Timing and route of delivery for pregnancies with diabetes.

This decision should be taken by both the clinician and the patient. The decision depends on the maternal and fetal factors.
Maternal factors
1. Period of gestation
2. Cervical maturity
3. Other cormobidities
Fetal factors
1. Maturity of the fetus
2. Weight of the fetus
3. Other biophysical factors


Select the timing of delivery to minimize morbidity for the mother and fetus. Delaying delivery to as near as possible to the expected date of confinement helps maximize cervical maturity and improves the chances of spontaneous labor and vaginal delivery. However, the risks of advancing fetal macrosomia, birth injury, and in utero demise increase as the due date approaches
Although delivery as early as 37 weeks' gestation might reduce the risk of shoulder dystocia, a coinciding increase in the incidence of failed labor inductions and poor neonatal pulmonary status would also occur. Because fetal growth from 37 weeks' gestation onward may be 100-150 g/wk, the reduction in net fetal weight and the risk of shoulder dystocia by inducing labor 2 weeks early may theoretically improve outcome
If the fetus is not macrosomic and results from biophysical testing are reassuring, the obstetrician can await spontaneous labor. In patients with GDM and superb glycemic control, continued fetal testing and expectant management can be considered until 41 weeks' gestation. In a fetus with an abdominal circumference measurably larger than the head circumference or with an estimated fetal weight of greater than 4000 g, consider induction. After 40 or more weeks' gestation, the benefits of continued conservative management are likely to be less than the danger of fetal compromise. Induction of labor before 41 weeks' gestation in pregnant women with diabetes, regardless of the readiness of the cervix, is prudent
Thus, an optimal time for delivery of most diabetic pregnancies is typically on or after the 39th week. Only deliver a patient with diabetes before 39 weeks' gestation without documented fetal lung maturity for compelling maternal or fetal indications. For elective induction, fetal lung maturity should be verified via amniocentesis.
Because the risk of shoulder dystocia and fetal injury in labor is increased 3-fold in diabetic pregnancy, elective cesarean delivery should be considered if the fetus is suspected to be significantly obese. The American College of Obstetricians and Gynecologists recommends offering diabetic patients cesarean delivery if the fetal weight is estimated to be 4500 g or more.