All major obstetric organisations recommend continuous CTG use during labour for women with gestational diabetes. This is in line with the general approach of recommending CTG monitoring for women who have any risk factors for poor outcomes for the baby. If the guidelines are evidence-based – you would expect the writers would have done some due diligence work to figure out if CTG monitoring improves outcomes for the babies of women with gestational diabetes.
Jabak and Hameed (2022)asked whether the use of CTG monitoring in labour for women with gestational diabetes can be justified on the basis of existing evidence. Their literature search (unsurprisingly) located no randomised controlled trials addressing this question.
Two non-interventional studies were identified, one from 2011 and the other from 1983. The more recent study found that women with pre-existing diabetes were more likely to develop CTG changes categorised as pathological according the FIGO guideline criteria than women with gestational diabetes. They provided no comparison with women who didn’t have diabetes. And they didn’t look at outcomes for the baby.
The older study included women who were managed with insulin without clarifying whether they had pre-existing diabetes or new onset in the current pregnancy. The diagnostic criteria for diabetes have significantly changed since this research was conducted in 1983 making it difficult to apply today. CTG abnormalities were found to be more common with insulin treated diabetes than women without diabetes. The paper says nothing about baby outcomes either.
Jabak and Hameed conclude that:
“with the lack of current evidence, we find it difficult to recommend mothers with well-controlled gestational diabetes to give birth in obstetric led units with continuous fetal monitoring and deny them a chance to have home birth or birth in midwifery-led birth units.”
The inclusion of gestational diabetes (in the absence of other complications) in professional guidelines for CTG use in labour isn’t “evidence-based” as there is clearly no evidence to support this recommendation.
As the authors of this review pointed out, the “requirement” to use CTG monitoring impacts on other choices that women might wish to make about where and how they give birth. In the presence of guideline recommendations for CTG use, maternity clinicians who share accurate information about the lack of evidence supporting the use of CTG monitoring for women with gestational diabetes may find themselves in hot water when women choose intermittent auscultation instead.
Wouldn’t it be great if professional organisations that write fetal monitoring guidelines genuinely supported evidence-based care?
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References
Jabak, S., & Hameed, A. (2022). Continuous intrapartum fetal monitoring in gestational diabetes, where is the evidence? Journal of Maternal-Fetal & Neonatal Medicine, 35(22), 4354–4357 . https://doi.org/10.1080/14767058.2020.1849117
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Birth Small Talk 
It’s so hard to find evidence and research on this topic! To complicate things further, I’m looking for information specific to insulin-dependent pre-gestational diabetes that is well-controlled. My a1c levels are considered “non-diabetic” but because I’m on insulin my providers expect me to accept any and all interventions. It’s hard to know what is best for me given the lack of data. I’m grateful for your blog for providing some insight!
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Thanks! Many of the “high risk” trials had diabetes as one of the inclusion criteria, but the diagnostic criteria and management of diabetes are likely to be vastly different to current practice.
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Absolutely, it’s a little scary how wide the gap is between current diabetes management best practices and what obstetricians recommend and practice.
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