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Childbearing Clinical Case Study: Gestational Diabetes
Susan B. Paschal
Student UIN# 00799934
Sentara Leigh Hospital
Submitted in partial fulfillment of the requirements in the courseN331 Clinical Management of the Childbearing Family
in the School of NursingOld Dominion UniversityNORFOLK, VIRGINIA
Spring, 2011
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Childbearing Clinical Case Study: Gestational Diabetes
The purpose of this paper is to discuss one woman’s obstetrical experience from prenatal
to postpartum care. Because the patient was diagnosed with gestational diabetes, this paper will
also review the risks and pathophysiology associated with gestational diabetes. An examination
of intrapartal and postpartal interventions as related to this patient and infant will include:
induction, epidural, medications, lab values, position changes, FHR, contractions, labor
progression, fundal massage, lochia, mother - infant bonding, and breastfeeding . Nursing care
will be evaluated according to the Association of Women’s Health, Obstetric, and Neonatal
Nurses (AWHONN) Standards of Care.
The patient described in this study is a Christian, African American female, 24 years old,
primigravida, who delivered by spontaneous vaginal delivery at 38 weeks and 5 days on January
19, 2011 at 2117. Her last menstrual period was on April 24, 2010 and her estimated date of
delivery was January 26, 2011. This was not a planned pregnancy. Pt had a PAP exam on July
13, 2010. A vitamin D deficiency was also noted at this time and supplements were prescribed.
Patient began prenatal care at 11 weeks gestation, July 16, 2010, and prenatal vitamins were
prescribed during this visit. During prenatal care, consisting of 10 visits, pt had a total of 4
ultrasounds and a positive HSV 2 test with vaginal discharge indicating genital herpes. The
patient tested positive for gestational diabetes on November 9, 2011. A one hour glucose test
was performed with a result of 154 mg/dL and a three hour test resulted in a fasting glucose level
of 100 mg/dL and nonfasting glucose level of 204 mg/dL. It was also discovered that the patient
was iron deficient with a hemoglobin of 9.5 g/dL and noncompliant with her vitamin D regimen.
Supplements were prescribed again. Additional risks to this pregnancy include: family history
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of spina bifida, toxoplasmosis, degenerative joint disease in right hip, asthma and smoking.
Intrapartal Procedures
The patient was admitted to the hospital in the first stage of labor on January 18, 2011 at
2100 for induction with Cervidil (See appendix A for vital signs and medication description). At
2200, it was determined that the patient’s membranes were still intact with her cervix in the
posterior position, tilted backward, indicating she was not ready to deliver. A tocodynamometer
was applied to the patient’s fundus to record the duration of the contractions and the interval
between contractions. Occasional contractions were noted, with a frequency of every one to two
minutes and lasting 50 to 100 seconds. Fetal heart rate was 145 bpm, reactive and reassuring. A
reactive fetal heart rate (a non-stress test) is considered a sign of the baby's well being and a
reassuring heart rate indicates that the baby is oxygenated and tolerating labor and delivery well.
Intravenous access was established, in the right hand with an infusion of Lactated Ringer’s and
blood was drawn for laboratory evaluation (See appendix A for medication information and
laboratory results).
Overnight, from 1200 – 0700, contractions continued to appear occasionally or
completely disappeared with a median duration of 50 – 100 seconds. Fetal movement remained
active with fetal heart rate constant between 110 – 160 bpm with moderate variability.
At 0935 on January 19, 2011, a sterile vaginal exam was performed. It was discovered
that the patient’s cervix was dilated to 1 cm, but not thinned out, with the fetus at -3 station and
contractions 5-7 minutes apart. Membranes were artificially ruptured and meconium staining
was present in the amniotic fluid. At 1000, contractions were 1-5 minutes apart with a duration
of 60-90 seconds. Oxytocin, 2 milliunits, was administered via IV in the left hand at 1000 and
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1047, 4 milliunits was administered at 1132, 6 milliunits at 1205 and another 8 milliunits at 1253
(See appendix A for medication description). Fetal heart rate, at 1200, indicated variable
decelerations, most probably due to umbilical cord compression. Patient’s contractions were
moderate in intensity at this time. Cervical dilation at 1350 was 2 cm with 80% effacement and
fetus at -3 station with a fetal heart rate of 130 bpm, reactive with moderate variability. The
anesthesiologist administered an epidural at 1400. Oxytocin administration was continued at
1445 with 10 milliunits and 12 milliunits at 1520. Fetal heart rate at this time continued to
maintain at 130 bpm, reactive with moderate variability. Fetal heart rate early decelerations
were detected at 1630, most probably due to the force of contractions pressing on the fetal head
as it descended. At 1659, patient was dilated 5 cm with 90% effacement and fetus at -1 station
and positioned midline. Contractions were strong, 1.5 to 4 minutes apart and lasting 80-110
seconds. Fetal bradycardia, heart rate below 100 bpm, was noted at 1744, patient was asked to
change position and oxytocin discontinued. Patient is now 8 cm dilated and fetus at -1 station.
