the keynote speaker at our upcoming conference where we’re going to be focusing on respectful maternity care. So I’m really excited about that. And I thought of one more resource as you were speaking, and that is at EBB, we do have a Pocket Guide to Labor Induction. So whether you’re interested in natural labor induction techniques to help prepare your cervix or try to get things kickstarted before you need an actual medical induction, or if you are just interested more on the evidence on induction, the evidence on the different methods of induction, that’s all covered in the Pocket Guide. And we’ll link to that in the show notes as well.

So I think this is a really interesting area of research. It impacts a lot of families. Gestational diabetes is like one of the most common complications or health conditions that you can be diagnosed with in pregnancy. So it affects a lot of families as they’re navigating their diagnosis, they’re planning their own labors and birth. And maybe for some people, you know, it doesn’t matter to them whether or not they’re induced, but for other people, it’s a big deal. It’s a big question to ponder and talk with your provider about. So I think what I’d like to do to close this out is to kind of wrap up with our classic bottom line. What’s the bottom line on inducing for gestational diabetes? So that you have takeaway points and then hopefully you’ll leave this conversation with just more concrete knowledge about the evidence on this topic. So one of the big takeaways is that we still don’t have enough evidence. We don’t have enough high quality studies. We don’t have enough randomized trials to strongly make a recommendation as to whether you should be induced or not. And if so, at what time? The research that we do have points to the fact that there are different sets of benefits and risks depending on the timing of birth, the week of pregnancy, and whether the birth was induced or expectantly managed. We do have evidence suggests that there are higher risks of health problems for those with GDM and their babies when birth happens before 39 weeks, zero days, or after 41 weeks and zero days. However, the benefits and risks of induction and expectant management also look different depending on how well your blood sugar levels have been controlled throughout pregnancy. So someone whose blood sugar levels were well controlled with diet and exercise might not benefit as much from an earlier induction or birth, especially before 40 weeks.

And so it really has to be an individualized decision and conversation with your healthcare provider about your unique situation. Studies have found no differences between induction and expectant management in most maternal health outcomes, including serious health issues or Cesarean rates before 40 weeks. However, inductions after 40 weeks, so if you wait until after that 40-week time point, those inductions might carry a higher risk of Cesarean birth compared to expectant management. For babies, research suggests that induction does lower the chances of having a big baby if you have GDM. Studies also generally show higher rates of health issues if babies are born before 39 weeks and zero days, meaning that it’s probably best to avoid an induction before that time point unless you or your baby have health issues or medical issues or blood sugar levels that are not controlled that would indicate an earlier induction could be needed. Studies also show a potentially lower risk of death in babies who are born between 39 weeks and 40 weeks, suggesting that an induction might be more beneficial if your labor has not yet started on its own by this time point. However, the overall risk of perinatal death is very low, and some studies have found no differences between induction and expectant management. I think the bottom bottom line, the final takeaway point is that inductions carry both benefits and risks. And so the decision to induce or not should be based on your individual circumstances, like how well your blood sugar is controlled, any other potential health issues, and your values, preferences, and goals. And because the research isn’t super strong, I think there is a lot of gray area in there for people to make different decisions. Like everybody has slightly different perspectives on induction versus expectant management.

