Stillbirth and perinatal mortality rates are 5 times greater for an insulin-dependant diabetic mother than in the general population. Neonatal and infant mortality rates are 15 and 3 times greater, respectively. In addition, macrosomia is a major problem resulting in both fetal and maternal injury. Fetal monitoring is considered mandatory in such pregnancies. The rational approach would be to use surveillance strategies based on the underlying pathophysiology. However, in the diabetic pregnancy, the underlying pathophysiology is poorly understood and is likely to be multifactorial. Thus, in practice, a pragmatic approach is followed using methods that are applied in other high-risk pregnancies although the pathophysiology is different. Given the limitations in the predictive power of many fetal monitoring methods and the lack of randomised controlled trials, it is not surprising that there is no agreement over the best way to monitor fetal health in diabetic pregnancies. This article analyses the evidence regarding the value of these tests and proposed protocols for their use in the context of the diabetic pregnancy.