Oxytocin administration resumed at 1800 with 10 milliunits. Fetal bradycardia was again noted
at 1820 and patient once more asked to change position and oxytocin discontinued. At 1849,
oxytocin administration resumed with 2 milliunits. Patient was dilated to 9.5 cm at 1900 with
fetus at 0 station. Accelerations were noted to be present during contractions. Contractions were
moderate, 1-3 minutes apart with a duration time of 50-70 seconds.
Second stage of labor began at 2010. Patient was fully dilated with 100% effacement;
contractions occurred every 1-4 minutes and lasted 50-110 seconds. Fetus was at 0 station with a
heart rate variability of 6-25 bpm. The resting tone of the abdomen was soft by palpation
between contractions. A male infant, weighing 7lbs 8 oz, was delivered at 2126 on January 19,
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2011 under epidural anesthesia by spontaneous vaginal delivery in the cephalic vertex right
occiput anterior (ROA) position. This is the optimal position for delivery with the back of the
infant’s head facing away from the spine. Patient did not require an episiotomy. The infant’s
shoulders were delivered with no difficulty, mouth and nares suctioned. The cord was clamped,
cut and contained three vessels, one vein and two arteries.
The third stage of labor began immediately with the delivery of an intact placenta.
Oxytocin was administered at 2120, 3 milliunits by IV, to increase uterine contractions and
minimize bleeding. Estimated blood loss during the delivery was 400 mL.
Postpartal Procedures
Following delivery, Cytotec, 400 mcg, was administered rectally to decrease blood loss
(See appendix A for medication description). Percocet and acetaminophen were also prescribed
on an as needed basis to control pain (See appendix A for medication description). Vital signs
were assessed every 15 minutes the first hour after delivery, then every 30 minutes for two hours,
followed by every 2 hours times two and then every shift until discharge. A postpartal
assessment was performed on patient using the BUBBLEHE (breasts, uterus, bowel, butt, lochia,
episiotomy, Homan’s and emotional) method. The fundus was one finger width below the
umbilicus and firm the morning after delivery with scant light red lochia. No hemorrhoids were
observed. Breasts were soft with no masses or bruising and erect nipples. There was +1 edema
to lower extremities bilaterally and a negative Homan’s sign. Lungs were clear to all lobes
bilaterally and no adventitious cardiac sounds were auscultated. An ice pack was provided for
comfort to the perineal area. Patient and spouse were educated about fundal massage, lochia and
blood clots in the urine or discharge. The patient and spouse were educated on the importance of
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maintaining adequate fluid intake, voiding every 2-4 hours, and changing pads after every void.
Additional education included the importance of early ambulation to avoid deep vein
thrombosis, and pain management. Since the patient planned to breastfeed, the importance of
continuing her prenatal vitamin, vitamin D and iron supplements were discussed (See appendix
A for medication description). During breastfeeding the patient was assisted in proper
positioning and “latching on” of the infant. The importance of a TDAP vaccine which protects
against diphtheria, tetanus, and pertussis (whooping cough) was also discussed and information
in the form of a handout was provided to the patient and her spouse.
After delivery the infant’s mouth and nares were suctioned to remove any remaining
mucus. An APGAR test was completed at one and five minutes with a score of 8 and 9
respectively. A fetal assessment was performed and the infant was measured and weighed. The
cord blood was tested, however, it was determined to be a bad sample and the results were not
viable. A blood glucose test was also performed with a result of 58 mg/dL which is in the
normal range of 30-80 mg/dL (See appendix A for laboratory results). A circumcision was
performed the day after delivery.