So again, I want to encourage you to go to our website to find the fully updated Signature Article and handout on inducing gestational diabetes. You can find that at ebbirth.com/inducingGDM. So we do have a free handout on this topic that you can download to take to a doctor’s appointment or share with a client if they’re facing this question of should I induce and when for gestational diabetes. And go and learn more about gestational diabetes and how it’s diagnosed in episode 370. And we have some really good episodes on induction. So, you know, a lot of people do choose induction, and to support those families, we have a variety of resources. There is the Pocket Guide to Labor Induction at EBB that I already spoke about. We also have some really great episodes. We have podcast episode with Jen Anderson on team EBB that’s episode 367. Where she talks about the latest trends in induction. And we also have guests from Partner to Decide, which is a website that has decision aids to help guide people in making decisions about induction. That’s episode 257. Again, we have so many resources for you. So if you want to dive down a rabbit hole or you just want to get that handout for free, you can find that in the show notes. And I also can’t talk about gestational diabetes without recommending the book Real Food for Gestational Diabetes by Lily Nichols, who is a specialist in prenatal nutrition and gestational diabetes. It’s a great resource for those who’ve been diagnosed with GDM and want to try and manage their blood sugar levels with diet. It is evidence-based, includes citations to the research articles she used to formulate her recommendations. And I have found that book to be really empowering. And the family and friends I share it with also feel empowered. Like they don’t feel stuck. Like I’ve had this diagnosis now. I’m helpless. I can’t do anything. You actually do have access to information. You can get empowered with information and you do have choices and it’s your body. So we want to encourage you if you’re listening and you have gestational diabetes, you’re not alone. Other people have been there too. And there are resources and choices for you. So we wish you all the best. Thanks everyone for joining us and we’ll see you next week. Bye.

Today’s podcast was brought to you by the Signature Articles at Evidence Based Birth®. Did you know that we have more than 20 peer-reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com? It takes six to nine months on average for our research team to write an article from start to finish. And we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, Pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB Signature Articles.

A systematic review uses a very structured approach to looking at studies on a specific topic. They are guided by specific research questions and have clearly defined methods that let the reader know exactly how the researchers searched for and included studies. In a systematic review, the researchers compare and summarize all the findings from these studies. They also look for potential biases or issues with each study and report on each study’s quality (categorizing them as “high”, “low”, or “unclear” quality). Some systematic reviews only include randomized controlled trials, while others include other types of studies too.

Systematic reviews are often (but not always) done alongside meta-analyses. In a meta-analysis, the researchers combine all the quantitative data from each study included in their review. By creating this larger, combined pool of data, the researchers can do more powerful statistical analyses that have more accurate results.

Systematic reviews and meta-analyses are considered the highest quality of research evidence and are often used to develop practice guidelines for health care providers.  However, the quality of both systematic reviews and meta-analyses depends on the quality of the studies they include. If only low-quality studies are included and analyzed, then the overall result will also be low-quality.

Relative risk is the risk of something happening to you in comparison to someone else. The absolute risk is the actual or true risk of something happening to you. Let’s look at the real study by Rosenstein et al. (2012) as an example. You can read more about this study in the section on “Stillbirth and Perinatal Death.”  

This study done with people with GDM found that expectant management at 39 and 40 weeks carried an 80% higher relative risk of stillbirth or newborn death compared to giving birth at that time (Rosenstein et al. 2012). However, when we look at the absolute risk, we see that it’s still low overall. At 39 weeks, the absolute risk of stillbirth or newborn death was 8.7 deaths per 10,000 for people who gave birth versus 15.2 deaths per 10,000 with expectant management for one more week. At 40 weeks, the absolute risk for those who gave birth was 9.5 deaths per 10,000 versus 17.1 deaths per 10,000 for those who had expectant management for one more week. When looking at 39 weeks as an example, 15.2 per 10,000 is 80% higher (if you do the math!). But the overall, or absolute risk, is low.

The relative risk and the absolute risk of something are meaningful in different ways, and it may be necessary to present them together to paint a true picture of the risk. How we communicate risk is important and impacts our perceptions of risk. If a provider only uses relative risk and says, “Your risk of stillbirth is 80% higher with expectant management,” a parent might incorrectly assume the provider means that the risk of stillbirth is 80% if they wait another week to go into labor on their own—which is not true.

A Bishop score, also sometimes referred to as a pelvic score or cervix score, is a useful tool for helping determine how ready your body is to give birth and how likely it is that an induction will result in a vaginal birth. However, it is not a “crystal ball” and does not mean you will or will not have a vaginal birth.

It includes 5 components:

• Cervical dilation, or how open the cervix is. This is measured in centimeters, and 10 centimeters means the cervix is fully open.
• Cervical effacement, meaning how short or long the cervix is. This is measured as a percentage, from 0%-100%.
• The consistency of the cervix, or how hard or soft it is.
• The position or direction of the cervix, like whether it’s facing the front (anterior) or back (posterior) of your body.
• Fetal position, which has to do with where the baby’s head is in the pelvis. This is typically measured from a -3 to a +3, where positive scores mean the baby’s head is lower in the pelvis.

