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Two
and Counting by Anneika Hart I sit staring intensely at this tiny helpless creature in front of me and can’t help but return to a place long gone now and remember those words that were to change my life. “You do realise it would be best to have your children before you turn 30?” were the words that rolled fluidly off my endocrinologist’s tongue. Hanging momentarily in the air before I gulped helplessly at them, forcing them to the back of my throat. How was I to deal with that? I was only 20 and that was less than 10 years away, hell I didn’t even have a boyfriend! I went home that night deciding I had enough to worry about, just dealing with the up’s and down’s of managing my type 1 diabetes. And kids, I’d never thought much about having kids. Chapters in this article:
It wasn’t
until I was to meet my now husband’s sister, that I was to think
any more about that day. My husband Peter had shown a great interest
in my diabetes and explained how his sister Susan had also been diagnosed
with diabetes when they were younger. She was now on an insulin pump
and pregnant with her first child. Planning, conception and 8 hour round trips to hospital I made the decision to visit the Diabetes & Pregnancy Clinic at the Royal Women’s Hospital (Vic) to gain some further information on what I needed to do before becoming pregnant. I was given a long list of instructions to follow and these became part of my new daily routine. For me my blood sugar control has never been an issue - I work on the theory that if I can look after my health now it will give me more hope for the future. I decided that for me, the best range I could achieve and maintain was to keep my blood sugar levels between 4-6. Pre pregnancy I was achieving hba1c of 5.7 – 6.5. Combine this with a lot of hard work my levels tightened quickly. I found that having the constant feedback from regular hba1c checks (monthly) helped me stay positive and keep reassuring myself I could keep it up, even if only for 12 months. My hba1c hovered around 5.4 for my first pregnancy and for the second was 5.2 for all but one reading which was 5.3. As my Endo said: “What are you here for?” After a three-month course of Folate I made the decision to stop taking the pill. It was within three months that I had conceived our first child. I had an idea I was pregnant, so while at a doctor’s visit asked if I could also do a pregnancy test as I believed I may be pregnant. The test came back as positive. Elation and apprehension, what were we doing? I had just been offered a lead role in the musical stage production of “The Mikado” and how would I explain I could no longer commit to this without anyone knowing? I made contact with the Diabetes Clinic indicating I was now pregnant and organised my first appointment for two weeks later. It was with then that I began the eight hour return trips from our home in country Victoria to Melbourne for Diabetes Clinic. I found the apprehension of visits to the diabetes clinic somewhat unsettling. Trying not to blame me and my diabetes for every possible complication along the way is hard work. I had to constantly remind myself that every pregnancy carries risk to both the mother and unborn child. In a way, I had it easy. I already had an understanding of my Diabetes and how my blood sugar levels are affected by everyday things, such as eating out, exercise and illness. Unlike the people with Gestational Diabetes who are thrust a glucometer and expected to keep their sugar levels in an acceptable range, I had years of experience (I was diagnosed aged 16). I knew that the best way for me to approach each pregnancy was to stay positive and as long as I did everything I could, it didn’t matter what the outcome was. I felt that nine months was a short period out of my life to maintain my blood sugar levels and if it meant reducing the list of possible complications to both me and the baby, I could do it. For me, a balanced diet, lots of fresh fruit and vegetables, low GI bread (burgen – honey & oat), dairy, a variety of meats and regular exercise (swimming, walking etc) helped keep my blood sugars stable. Going back to basics, knowing exactly what I was eating without all the additives. I did bend the rules now and then though and consumed spearmint icecream at any given opportunity (my only craving)! I think that my diabetes allowed me to better understand the changes and additional needs our body faces as it nurtures a growing fetus. I did suffer from increased low blood sugars in the first trimester of pregnancy and as a result began to drink milk before bed which helped to reduce the amount of overnight lows. But the hardest thing for me was to adjust my way of thinking as my insulin requirements started to increase. When by the third trimester I was having 2-3 times my regular insulin doses it messed with my head for a while. I was lucky, and having an insulin pump helped. My insulin doses are fairly small but I did speak with another diabetic about using a pump for basal doses and giving injected boluses so that your injection sites are not too over worked. I didn’t end up doing this myself though.