Positive maternal and paternal bonding was observed during multiple interactions with
the parents and infant. Mother held infant enface, was calm and positive. She was observed
massaging the infant’s ear to stimulate wakefulness in the infant while attempting to breastfeed.
Father frequently held and cuddled infant and stated, “I am taking off two weeks from work to
take care of my wife and son alone. The grandmothers can come after that, when we invite
them.”
Care Analysis
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The AWHONN standards of care for nurses involved in the care of women and
newborns, provides a guideline for nurses to deliver the highest quality of care whether in the
hospital, home or ambulatory setting. The standards of care were met in several ways for this
patient as described in the following paragraphs.
Standards I to VI, Assessment, Diagnosis, Outcome Identification, Planning,
Implementation, Coordination of Care, Teaching and Evaluation, can be demonstrated by
examining the patient’s initial experiences with breastfeeding (Association of Women’s Health,
2009). The patient was experiencing difficulty breastfeeding because the infant would not
remain awake at the breast. My instructor, Dr Bennington, and I reassured the patient that this is
sometimes normal. We assessed the patient’s breasts noting no bruising or cracking around the
nipples, nipples were erect and there was no tenderness, increased warmth or pain to any areas of
the breasts. We then assessed the infants latching on and positioning making some minor
corrections. The patient was educated on fetal stimulation, “C” hold for the breast and to stroke
the infant’s bottom lip with the nipple. The patient was then monitored and assisted as needed or
requested. A consult with the lactation nurse was also established. During my shift it was
difficult to determine if breastfeeding was effective, but patient remained calm and positive that
with additional practice and guidance she would be able to effectively breastfeed.
Standard X, Ethics, relates to the nurses ability to deliver care in a compassionate manner
that preserves patient autonomy, dignity, safety, and rights (Association of Women’s Health,
2009). I applied this while my patient was breastfeeding and was initially uncomfortable with
having someone observe her. I told her it was normal to feel that way and breastfeeding was a
natural phenomenon. I asked permission to observe and assess the baby’s latching on and
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sucking. I praised her for her technique in stimulating the baby to stay awake and offered
reassurance and education in feeding technique.
Standard XII, Collaboration and Communication, and Standard XV, Leadership, were
demonstrated during the labor stages as the labor nurse, nursery nurse, anesthesiologist, and
physician collaborated as a team to provide the best possible care for this patient and a safe
delivery. Leadership was implemented with the delegation of the postpartum assessment to the
student nurse. Standard XIV, Resources and Technology, was implemented with the referral of
the patient to the lactation nurse for breastfeeding education (Association of Women’s Health,
2009).
The first nursing diagnosis for this patient would be, “Ineffective Tissue perfusion related
to decreased fetal heart rate”. This is the priority nursing diagnosis because without adequate
perfusion to the fetus there is an increased risk of fetal hypoxia and death. Contributing factors
may include: uterine hyperstimulation with the administration of oxytocin, prolonged umbilical
cord compression and vagal stimulation in the second stage of labor while the mother is holding
her breath and pushing (Ladewig, London, & Davidson, 2010). Supporting evidence for this
diagnosis includes two incidences of fetal bradycardia at 1744 and 1820. However, it must be
noted that this patient should not have been pushing during this time period because she was not
fully dilated at 8 cm. A desired outcome for this diagnosis is that the fetus will receive adequate
perfusion as evidenced by a fetal heart rate between 110 and 160 bpm.
Interventions for the first nursing diagnosis include: monitoring the fetal heart rate,
discontinuing oxytocin administration, turning patient on her left side to relieve pressure to the
vena cava and increase perfusion to the fetus, increase IV fluids (Lactated ringer’s), perform a
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vaginal exam to ensure the umbilical cord has not prolapsed, notify physician and provide an
explanation to the patient and her spouse/family of what is occurring (Ladewig, London, &
Davidson, 2010). The interventions were effective, although they had to be repeated twice in a
40 minute period. Fetal heart rate returned to within the normal parameters of 110-160 bpm
indicating adequate oxygenation. A reactive response was noted with fetal heart rate
accelerations monitored during subsequent contractions.