Each component is scored from 0 to 3. Scores are highest when the cervix is open at least 5-6 centimeters, effaced at least 80%, soft, facing the front of your body, and baby’s head is at a +1 or +2 position in the pelvis. A score of 8 and above (for first time birthing people) or 6 and above (for people who have given birth before) indicates that the cervix is “ripe” or favorable, and an induction is more likely to result in a vaginal birth. A lower score means your body is not quite ready to go into labor, and that an induction might be more likely to result in a Cesarean birth (unless special cervical ripening procedures or medications are taken).

Several studies have found that the risk of Cesarean birth increases after completing 40 weeks of pregnancy (Melamed et al. 2016, Feghali et al. 2016, Reischer et al. 2023, Sutton et al. 2014, Seimon et al. 2022). One study found that this risk increased for everyone, regardless of whether their labor began spontaneously or was induced (Feghali et al. 2016), while others have only seen a higher risk in people with inductions (Sutton et al. 2014, Reischer et al. 2024, Seimon et al. 2022). Specifically, Reischer et al. found that people who were induced after 40 weeks had over twice the odds of having a Cesarean birth compared to people induced earlier (Reischer et al. 2024). 

Why might this be?  Perhaps continuing a pregnancy to after 40 weeks leaves more time for potential medical problems to develop. It could also be that care providers are quicker to recommend Cesareans beyond 40 weeks (and they may be less patient with the labor, labeling it as “failed” earlier in the process).

It’s also possible that an increase in the baby’s weight contributes to the increase in Cesarean rates at later gestational ages, or the provider’s perception that the risk of having a big baby has gone up, leading to an increased risk of Cesarean (even if the baby is born a normal weight). See the section, “How is the topic of big babies related to gestational diabetes?” above for more information, along with our Signature Article, the Evidence on: Induction or Cesarean for a Big Baby (ebbirth.com/bigbaby).

If you have GDM, treatment with diet changes, exercise, and sometimes medicine, is necessary to maintain healthy blood sugar levels. The most common approach to GDM treatment is to first make changes to your diet and exercise. If blood sugar levels remain above target levels, then you may also be prescribed medication. With either approach, you will be asked to regularly monitor your blood sugar levels. It’s important to note that target levels or the criteria for what is considered “controlled” blood sugar levels can vary across care providers, and this can be frustrating for some people with GDM.

Nonetheless, the evidence shows that treatment for GDM does improve outcomes. There have been several meta-analyses and systematic reviews on different types of treatments or interventions and their impact on outcomes for people with GDM. Two of these reviews suggest that a combination of lifestyle changes, supplemented with medication if needed, result in the best outcomes. This combination can lower the risk of large-for-gestational age babies, large birth weight babies, and shoulder dystocia as compared to usual care. Lifestyle changes include things like improved diet and increased physical activity or exercise. Usual care can vary from place to place or study to study, but can include things like patient education, nutrition or dietary counseling, and monitoring blood sugar levels.

Importantly, when the risk of complications from GDM is reduced with treatment, there is less potential benefit from labor induction. Lifestyle interventions like nutrition counseling and exercise can be especially helpful for people with GDM who also have bigger bodies or a high body mass index (BMI), who may face additional risk factors as well as discrimination based on their size.

Lifestyle changes used in combination with medication (if needed)

In 2018, Cochrane researchers published an overview of 14 of these systematic reviews, and pooled data from 10 of these reviews in a giant meta-analysis (128 trials, nearly 18,000 mothers) (Martis et al., 2018). They looked at dietary interventions, exercise programs, insulin and oral-glucose-lowering drugs, supplements, combination lifestyle interventions, and obstetric management strategies (induction or planned Cesarean). The only intervention found to provide effective treatment for GDM leading to health benefits for mothers and babies was lifestyle changes that combined two or more interventions. At a minimum, the lifestyle intervention included healthy eating, exercise, and self-monitoring of blood sugar levels. However, there wasn’t clear evidence to support one particular approach or version of the lifestyle intervention, and many of them varied across studies.

