Gestational Diabetes Mellitus

In order to ensure that the outcome of the pregnancy is the best for mother and baby, a routine is undertaken which is embraced by the term Ante Natal care. Ante natal care is simply caring for the mothers before labour and delivery and also preparing the mothers fully for delivery because of safe motherhood. This can only be achieved by if mother is seen early preferably before the 10^th week and at regular intervals thereafter. In this essay, I will be discussing one of the factors which are (GDM) gestational diabetes mellitus which affects the normal physiological pregnancy state. Gestational diabetes mellitus (GDM) is defined as carbohydrate in tolerance resulting in hyperglycaemia of variable severity with its onset and first recognition during pregnancy. Insulin is an essential hormone required for glucose transfer into the muscle and adipose tissue cells. For women with diabetes mellitus, pregnancy can present some particular changes for both mother and the child. If the woman who is pregnant has diabetes, it can cause early and very large babies (Macrosomia). Management of pregnant mothers with diabetes needs very firm and accurate control even in advance of having pregnancy. There are question whether the condition is natural during pregnancy or not. Gestational diabetes is caused when the insulin receptors do not function properly, due to pregnancy related factors such as the presence of human placental lactogen that interfere with susceptive insulin receptors. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied, so may be a natural occurrence (Littleton, 2005,). During a normal pregnancy, many physiological changes occur such as increased hormonal secretions that influence blood glucose levels, such as glucose – drain to the fetus, slowed emptying of the stomach, increased excretion of glucose by the kidneys and resistance of cells to insulin.

Moving further, I as the ante-natal clinic nurse will first try to collect as much information as I can from the patient. During her 12^th week of gestation, Mrs. B came for her ante natal case booking. She was already 3 months and this was her initial visit to the ante natal clinic. I booked Mrs. B by obtaining subjective data from her. I as the nurse, firstly I offered her seat so that she can sit in level with me. After that I took her personal history after greeting the client. She was feeling ease and welcomed. I communicated with her in English because she was able to understand and I also kept in mind that level of education might be low so I used simple interpretations of facts. Her first impression was very good because she was a Primip-gravida and she looked happy and relaxed. Her physical characteristics were good, because (posture) she was sitting comfortably and even she was working normally without any problem (gait). She looked health during her first visit to the clinic. After this observation during interview, I had taken her full personal history. Her full name is Mrs. B. She was born on 15^th of April, 1989 at Labasa Hospital. Her age now is 24 years. Just because she is Fijian, I did not ask for her father’s name, nevertheless, she is married to a Fijian, 25 year old businessman. She is a primary school teacher. Her husband’s name is Mr. C and they reside in Namara, Labasa and both of them are Methodist. Both have attended tertiary institutions and are well educated. She gave her husband’s name and phone number for emergency purpose. Secondly, I obtained Mrs. B family history. Not much information was given by Mrs. B because her parent and grandparents were of Fijian origin and they lived in village. Her mother had diabetes only. Thirdly, I took the medical history of Mrs. B, according to her she is not having any medical problems and she was never admitted before for any illness. Mrs. B is only allergic to penicillin antibiotic. In her social history, it is interesting to know that this would be their first child in the family, so no case of negligence or overcrowding in the home. They both, husband and wife earn enough for their upcoming family. She is not a teenager and has a good age for first child bearing. She is physically, psychologically and financially strong to mother a child. They live in a concrete and iron roofing house and they reside in an industrial area. They both neither smoke nor consume alcohol or drugs. She did not have a surgical history. She did not have any abdominal, pelvic, cardiac surgeries or either injuries. I did not ask anything about her previous obstetric history because this was her first pregnancy. As a nurse, I asked her about any abortionsmiscarriage but Mrs. B said no because they used family planning devices before so she did not had any abortions and miscarriage. There was no gynaecological history for Mrs. B. Her menstrual history, she has menses which last for 3 days- 4 days. She was fourteen years when she had had her first menses (menarche). Just because Mrs. B was 12 weeks pregnant, I did not ask her about on set of movement but calculated her expected date of delivery (EDD). Her last menses occurred on 17^th of February until 20^th of February. It is a four days regular flow according to Mrs. B. So her expected date of delivery would be seventeen plus seven and add 9 months from indicated date, so that will be on 24^{th day} of November. After this assessment, I did the physical examination of Mrs. B.