The second nursing diagnosis for this patient is, “Ineffective breastfeeding related to poor
infant sucking reflex.” Contributing factors may include: infant inability to latch on to the
maternal breast correctly, knowledge deficit, inadequate milk supply, nonsustained suckling due
to infant sleeping (Ackley & Ladwig, 2011). Supporting evidence for this nursing diagnosis
consists of observations made by this student during postpartum care and subjective statements
by the patient. It was observed that the mother made repeated unsuccessful attempts to
breastfeed throughout the morning shift. The infant did not maintain a consistent or prolonged
time latched onto the breast and did not display a strong sucking instinct. The infant was also
difficult to arouse and often slept at the breast rather than suckle even with the mother massaging
the infant’s ear to keep him stimulated. Both parents questioned whether this was normal and
were reassured this can be a normal response and some infants need more time to learn how to
suck and latch on. A desired outcome for this nursing diagnosis is that the patient will achieve
effective breastfeeding before discharge from the hospital.
Interventions for the second nursing diagnosis include: providing time for the patient and
spouse to express their concerns, give emotional support, provide breastfeeding teaching and
assistance both verbally and written, provide referral to lactation nurse, monitor breastfeeding
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sessions to ensure proper positioning and latching on, avoid supplemental feedings, promote
comfort and relaxation to decrease anxiety which can reduce the milk let down reflex (Ackley &
Ladwig, 2011). I could not determine if these interventions were effective since the patient was
still having difficulty with breastfeeding at the end of my shift and was waiting for a consultation
with the lactation nurse. However, patient was calm and positive in her ability to breastfeed with
some additional education, guidance and practice.
“Risk for unstable blood glucose related to gestational diabetes and postpartum status” is
the third nursing diagnosis for this patient. Though glucose levels often return to normal after
delivery the patient’s blood glucose levels still need to be monitored by a physician. Fasting
blood sugars should be drawn at the 6 to 8 weeks postpartum visit. Contributing factors include:
pregnancy, weight gain, stress and dietary intake. Supporting evidence is the patient’s diagnosis
of gestational diabetes, a one hour glucose test with a result of 154 mg/dL and a three hour test
resulting in a fasting glucose level of 100 mg/dL and nonfasting glucose level of 204 mg/dL. The
desired outcome of this diagnosis is patient will “maintain preprandial blood glucose < 95 mg/
dL , 1 hour pc level < 140 mg/dL and 2 hour pc level < 120 mg/dL” (Ackley & Ladwig, 2011,
p.407).
Interventions for the third nursing diagnosis include: monitoring blood glucose levels,
educating the patient and family on the signs and symptoms of hyperglycemia and
hypoglycemia. If the patient is hyperglycemic an oral antihyperglycemic medication may be
administered if the patient is not breastfeeding. If patient is breastfeeding, insulin may be
needed for a period of time if diabetes cannot be controlled with diet and exercise. Reassess the
patient at six weeks postpartum for blood glucose levels, if the glucose levels are normal then
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reassess patient every three years. Also educate the patient that she will require 500 to 800 extra
calories a day during breastfeeding and insulin dosage must be adjusted accordingly (Ladewig,
London, & Davidson, 2010). The interventions were deemed effective because the patient was
able to verbalize proper diet and exercise requirements to maintain her blood glucose within the
normal limits, verbalized the signs and symptoms of hypoglycemia and hyperglycemia and
verbalized an understanding of the need to reassess her blood glucose levels at six weeks
postpartum though her blood glucose levels are currently normal.
Current Literature
“The effects of different maternal positions on non-stress test: an experimental study”, by
Alus, Okumus, Mete, & Guclu, 2007, the only study currently available within a five year
period, explored the effects of supine, left side lateral , sitting and semi-fowlers positioning on
fetal heart rate. It was found that the supine position resulted in the lowest heart rate reactivity.