People randomly assigned to a lifestyle intervention versus usual care had a 40% lower chance of having babies large for gestational age, defined as weighing more than 90% of other babies (6 trials, 2,994 participants). They also had around a 60% lower chance of experiencing shoulder dystocia (5 trials, 2,894 babies).

And, of the people assigned to lifestyle intervention, 10% also received pharmacological (drug) interventions, such as insulin or oral anti-diabetic therapies if they needed additional help managing their blood sugar levels. However, this means that most participants (90%) achieved these benefits from lifestyle changes alone (without any medication). When we talk about these lower chances or risks for participants in the lifestyle group, these are relative risks that are in comparison to the participants in the other intervention groups. This is different from the absolute risk, or true risk, of these health issues occurring for participants. To learn more about relative and absolute risk, you can review the section near the beginning of this article titled “Let’s review some common terms before we dive into the research!”

There was no clear evidence of a difference between groups for the risk of stillbirth and infant death, pre-eclampsia, Cesarean, the later development of Type 2 diabetes, perineal trauma (i.e., perineal tears), or induction of labor. While the difference in the rate of induction between groups was not significant, the authors mention several times that there was a trend toward lifestyle intervention increasing the risk of induction of labor. They found this trend worrisome enough to conclude “lifestyle intervention may increase the number of inductions, causing possible harm.” However, this trend was not statistically significant, and all it means is that we need more research on whether prescribing lifestyle intervention can lead to an increase in the risk of induction.

Another meta-analysis and systematic review from 2017 included 12 RCTS that compared ‘bundles of care’ (or starting with lifestyle changes and then using medication as necessary to lower blood sugar levels) versus routine care (Farrar et al. 2017). They found that bundles of care cut the risk of large birth weight babies by half and shoulder dystocia by more than half. They did not find a significant difference in the risk of pre-eclampsia, Cesarean, NICU admission, newborn low blood sugar, preterm birth, low Apgar scores, use of forceps/vacuum, or labor induction. In two of the trials, mothers reported a higher quality of life after treatment for GDM.

Probiotic treatment

In 2020, Cochrane researchers look at the safety and effectiveness of probiotic treatment for people with GDM and its impact on outcomes (Okesene-Gafa et al. 2020). They found nine small RCTs, representing 695 pregnant people with GDM, and found no impact on most of the maternal outcomes they looked at, including pregnancy-related hypertension, induction of labor, and Cesarean birth. They did find that probiotics might help lower triglycerides and cholesterol levels. Overall, more research with larger studies is needed.

Use of metformin compared to insulin

If blood sugar levels cannot be well controlled or remain above target levels after changes to diet and exercise, then medication may be prescribed. The two most commonly prescribed medications are metformin and insulin. Metformin is an oral medication (pill) that is a safe and effective medication for people with Type 2 diabetes. Insulin is a medication that is typically injected, and is another common medication used in treating diabetes.

Different people respond differently to these two medications, and we don’t know for sure which medications (insulin or oral anti-diabetic medications like metformin) work best for individuals with GDM. Some people might find metformin easier to take because it is a pill (and doesn’t require injections).

However, as far as safety, metformin use can be controversial because it crosses the placenta, and we don’t have enough research on the long-term impact for children exposed to this medication while in the womb (Mason et al. 2024). Insulin, on the other hand, does not cross the placenta and thus is highly unlikely to cause any harm to the baby (Martis et al., 2018).