Over the years of living with diabetes I have come to know my body and understand the slightest change in sugar levels even without the aid of my glucometers. I’m sure my endocrinologist was always puzzled as to how I could maintain my HBA1c at 5.2 and never have any readings to show her (I did test, I just never recorded). I just can’t work like that. I find that my bsl readings spiral out of control when I try to over-analyse everything. I chose not to put too many restrictions on my diet but to be vigilant in giving the insulin required. I did have un-nerving complications of pregnancy all the same, none of which were related to diabetes. During a routine ultrasound at 32wks, a measurement of fluid in my baby's brain was found to be on the higher side of normal. I was sent for blood tests to rule out the possibility of the baby having a virus such as Toxoplasmosis or Cytomegalovirus. The results came back negative and further ultrasounds found this to be of no ongoing concern. I also
had issues with the size of my baby. Many of my ultrasounds reported
that the baby was small which, looking back probably just meant that
the baby had no signs of Macrosomia. My Obstetrician gave me a valuable
insight when he said: “All this technology serves in making
us paranoid.” He then went on to ask if I believed the
baby was small? In comparison to my first pregnancy there seemed little
difference to me. He said: “Then that is what matters. The mother
is usually right.” After an episode at around ten weeks pregnant where my blood sugar dropped rather severely in the early morning, I decided to sit my two year-old down and explain to her the possible dangers of me having a hypo in her company. She is now well aware of what it takes to prize open the container of lollies on our kitchen bench! So only a few weeks after our discussion, my daughter, who I though was happily watching Playschool, sneaks quietly into the kitchen finding me hiding in the corner, trying to stuff a fist full of lollies in my mouth and exclaims: “Mum, I’m feeling a little bit sick too, I might need to do a blood test and have some lollies! Okay?” How do you explain to a two year-old that you can have as many lollies as you want (in her eyes) and she should not have any? As the frequency of my appointments at the diabetes clinics increased, so did the need to find suitable childcare arrangements for my daughter. I didn’t like the idea of subjecting her to the arduous trips up and down the highway but soon I had no choice. Ebony became my travelling companion and settled into her role as my social advocate in the waiting room. She soon became a constant source of entertainment which enabled my mind to stray from the clinical side of my pregnancy. Her long-winded conversations with other patients’ children in the waiting rooms kept everyone amused. And her power of observation as she studied the anatomical posters of the trimesters of pregnancy in the waiting room. “Look at that Mum, the baby has a big swimming pool at its house!” or her reasoning with the Pathologist:“My Mum’s going to have a blood test now, but you can give me the band-aid.” I had underestimated how well she would cope with what I was going through. The induction - A Calm before the Storm This for me was one of the hardest parts of pregnancy. After fronting myself up to the hospital on the agreed day at 38 weeks, a little earlier than I had hoped, but due to the imminent closure of the old Royal Women’s Hospital, I was left no choice. My last pregnancy I had also been induced (at 39 weeks) so I knew well what to expect. After some uterine palpating and a quick check on the Fetal Heart Monitor I was ready to bare all. My last chance for any dignity had passed, I was now property of the hospital. After my dose of Prostaglandin Gel and some monitoring I was escorted to the Antenatal Ward to sit it out and wait for the grueling task that is Prostin Labor. I had decided this time however that when I became restless I should continue to rest rather than climb flights of stairs for four hours hoping gravity would take effect. I decided against the sleeping tablets, as last time they had sent me into a night of mind-numbing insomnia. Quite the opposite of what I had been aiming for. They say each baby is different and this one was. In my first pregnancy, after one dose of Gel my waters broke spontaneously some hours later. Not that it was anything too serious, no gushing as I had expected instead just a question of please don’t let me loose my bladder control now and an uncomfortable dampness. But this second baby did not want to come out so easily. Over a period of 24 hours I had three doses of Gel, each more frustrating than the previous. I thought second babies were supposed to come out quicker? This was when my mother decided to tell me that if I laboured the same way that she had, they would all take their time. I was now quite annoyed by the whole process. I had been contracting in 3 minute intervals for 20 hours and ‘what do you mean I am + or - 3cm dilated?!’