Women lying in the supine position during the third trimester for an extended period were more
likely to exert pressure on the inferior vena cava and decrease blood flow to the fetus thus
decreasing fetal oxygenation and reactivity. Pregnant women in the supine position also reported
the most back pain and difficulty breathing. For review, a reactive non- stress test indicates that
fetal heart rate accelerations are present with a minimum of two accelerations of 15 bpm lasting
15 seconds, 15 x 15, in a 20 minute period. This is a sign of fetal well being and adequate
oxygenation. Mothers placed in the left lateral position reported the lowest incidence of
discomfort (1%) as compared to the semi fowlers (3.9%), supine (64.7%) and sitting (2.9%)
positions. The semi fowlers (85.3%) and left lateral (83.3 %) positions produced the highest
reactivity results. However, it must be noted that women placed in the supine position experience
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reactive fetal rates 69% of the time (Alus, Okumus, Mete & Guclu, 2007). From this study we
can conclude that placing the mother in the semi fowlers, left lateral or sitting position when the
fetal heart rate is non reactive is advantageous.
A second research study, “Breastfeeding support and early cessation” by Lewallen, Dick,
Flowers, Powell, Zickefoose, Wall and Price, 2006, examined the types of help women receive
in the hospital and why they stop breastfeeding. This study sampled 379 women who were first
time breastfeeders over an eight week postpartum period. Ninety percent of the women reported
having help in the hospital from a lactation consultant, nurse, or nursing student. Fifty four
percent of the women reported receiving help at home once discharged from the hospital from
lactation consultants. The other most common source of breastfeeding information at home was
books or pamphlets. At eight weeks postpartum, 121 women had stopped breast feeding. The
two most common reasons stated were, “I wasn’t making enough milk /satisfying him” and
complaints of painful nipple or latching on problems. Women often began supplementing with
formula which also decreased breastfeeding duration. By initiating breastfeeding immediately
after birth nurses can educate, monitor and assist mothers before they leave the hospital. Thus
increasing the amount of time a mother may breastfeed overall. This study postulates that
education in the hospital by lactation and nurses to first time breastfeeders can play a significant
role in developing longer and more satisfying breastfeeding experiences.
Pathophysiology
Gestational diabetes is a type of diabetes that occurs only during pregnancy. It can cause
high blood sugar levels that are problematic for the mother and can threaten the health of the
infant, even resulting in infant death. Gestational diabetes may also have long term
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consequences later in life for both the mother and the infant (Fink, 2010). I chose gestational
diabetes as the prevalent risk factor because the risks to the infant are significant if the diabetes
is not found early, typically between the 24th and 28th week of gestation, and interventions
begun. Successful treatment is based on early detection, blood sugar monitoring, controlling
diet, exercise, and possible insulin administration (Fink, 2010).
Gestational diabetes occurs when the pancreas cannot produce enough insulin to meet the
increased glucose production required during pregnancy. Without enough insulin, glucose cannot
enter the body’s cells and the cells are depleted of energy. When blood glucose levels are high,
hyperglycemia, the cells begin to break down fat stores and protein to replace the lost energy
(Ladewig, London, & Davidson, 2010). In the first trimester of pregnancy, estrogen and
progesterone causes the mother’s pancreas to produce more insulin. However, by the second and
third trimester, the liver produces more glucose to supply both the mother and growing fetus
with energy. This in turn increases the blood glucose. At the same time, the increased pregnancy
hormones create insulin resistance and decrease insulin’s ability to lower blood sugar levels
causing gestational diabetes (Fink, 2010). It is important to remember that glucose production
increases as the pregnancy progresses and thus insulin needs will also change. Close blood sugar
monitoring is essential.
Risk factors for developing gestational diabetes are obesity, family history of diabetes
and previous delivery of a large for gestation age infant. However, some cultures are at increased
risk for developing diabetes such as African Americans, Native Americans, who have a ten times
higher risk and is the highest risk culture, Hispanics and Pacific Islanders (Fink, 2010). There are
four typical symptoms of diabetes to monitor for: polydipsia, polyuria, polyphagia and
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unexplained weight loss. If left untreated gestational diabetes can increase the risk for
preeclampsia, premature rupture of the membranes and preterm labor in the mother. It can also
result in hydramnios, increased amniotic fluid, due to increased fetal urination, and ketoacidosis,
increased acids in the blood produced from the breakdown of fat. Ketoacidosis may result in
coma and death for both the mother and infant (Ladewig, London, & Davidson, 2010).