In 2024, a group of researchers conducted a meta-analysis to compare the effects of these two diabetes medications on health outcomes in birthing people and babies (Wu et al. 2024). Their review included 24 RCTs with 4,934 participants with GDM. They found that people treated with metformin had a 45% lower relative risk of newborn hypoglycemia (low blood sugar), 39% lower relative risk of preeclampsia, 33% lower relative risk of macrosomia (having a big baby), 25% lower relative risk of NICU admission, 20% lower relative risk of large-for-gestational-age (LGA) babies), 10% lower relative risk of induction, and 9% lower relative risk of Cesarean birth. There were no differences in the risk of pregnancy-related hypertension high blood pressure, spontaneous vaginal birth, emergency Cesarean birth, shoulder dystocia, preterm birth, polyhydramnios (too much amniotic fluid), birth trauma for the baby, low Apgar scores, respiratory distress syndrome, jaundice, or birth defects. However, as noted above, the authors wrote that more studies are needed, particularly on the long-term effects of metformin use.

Overall, the American College of Obstetricians and Gynecologists (ACOG) considers insulin the preferred medication for GDM, although they say that metformin can be used for people who decline insulin or who would otherwise be unable to use or afford insulin (ACOG 2018). There is also some evidence suggesting that insulin may increase the risk of high blood pressure disorders of pregnancy compared to oral medications (Sun et al. 2021, Martis et al. 2018).

Gaps in the research on GDM treatment

In general, there are still many things we don’t know about treatments for GDM. For example, we don’t know for sure which combination lifestyle intervention is most effective. There is also very little research on potential long-term health benefits from treatment for birthing people or babies. And, we don’t have enough research on the long-term impact of oral diabetic medications (like metformin) when taken during pregnancy.

GDM diagnosis and treatment can present many different challenges, including stress, worry, and fear (Siahkal et al. 2022; He et al. 2020). People with GDM may experience challenges adhering to recommended diet, exercise, and medication treatments. Some of these include lack of clear communication and information from care providers, being unable to get childcare for medical appointments or for exercise, and not getting enough social support from family or their communities (Siahkal et al. 2022; He et al. 2020).

People diagnosed with GDM face more medical appointments (to meet with a registered dietitian, a diabetes educator, or both) and are told to carefully watch what they eat and monitor blood sugar levels several times a day (CDC 2024). Testing supplies, blood sugar medication (if needed), and extra monitoring all come with significant costs, which are not always fully covered by insurance. However, in two RCTs included in a meta-analysis by Farrar et al. (2017), mothers reported higher quality of life after treatment for GDM, including lower levels of postpartum depression.

We recommend the following resources if you’d like to learn more about treatment and management options for GDM:

• National Health Service (U.K.) “Treatment: Gestational diabetes” 
• The American Diabetes Association (U.S.) “Gestational Diabetes: Can you have gestational diabetes and a health baby? Yes.” 
• World Health Organization (WHO). WHO recommendations on care for women with diabetes during pregnancy. 

Someone might be told they have “borderline” GDM (BGDM), which means they might have had a positive oral glucose screening test (suggesting that they might have GDM) but then the follow-up diagnostic test is normal. So, this person might have blood sugar levels that are higher than “normal” but lower than those used to officially diagnose GDM.

Studies suggest that people with BGDM and their babies are at increased risk for poor health outcomes compared to people whose blood sugar levels fall within the normal range or who do not have a positive screening test (Ju et al. 2008).  Evidence also suggests that people with BGDM whose blood sugar levels are monitored and managed have better outcomes than those whose are not (Han et al. 2012). A Cochrane review from 2012 found that birthing people who received management for their BGDM (like dietary counseling and blood sugar monitoring) had a lower risk of having big babies or large-for-gestational age babies compared to those who received routine care (Han et al. 2012). They did not find any differences in the risk of Cesarean birth or instrumental vaginal birth (e.g., with forceps or vacuum). However, this review was limited by a low number of studies and participants (only 521 mothers and their babies) and most of the studies had a moderate to high risk of bias.

If you are told you have BGDM, you might be treated similarly to someone officially diagnosed with GDM. That is, you might be advised to follow a healthy diet, exercise regularly, and monitor your blood sugar levels. You might be told or treated as if you are too high-risk for midwifery care or for community birth options, like a birth center or home birth. You might also experience pressure to be induced before 41 weeks. In this case, it would be helpful to know the risks and benefits of induction, especially for someone with GDM (see the section, “Potential Benefits and Risks of Induction for GDM” near the beginning of this article). For example, all inductions carry the risk of what we call the cascade of interventions, or the need for even more medical interventions during labor and birth. One example of this is the increased need for pain management in labor, like an epidural, which can increase your risk of having an even longer labor and needing more interventions during the birth.