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Firstly, I took Mrs. B height and it was 168cm, her weight was 62.5kg and to notice difference in her weight, it had to be taken on every visit. Mrs. B urine test was done for protein and glucose, mid stream specimen was taken and this was done in all the visits to get the results from laboratory. Her blood pressure was taken. Blood test was also done for emergencies and surgical procedures. As a nurse, we also checked for edema. This may not be seen during initial visit but as pregnancy progress it can be noticed. All this assessments and examinations were done by two nurses since I had to have a female nurse since I was interviewing a female client and received a lot of information about Mrs. B and her health. This also built a foundation of a trusting relationship.

In addition to this, a goal of antenatal care is equally important because this acts as guidance in caring for the antenatal case holistically. Firstly, the aim that is to monitor the progress of pregnancy in order to support the maternal health and normal fetal development and to ensure that the mother reaches the end of pregnancy in a healthy state and delivers a healthy baby. Nurses and midwives are the best people to detect the problem early, diagnose it and treat the problem before progression of labour and delivery. More of our aims include identification of women at risk. As a nurse you must educate clients at high risk pregnancy on their medications, follow-up, nutrition and exercise, so that they can get a positive result. To assess levels of health by taking a detailed history and to after appropriate screening test. Ask to identify risk factors by talking accurate details of past and present obstetric, medical, family and personal history. Another aim is to provide a good opportunity for the women and her family to express and discuss any concerns they might have about the current pregnancy and previous pregnancy loss, labour, birth or pueperium.. Lastly, the most vital is the delivery of the healthy term infant without signs of distress or any abnormality.

Furthermore, the nurse’s role independently in managing for the gestational diabetes mellitus women are broad and as follows. A nurse must carry out a proper procedure when dealing with a GDM mother so that she and the infant’s risk of complications are reduced. Firstly, a nurse must obtain baseline data from the patient. Secondly, I carried my nursing assessment on Mrs. B, I took her vital signs. This was very much important because an increase in blood pressure and weight may be a sign of PIH, which is a frequent complication associated with diabetes. After that I asked Mrs. B about her gestational age because it assists in managing pregnancy and planning timing and method of delivery. Apart from this ultrasound examination was also carried out on Mrs. B for abnormalities, confirm age of gestation, and monitor the size and weight of fetus. Uterine size, fetal activity, fetal heart rate evaluate and reflect fetus status and well. Other intervention which I carried out independently was to monitor blood sugar level frequently, as this was checked more often than usual according to the doctor. Also I made sure that each time when checking the blood sugar level a proper record of the result and presented to the health care team for evaluation and modification of the treatment. Many may need extra insulin during pregnancy to reach their blood sugar targets since insulin is not harmful to the baby. During her one of the clinic, Mrs. B was examined routinely and was found that there was glucose in the urine and the blood system level was above targets. I gave insulin therapy to control the sugar further. Also I advised on the meals, to cut down sweets, eat three small meals and one to three snacks a day, maintain proper meal times and include balanced fibre intake in the form of fruits, vegetables and whole grains. Mrs. B attended her clinic when she was 24 weeks, after examining Mrs. B, her blood glucose level was not in control as a result. So we had to admit Mrs B to the ante natal ward for insulin therapy. The aim here was to stabilize the blood glucose level. Mrs. B was admitted. I explained her about the ward, orientated about the ward protocols, meal hours and the special diet which she will have. The first 2 to 3 days, 4 point was done to find out if patient should be adequately controlled on diet, if not then insulin was recommended. Mrs. B was supposed to have 4 points procedure, so I kept her on nil by mouth post midnight. Blood specimen one was collected at 7am, then patient to have breakfast. Specimen 2 was taken at 9.30am. Specimen 3 was taken at 1.30pm and 4^th one was taken at 6.30pm.

Moreover, the health care team as a whole had collaborative role towards care of the pregnant mother who was reaching 26 week gestation. Effective ante natal care for women with diabetes mellitus should be provided by a multidisciplinary team in a joint diabetes and antenatal clinic (Fraser, 2009). The woman is seen often as required in order to maintain good glycaemia control. Treatment depends on the blood glucose levels. The midwife should involve both the diabetic nurse or (midwife) specialist and dietician in dietary interventions. Mrs. B was advised by the dietician about nutrition; ideally diabetic women who anticipate pregnancy will follow a prescribed well balanced dietary regimen before conception and will be in a state of good metabolic control. The dietician advised Mrs. B on the caloric requirement for the normal weight client is 35 calories per kilogram. Doctors advised Mrs. B on insulin treatment. Physiotherapist advised Mrs. B on importance of moderate exercise during pregnancy example walking, swimming because it helps lower blood glucose level this decrease need for insulin. Also Mrs. B was advised by the doctor on other medical management such as oral metformin medications. Nurses should also monitor blood glucose on a regular basis throughout pregnancy. So counselling before pregnancy (for example about preventive folic acid) and multi disciplinary management are important for good pregnancy outcome.