Fetal risks due to gestational diabetes include: various congenial abnormalities of the
heart, central nervous system and skeletal system. A type of skeletal anomaly is sacral agenesis
in which the “sacrum and lumbar spine fail to develop and the lower extremities develop
incompletely” (Ladewig, London, & Davidson, 2010, p 316). Other risks are: macrosomia,
hypoglycemia two to four hours after delivery, respiratory distress, intrauterine growth
restriction, polycythemia, hyperbilirubinemia, shoulder dystocia, Erb’s palsy, placental
hypoxemia and delayed lung maturation (Fink, 2010; Ladewig, London, & Davidson, 2010).
The most detrimental risk factor of gestational diabetes to the infant is death.
There are currently two schools of thought related to screening for gestational diabetes.
According to the American Diabetes Association, women who do not present with any of the
earlier stated risks such as ethnicity or obesity do not need to be screened for gestational
diabetes. The American College of Obstetricians and Gynecologists had a different view. They
recommend that all pregnant women get tested for diabetes between the 24th and 28th week of
pregnancy. Screening initially consists of a one hour, non- fasting, glucose test that can be
administered at any time of the day in which the patient drinks 50 grams of a glucose solution. If
the glucose level is > 140 mg/dL the patient must be tested further. A three hour fasting glucose
test is administered. For this test the patient must fast for 8-14 hours and the test is administered
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after fasting and again at one and three hours after drinking 100 grams of a glucose solution.
The patient should not exceed 95 mg/dL after fasting, 180 mg/ dL at one hour or 140 mg/dL.
Diabetes is diagnosed if the patient’s glucose levels are higher than the normal values in two of
the tests (Fink, 2010).
Treatment of gestational diabetes depends upon early detection and intervention. If the
patient was not diabetic before becoming pregnant treatment mainly consists of diet, exercise (a
30 minute walk 3-4 times a week) and close monitoring of blood glucose levels. A diabetic
patient will often be referred to a nutritionist for diet education. It is recommended that the
patient ingest three meals and three or four small snacks throughout the day to maintain
consistent blood glucose levels. Food should consist of 40%- 45% complex carbohydrates, 10% -
20% protein and 35% - 40% fats. Patients should also eat a snack before bedtime to prevent
hypoglycemia during the night (Ladewig, London, & Davidson, 2010). Oral hypoglycemic are
not usually prescribed during pregnancy because it can cross the placenta. However, new oral
hypoglycemics, Metformin and glyburide, have recently been administered to patients with good
results. These drugs are easier to store, most patients prefer them to the subcutaneous injections
required with insulin and they also cost less (Fink, 2010). It is important to remember to educate
the diabetic patient and her family about the signs and symptoms of hypoglycemia. These
include: “sweating, nervousness, shakiness, weakness, extreme hunger, slight nausea, dizziness,
headache, and blurred vision- and tell her to keep low fat milk, fruit juice, candy, or other quick-
sugar foods available” (Fink, 2010, p 29). A final and essential intervention is to support and
listen to the patient’s concerns and to assess her stress and coping ability.
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After the birth of the infant and delivery of the placenta the mother’s blood sugar levels
return to prepregnancy levels. Women with gestational diabetes usually do not need insulin
following the delivery. If blood sugar levels remain high she may need insulin and breastfeeding
is still recommended (Ladewig, London, & Davidson, 2010). “The American Diabetic
Association recommends that women undergo a two – hour, 75gm GTT at their six week
postpartum checkup” (Fink, 2010, p 30). If her blood glucose levels are within the normal
ranges she should then be retested every three years.
Interventions for an infant born of a gestational diabetic mother are at risk immediately
after birth of hypoglycemia and respiratory distress. According to Fink, 2010, the hypoglycemia
generally resolves as soon as the infant is fed. If the infant’s blood glucose levels remain
elevated, a solution of 10% dextrose maybe administered by IV, and the blood sugar is
monitored hourly. Infants’ with respiratory distress are administered oxygen and possibly a
surfactant replacement to encourage greater lung elasticity and expansion. The infant is then
closely monitored until it can breathe on its own.
Conclusion
The patient in this case study was diagnosed with gestational diabetes November 9, 2010
at approximately 29 weeks gestation. She had a one hour glucose test with a result of 154 mg/dL
and a three hour test resulting in a fasting glucose level of 100 mg/dL and nonfasting glucose
level of 204 mg/dL. For the remainder of the pregnancy blood glucose levels were controlled
with diet and exercise. After delivery it was determined that there was no need to test her blood
glucose levels until her six week postpartum checkup. The infant’s blood glucose after delivery
was tested at 54 mg/dL, which is with the normal limits of 20 -80 mg/dL. Infant displayed no
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respiratory distress or other adverse effects of mother’s diabetes and had a one minute and five
minute Apgar of 8 and 9 respectively. Before discharge mother and spouse were educated on the
signs and symptoms of hypoglycemia and to continue with current diet and exercise program.