Overall, it’s important that you learn more about the typical practices in your area and talk with your care provider about your options if you are told you have borderline GDM.

People who are diagnosed with GDM are often recommended to have extra fetal testing and monitoring, particularly as their pregnancy progresses and gets closer to term.

There are two primary types of tests: 1) tests to check or monitor the fetus’ growth, and 2) tests to monitor the fetus’ wellbeing. The second type of testing can include things like nonstress tests (NSTs) to check the baby’s heart rate, Doppler ultrasounds to check blood flow in the umbilical artery, and comprehensive ultrasounds to check amniotic fluid levels, and their biophysical profile (BPP) (i.e., breathing motions, muscle tone) (Braverman et al. 2024). The extra monitoring is often suggested because of the increased risk of complications and poor health outcomes in birthing people with GDM and their babies.

However, there is no consensus around this extra fetal monitoring, and its use is controversial. We’ve summarized the guidance and recommendations from a few different sources below.

American College of Obstetricians and Gynecologists (ACOG)

ACOG states that extra monitoring is usually started at 32 weeks of pregnancy for people who either need medication to control their blood sugar levels (A2 GDM) or who have blood sugar levels that are not well controlled (ACOG 2018). However, because research does not strongly suggest increased risks of stillbirth for people whose GMD is controlled well with diet and exercise (A1 GDM), they state that extra fetal monitoring might not be necessary for these people. They also do not specify which specific types of tests should be used or how often, instead leaving it up to clinicians and local practices.

Clinical guidance

On the clinical guidance website, UpToDate, the authors report that they conduct an ultrasound between 36-39 weeks in all pregnant people with GDM to estimate the baby’s size (Caughey 2025). For people with A1 GDM whose blood sugar levels are not well-controlled and for people with A2 GDM, the authors also conduct NSTs and check amniotic fluid levels twice a week starting at 32 weeks. They do not do any further fetal surveillance on people with A1 GDM whose blood sugar levels are well-controlled. Overall, they note that most of the research on this topic is older and that there have been few randomized controlled trials (RCTs). Generally, the need for extra monitoring is based on how well the person’s blood sugar levels are controlled and whether there are other health issues and risk factors.

The Perinatal Services BC (British Columbia, Canada) provides recommendations for fetal growth assessments and monitoring for people with GDM on their Perinatal and Newborn Health Hub (https://www.psbchealthhub.ca/clinical-guidance/936). Based on their review of the current evidence, they recommend the following:

• For people whose blood sugar meets target levels with diet and exercise: regular fundal height assessments and recommending that parents monitor and remain aware of fetal movements (to notice if movement changes or stops).
• For people whose blood sugar meets target levels with medication: perform a fetal growth ultrasound every 3-4 weeks from diagnosis to birth, recommending that parents monitor fetal movement, and/or conduct an NST.
• For people whose blood sugar levels remain above target levels: perform a fetal growth ultrasound every 3-4 weeks from diagnosis to birth and begin NST surveillance in the third trimester.

International review of professional guidelines and practices around fetal monitoring

Recently, a group of researchers conducted a review looking at the different professional guidelines from around the world on antenatal fetal surveillance and the optimal time of birth for people with GDM, along with updated evidence on this topic (Braverman et al. 2024). They looked at 8 international guidelines and 17 different studies to develop their own recommendation around fetal surveillance for people with GDM. However, they also concluded that most of the research on this topic is based on observational studies, and that more research and more RCTs are needed.

Based on the existing guidelines and research evidence, these researchers recommend ultrasounds to check fetal growth and amniotic fluid for all pregnant people with diabetes (GDM or pregestational diabetes) beginning sometime between 28-32 weeks. If these results are normal, they recommend that this monitoring be repeated every 2-4 weeks.

