Delivery

GDM is not an indication for delivery by Cesarean section nor

for delivery before 38 completed weeks of gestation. The prolongation
of the gestation beyond 38 weeks increases the risk
of fetal macrosomia without reducing Cesarean section rates,
so that delivery during the 38th week has been recommended
unless obstetric considerations dictate otherwise.11 Other
authors suggest prolonging pregnancy till the due time in
women treated with diet alone and presenting good metabolic
control.13
Cesarean section should be considered in case of macrosomia
to reduce the risk of dystocic delivery and the maternal
consequences.59 The main objectives during labor are to maintain
normal glycemic values, adequate hydration and caloric
intake.60,61 If women are only on diet therapy, it is suggested
that breakfast is avoided on the morning when the delivery is
planned. During delivery an intravenous infusion of saline solution
at a rate of 100150 mL/h and regular glucose monitoring
are advised.
In the case of women on insulin treatment it has to be considered
that labor determines a reduction of insulin need and
an increase of caloric necessity. The day before labor, women
should follow their usual insulin and diet regimen with an
injection of bedtime intermediate insulin adjusted to produce
a satisfactory fasting blood glucose. On the morning of the delivery,
women should not receive either breakfast or rapid acting

insulin bolus. An intravenous insulin infusion of 12 units

of short-acting insulin per hour together with a 5%
glucose solution or a saline solution at 100150 mL/h is recommended.
Blood glucose should be evaluated every hour
and the insulin infusion should be adjusted accordingly in
order to obtain a glycemic target between 70 and 130 mg/dL
(3.87.2 mmol/L).
During delivery insulin infusion should be suspended while
glucose infusion and glucose monitoring should be continued.
The neonates of mothers with GDM or with pre-gestational
diabetes are at the same risk for complications, particularly
those infants born macrosomic (birthweight >4000 g).62
A pediatrician experienced in resuscitation of the newborn
should be present whether delivery is vaginal or by Cesarean
section. As soon as the infant is born, the following actions are
essential:
1. Early clamping of the cord, i.e. within 20 seconds from
delivery, to avoid erythrocytosis.
2. Evaluate vital signs: determine the Apgar score at 1 and 5 min.
3. Clear oropharynx and nose of mucus. Later empty the
stomach: be aware that stimulation of the pharynx with the
catheter may lead to reflex bradycardia and apnea.
4. Avoid heat loss; keep the neonate warm and transfer to an
incubator pre-warmed to 34C.
5. Perform a preliminary physical examination to detect
major congenital malformations.

6. Monitor heart and respiratory rates, color, motor behavior

at least during the first 24 h after birth.
7. Start early feeding, preferably breast milk at 46 h after
delivery. Aim at full caloric intake (125 kcal/kg and 24 h) at
5 days, divided into six to eight feeds a day.
8. Promote early infantparents relationship (bonding).
The neonate is usually best cared for in specialized neonatal
units. Interference with the infant should be minimal. The
neonates should be observed closely after delivery for respiratory
distress. Capillary blood glucose should be monitored at
1 h of age and before the first four breast feedings (and for up
to 24 h in high risk neonates). Currently, some amperometric
blood glucose meters are acceptable for use in neonates, provided
that suitable quality control procedures and operator
training are in place. A neonatal blood glucose level
<36 mg/dL (2.0 mmol/L) needs to be verified by repeat testing
(laboratory verification is preferred but should not delay the
initiation of treatment). Levels <36 mg/dL (2.0 mmol/L)
should be considered abnormal and treated. If the baby is
obviously macrosomic, calcium and magnesium levels should
be checked on day 2.11 Breast feeding, as always, should be
encouraged in women with GDM.17