Moreover, highlighting the reasons for the interventions carried out gives an idea that why this particular nursing intervention on Mrs. B who was diagnosed as gestational diabetes. Firstly as a nurse, I identified Mrs. B at GDM risk. It was better that her problem was identified earlier or else if she would not have been attending her clinics there would have been increased risk for hyperglycaemia, infection, pregnancy induced hypertension and also hydramnios. Since Mrs. B was diabetic, the infant would have been at high risk of macrosomia and also congenital abnormalities. All this would have lead to difficulties in vaginal deliveries. Secondly, baseline vital signs, height, weight should be monitored in every subsequent visits. Blood pressure was taken when I asked Mrs. B to lie in a left lateral position so that an accurate reading was achieved. Mrs. B was also monitored by (sonography) ultrasound examining subsequently during her visits for fetal abnormalities, confirmation of gestational age and also to monitor size and weight of fetus. Activity (kicking) fetal movement was also maintained by nurses to find that fetus remains active. Collaboratively, urinalysis, culture and sensitivity were done to detect asyptomatic bacteriuria, a precursor to event pyelonephritis, to which the diabetes is especially prone. Midwives also performed a fundal examination, initially and subsequently atleast once a trimester for Mrs. B to detect any vascular changes accompanying diabetes. Mrs. B was also advised by the dietician on nutrition and hydration to maintain blood glucose targets to normal. Client knowledge about self monitoring by the midwives allows the development of an appropriate teaching plan to ensure compliance and minimize risk of complications. Mrs. B was also educated on support system and services because of the high risk of the pregnancy so that necessary support system and assistance can be obtained. Psychosocial and economic factors with special consideration to the parental stress evoked by the high risk pregnancy was explained to her so that she does not take too much stress which can lead to high risk pregnancy, research has shown that gestational diabetes experience more stressful responses than pre gestational diabetics for all aspects of the medical regimen (Perry, (2006). 4 points procedure was done on her following the glucose tolerance test for the proceeding of insulin therapy. After insulin therapy Mrs. B was discharged and called for her clinic subsequently to detect whether blood glucose was maintained or not. During her visits, the midwives performed abdominal examination, vaginal examination and fundal palpation to establish and affirm that fetal growth is consistent with gestational age during progression of pregnancy. This was done to detect fetal growth, fetal lie, fetal presentation etc. When Mrs. B was 35 weeks, during her clinic it was found that the blood glucose level was maintained, there was no glucose in urine and no other signs as before due to gestational diabetes two which was medically controlled.

To sum up, later on during her 37 weeks of gestation Mrs. B was having labour pain and she was rushed to hospital with all her belongings needed together with the babies’ clothes and other things. She was admitted direct to the labour ward in the preparation room. fetal heart rate monitoring and vaginal examination was done. She was 3-4cm dilated and was taken to first stage room for further assessment on partogram and vaginal examination. The following morning she gave birth to a healthy term infant without signs of distress and or hypoglycaemia. Therefore, our strength was that we collaboratively, the health care team identified the patient at risk on an early stage that is why there was no complication during or after delivery. And our weakness lies if all the health care team do not identify high risk of pregnancy at an early stage therefore, early booking is equally very important.

(Approx words:2500)

References

Brown, D., & Edward, H. (2005). Medical-Surgical Nursing: Assessment & Management of Clinical Problem. Australia: Elsevier.

Crisp, J., & Taylor, C. (2013). Potter & Perry’s Fundamentals of nursing (4^th ed.). Australia: Elsevier.

Fraser, D, M., & Cooper, M, A. (2009). Myles Textbook for Midwives (15^th ed.). Australia: Elsevier.

Perry, L. (2006). Maternity Nursing (7^th ed.). Australia: Elsevier.

Mc Kinney, E., & James, S., & Murray, S., & Ashwill, J. (2005). Maternity Child Nursing (2^nd ed.). Australia: Elsevier.

Littleton, L, Y., & Engebretson, A. (2005). Maternity Nursing Care. USA: Elsevier.

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