. How do you answer this other than send in the roughest doctor on duty to rupture my membranes? All I could think of as I winced with pain was, ‘Did I tell you I have a long cervix?’ All of a sudden I felt it, that gush described in the books, as overlooking nurses ducked for cover. Oh relief, the swimming pool was emptied. It was just as I had began to relax again that I was faced with the necessary evil, the Syntocinin drip. It coursed through my veins and I began to feel the gripping tightness wave across my tummy. This is real I thought. This is Labour. I felt the contractions’ vicious bite, helped along by the Syntocinin. Feeling the need to move around I chose to stand for a while and rock my way back to happiness. Taking in the scenery and the seemingly endless line of trucks out front as they loaded machine after machine inside them – the hospital I was in was being relocated that week up the road to a new facility. Would there be any equipment left for me on the Wards? What if they take my expressed breast milk? The contractions
were coming hard and fast now and I broke the wandering attention of
the midwife who too was caught up in the buzz of traffic out front. It was
from here things moved along rather quickly, slowed down only by my
attempts to rid myself of the pain by sucking endlessly on the nitrous
oxide tube. I knew this sensation all too well. I’m thirsty and I need a drink. I’ve reached transition. I indicated to the midwife that my body needed to push, in fact it was impossible to stop it. The midwife begged with me to try my best to refrain as I may not be ready to push. “How about I get a doctor to check you and we can put in a catheter to see if we can empty your bladder?” “Okay” I agree, beyond really caring at this point. I had other things on my mind! As the midwife reached into the cupboard to gather up the catheter, my mum (also a midwife) exclaimed “You might want to catch this baby’s head” and in one swift movement the midwife turned from the cupboard, grabbing the baby’s head with one hand and the birthing trolley with the other. I had gone from 3cm to 10cm dilated and delivered in 20mins! It was then that the duty doctor and diabetes physician walked in!
After all the usual checks I gave him his first feed. The midwife excitedly weighed our little man who tipped the scales at 6lb 12oz. Wow! She exclaimed we don’t usually get to see a “diabetic” term baby this small. I smile inside. The first of the post delivery blood tests is performed. He passes the special care mark, but as a precaution we decide to supplement his feed with some of my expressed breast milk. On the diabetes side of things my husband believes that he did the most work. I gave him the job of safeguarding my insulin pump. Some nurses will do anything to get you to remove it. I also asked him to perform blood tests on me at 30 minute intervals. The hospital required them 2 hourly. This continual monitoring helped me to stay in control and prevent any rapid decline or rise in my blood sugar levels going unnoticed. The timing of when to reduce your insulin rate while in labour is a tricky one and I do believe a very individual one. I found I needed a little more insulin than instructed by the diabetes physician. I found the management of this similar to how I would undertake a long period of physical exercise. My blood sugars seem to go up if anything, but without food and an intense amount of exercise they did finally drop. They stabalised post delivery very quickly and then the hardest part was working out how many carbs my hospital meals contained. Combine this with breastfeeding and bed-rest it is no wonder why people loose all control. My stay in hospital was quite short. I was discharged 40 hours after my sons birth (the day the old Royal Womens Hospital was closed).