In the case of other complications, like uncontrolled blood sugar levels or other maternal health issues, they recommend that ultrasounds be performed every 1-2 weeks. If these ultrasound results identify potential health issues but fetal growth appears normal, they recommend the following testing every 1-2 weeks: ultrasound, amniotic fluid analysis, Doppler ultrasound, and NSTs or BPPs. If ultrasound results identify potential health issues and either intrauterine growth restriction (IUGR) (sometimes referred to as fetal growth restriction or FGR) or a large-for-gestational age baby, they recommend each of these tests twice a week.

No matter what health issues you might be experiencing in your pregnancy, you always have the right to say yes or no to any intervention, including induction. You also have the right to informed choice and consent, and to ask questions and have those questions answered with accurate, comprehensive, unbiased information. An induction can be both medically necessary and violate patient rights when it is pushed on a patient without complete information or their full informed consent.

Inductions carry both risks and benefits for people with GDM, and it’s important to discuss these with your care provider. In general, inductions can impact the delivery of care and how someone perceives their birth experience. For example, an induction can impact your freedom of movement and freedom to eat and drink during labor. While movement and nutrition are rights owed to all people during labor and birth, these rights can be more difficult to advocate for and obtain during an induction in hospitals with outdated policies.

Also keep in mind that benefits, risks, and recommended timing of induction can depend on how well your blood sugar levels are managed and whether there are any other health issues or concerns. The research suggests that inductions carry different benefits and risks at different weeks of pregnancy for everyone (regardless of whether you have GDM), and you can talk with your providers about these potential benefits and risks and how they might apply to your unique situation. (See the section on “Benefits and Risks of Induction for GDM.”) You can also download our free 2-page handout on Induction for GDM to take to health appointments, as a starting point to discuss these potential benefits and risks with your provider.

To learn more about your rights during care, we recommend checking out our podcast episodes, EBB #338 “Respectful Maternity Care” with Dr. Jessica Brumley, and EBB #369 “What is Mistreatment in Childbirth?” with Dr. Morgan Richardson Cayama (which includes a free 2-page handout from EBB on Respectful Maternity Care, including your rights in care).

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Here at Evidence Based Birth®, we have several resources that can be helpful for parents and families navigating birth with gestational diabetes.

We strongly recommend reading our Signature Article, the Evidence On: Diagnosing Gestational Diabetes (ebbirth.com/diagnosinggdm). This article goes into additional detail on what GDM is, what health issues it can cause, ways it can be screened for and diagnosed, and the evidence on early screening practices.

If you want to read more about induction or Cesarean for suspected big babies, you can read our Signature Article, the Evidence on: Induction or Cesarean for a Big Baby (http://ebbirth.com/bigbaby).

Want to learn more about trends in induction protocols and informed decision-making during an induction? Check out EBB® podcast episode #367 “Early AROM and High-Dose Pitocin with all Inductions?” with Jennifer Anderson, RN, Doula, and EBB Instructor.

You can learn more about your rights during care, what mistreatment in care can look like, and ways to improve your chances of receiving respectful care by checking out our podcast episodes, EBB #338 “Respectful Maternity Care” with Dr. Jessica Brumley, EBB #369 “What is Mistreatment in Childbirth?” with Dr. Morgan Richardson Cayama, and our free handout on respectful maternity care.

The website Partner to Decide has tools and decision aids to help guide pregnant people in making decisions about induction. We talk with the Founder, Dr. Anne Peralta, and one of her clinical advisors, Kari Radoff, CNM in podcast episode EBB #257 “Making Decisions about Elective Induction of Labor”.

The book Real Food for Pregnancy (https://realfoodforpregnancy.com) by Lily Nichols, RDN, CDE, is a great source of information on eating well throughout the entire pregnancy. She also has a book called Real Food for Gestational Diabetes (https://realfoodforgd.com) for people who have been diagnosed with GDM and want to try and manage their blood sugar levels with diet. Ms. Nichols is a specialist in gestational diabetes and prenatal nutrition. Both books are evidence-based resources with citations to the research articles she used to formulate her recommendations.