GESTATIONAL DIABETES 18
References
Ackley, B. J. & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to
planning care (9th ed). St Louis, MO: Mosby Elsevier
Alus, M., Okumus, H., Mete, S., & Guclu, S. (2007). The effects of different maternal positions
on non-stress test: An experimental study. Journal of Clinical Nursing, 16(3), 562-568.
Retrieved from CINAHL Plus with Full Text database.
Association of Women’s Health, Obstetric and Neonatal Nurses. (2009). Standards for
professional nursing practice in the care of women and newborns (7th ed.). Washington,
DC: Author
Fink, J. (2006). Diabetes in pregnancy and beyond. RN, 69(5), Retrieved from EBSCOhost
Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn
nursing care (7th ed.). Upper Saddle River, NJ: Pearson
Lewallen, L., Dick, M., Flowers, J., Powell, W., Zickefoose, K., Wall, Y., & Price, Z. (2006).
Breastfeeding support and early cessation. JOGNN: Journal of Obstetric, Gynecologic &
Neonatal Nursing, 35(2), 166-172. Retrieved from EBSCOhost.
Lilly, L. L., Harrington, S., & Snyder, J. S. (2011). Pharmacology and the nursing process (6th
ed.). St. Louis: Mosby
CASE STUDY CLIENT ASSESSMENT
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Prenatal Course
Age 24
Ethnic Background African American
Educational Level Completed high School
GTPAL G1,T1,P0,A0,L1
Past PregnanciesDate of DeliveryOutcomes (SVD or C/S)Risk factorsCurrent Status of children
None
LMP/EDCPlanned pregnancy?
LMP: 4/21/2010
EDC: 1/26/2011
Not planned.
Prenatal Care(Where, when started, number of visits)Number of ultrasounds/
significant findings
Other testing
Group For Women
July 16, 2010 at 11 weeks gestation
10 prenatal visits
4 ultrasounds
GDM –positive
HSV- Bacterial vaginitis culture – positive
Iron and vitamindeficiencies.
Nutrition/Vitamins (any changes with pregnancy
Prenatal vitamins at initial visit – July 16, 2010.
Vitamin D deficiency noted on 7/13/2011, Rx issued. Noncompliant - pt stated lost RX. New RX issued on 9/7/2010.
Iron deficiency noted on 11/9/2010, pt given low iron information sheet. RX iron on 12/6/2010.
GESTATIONAL DIABETES 20
Gynecological History
(Menarche onset, duration
and frequency, PAP smears,
problems, sexual partners,
history of rape or abuse
Onset: age 8
Duration: 3- 5 days
Frequency:30 day cycle
Pap: 7/13/2010 – no abnormal findings.
HSV lesion on labia, bacterial vaginitis.
Declined number of sexual partners question.
No history of rape/abuse.
Medical or Surgical History
Any traumas?
Normal childhood diseases?
Osteoarthritis, asthma, degenerative joint disease, sciatica.
No surgical history/traumas.
Chicken pox as a child
Psychological History
Postpartum Depression?
Evidence of Bonding?
No psychological history.
No sign of post partum depression.
Bonding with infant enface, holding close.
Social/Cultural Factors
Employment/insurance/living quartersReligious or spiritual beliefs
Support System/ Marital
Status
Community Resources
African AmericanCashier at storeLiving in apartment
Christian.
Family in vicinity for support.
Married in August to baby’s father
WIC.
Risk Factors or complications with this pregnancy
Gestational diabetes
Herpes- vaginitis Genetic history of spina bifida Toxoplasmosis
Asthma
Smoking
Vitamin D and Fe deficiency.
Intrapartal Course
GESTATIONAL DIABETES 21
Initial Assessment
Vital signs
SVE/SROM/Bleeding/
Problems
Tocodynamometer on admission: 1/18/2011 2100 for induction with Cervidil.