In the final weeks of my first pregnancy I expressed colostrum and froze it so I would have something to supplement the baby with, whatever my delivery outcome would be. I found no problem with this and am still glad I made my own educated decision to do so. My mother, being a Midwife and Maternal and Child Health Nurse, had given me a copy of an article that appeared in Vol 14 No 3 2006 of the Breastfeeding Review (An Australian Breastfeeding Association Magazine) by Suzanne G Cox titled “Expressing and storing colostrum antenatally for use in the newborn period.” She had come across the artice and thought it may be of interest to me. It explained that: “Colostrum is the antibody-rich first milk produced by women. This production begins during the second trimester of pregnancy.” Colostrum can be expressed antenataly by hand and until the late 1970s all women were encouraged to express colostrum during late pregnancy. In the recent past when antenatal breast expression has been discussed with medical practitioners, concerns have been raised that nipple stimulation and the consequent release of oxytocin during pregnancy could lead to either miscarriage or preterm labour even though this is not supported in medical literature. There are many other human interactions including eating, cuddling, and kissing which cause oxytocin release, yet they are not warned against during pregnancy. I was warned however, that if I experienced cramping pains in my uterus during this expression to stop and talk about it with my healthcare provider at my next visit This aside there was a number of reasons why I believed expressing coloostrum to be something I could do to positively impact the initial outcome for my unborn infant. The article my mother gave me went on to outline under a heading titled, 'Type 1 and gestational diabetic mothers':
I found after the birth of my first child that because it was night (12.40am) the healthcare professionals were keen to supplement feed my daughter with infant formula, so I could get some much needed rest. These feeds of artificial baby milk resulted in altering her feeding cues, thus making breast feeding very hard to establish. She was always asleep and had great difficulty staying awake long enough to even attach. I had attempted antenatal expression before the birth of my daughter as well, but as this was a bit left of field to most of the health professionals, there was no process in place for storage within the hospital or guidelines on how much should be used for supplementation. So I had to wait until I was on the ward to bring my frozen expressed colostrum in to hospital. This was the one thing I was able to change during my second pregnancy. I sought out advice from a lactation consultant within the hospital, on how to speak up about what I wanted. Therefore everywhere I went from induction to labour my expressed and frozen colustrum stayed with me.
I was fortunate enough to have a good supply of colostrum and would get around 5ml each time I expressed by hand. I never attempted to do this more than twice daily and never for longer than 5 minutes each time. By the time I was induced I was able to take with me to hospital over 200ml of frozen EBM (expressed breast milk). My son was able to be supplemented straight after his initial feed at birth and maintain his blood sugar control and avoid special care or any period of separation from me. I ended up coming home with most of the EBM I had collected because after the delivery I was able to express after each feed around 18ml of colostrum. I am unsure whether or not the ante-natal expression aided my milk supply or this outcome would have been possible anyway. But I do know I will never regret my decision. Breastfeeding, despite all the fuss has been both a rewarding and enjoyable time with both my children. I found that until I was comfortable with my post delivery control, that I would prepare myself with a drink of juice, to not only increase my fluid intake but to prevent my blood sugars’ rapid decline when I began my lounge workout. This has become a joking point with my husband. It has been the only time I have ever been able to lose weight by consuming added sugar and sitting on the couch! I constanty crave sweet foods after breastfeeding, which is my bodies way of telling me that my blood sugar is in need of a pick me up. This did settle down after I began reducing the number of night feeds that are required in early weeks post pregnancy. Early on you do have to be vigilant about blood sugars when breastfeeding because the tiredness you experience from simply being a new mum overwhelmes your hypo symptoms and does effect judgement greatly. I feel like I am consuming 3 times more kilojules than normal and know I am giving a 3rd less insulin. I do feel like I have been for an hour long walk after I have been feeding, but perhaps that is just chasing after an active toddler! I was fortunate enough to breastfeed my daughter until she weaned herself at 14 months and I have almost hit the 8 month mark with my son. I chose to exclusively breastfeed both of my children until 6 months and whether or not this will reduce the likelihood of them developing type 1 diabetes also I will have to wait and see. I made this decision to give their immune systems the best fighting chance. I can’t change the outcome but it may help me to reduce the self blame if I do pass on the diabetes genes.
I am
now blessed with two happy and healthy children and would not change
it for anything. And even better, I’m not 30 until this year so
who knows, there may be time still for one more? Related articles:
Published: February 2009 Last reviewed: February 15, 2009
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My
second pregnancy was the hardest to manage (somewhat due to constantly
snacking with my 2 year old throughout the day) but surprisingly my
diabetes was more tightly controlled.
The
midwife gently placed the baby on my chest and his sparkling blue eyes
stared intently back at me. A boy! Orlan Brody 
From
36 weeks during my second pregnancy, I began my antenatal expression
again. This time however I sought additional material on studies into
antenatal expression and with many differing opinions and much controversy,
I proceeded knowing that I did not go into early labor during the previous
pregnancy, that it should be okay. I planned on attending a lecture
outlining the results from a study into Antenatal expression in Type
1 Diabetics, but unfortunately missed it as I gave birth 24 hours prior.
I
can’t change the fact that I have diabetes but it is my choice
to educate those around me and work with the challenge I have been given.
I need to do this not only for myself now, but for my children as well.