Results: occasional contractions, every 1 -2 minutes lasting 50-100 seconds. FHR 145, reactive, reassuring.
VS: BP 120/71, HR 85, RR 18, T not taken, Pulse Ox 100%
Cervix posterior position.
AROM @ 1cm 0935 on 1/19/2011- meconium stained amniotic fluid.
Fetal MonitoringExternal or Internal or Both
FHR Baseline
Reactive/Nonreactive
Accels
Early/Late/Variable Decels.
External
FHR 140-145
Reactive accelerations
Variable decel x1 at 1200.
Early decel at 1630
Bradycardia - FHR below 100bpm at 1744 and 1820
Neonatal Course
Delivery SummaryGestational age at delivery
SVD or C/S
Forceps or Vacuum
Gestational age: 38 weeks 5 days. Jan 19, 2011 @ 2126 pm
SVD with epidural and pitocin augmentation.
No forceps or vacuum.
ROA position /No episiotomy / 3 vessel cord.
Placenta delivered spontaneously and intact.
Cytotec administered rectally to decrease bleeding.
Sex, Length/WeightApgar scoreResuscitation
Male, 20 in. /50.8 cm, 7lb 8 oz. Apgar: 1 min – 8, 5 min -9.
Nares and mouth suctioned.
Cord results not available due to bad sample.
Infant glucose 54 mg/dL = within normal level.
GESTATIONAL DIABETES 22
Risk Factors From GDM: Congenital anomalies- heart, CNS, skeletal- sacral agenesis, macrosomia, hypoglycemia,IUG, respiratory distress/ delayed lung maturation/hypoxia, polycythemia (/\ RBC= blood too thick), intrauterine hypoxemia, placental insufficiency, hyperbilirubinemia, shoulder dystocia, Erb’s palsy.
Laboratory FindingsPregnancy 7/13/2010
Postpartum7/20/2011
Blood type AB+
Rubella titer immune
VDRL/RPR Not documented
HBsAg (<1.00index) .25
GBS Not documented
HIV Not documented
Chlamydia negative
GC negative
Glucose- after delivery11/9/2010 – 1 hr 154 mg/dL
11/17/2010 – 3hr fasting 100 mg/dL non fasting = 204 mg/dL
Infant – 58 mg/dLNormal: 20 -80 mg/dL
Pt postpartum: not performed
BUN Not documented
GESTATIONAL DIABETES 23
Uric Acid Not documented
WBC (4.5 -13.0 k/uL) 4.3 k/uL 6.7 k/uL
RBC (4.0 -5.0 M/uL) 3.87 M/uL Low 3.5 M/uL Low
Hct (36.0 46.0 %) 33.3 % Low 27% Low
Hgb (12-16 g/dL) 11.2 g/dL low 9.1% Low
Urinalysis 6/15/2010 - Negative for glucose, pregnancy positive, <1.005 specific gravity
Medications/Dosage/Route PurposeSide effects /Contraindications/Nursing Implications
Percocet (Acetaminophen – Oxycodone)
Percocet - 325mg/5mg PO: 325 mg q 4hrs PRN. Maximum- 4 g/day.
Purpose: Relief of moderate to moderately severe pain.
Action: Inhibits prostaglandin synthesis in CNS, blocks pain impulses.
Side effects: hypersensitivity
Contraindications: active alcoholism, liver disease, or viral hepatitis, all of which increase the risk of hepatotoxicity.
Nursing Implications: assess for clinical improvement of and relief of pain, effect of medication is reduced if full pain response recurs prior to next dose(Saunder’s, 2010, p. 9- 11).
Cytotec (misoprostol)Dosage: 400mcg rectally. 1 application.
Purpose: Control excessive bleeding.
Action: produces uterine contractions.
Side effects: Abdominal pain, diarrhea, nausea, flatulence, dyspepsia, headache.
Contraindications: Pregnancy (produces uterine contractions)
Nursing Implications: Avoid magnesium-containing antacids- minimizes potential for diarrhea. (Saunder’s, 2010, p. 755, 762 - 763).
GESTATIONAL DIABETES 24
Dinoprostone (Cervidil)
1 application
Purpose: Initiation of cervical ripening for induction of labor.Action: Acts directly on the myometrium, causing softening, and dilation of cervix.
Side effects:Drowsiness, dizziness, urinary retention, dry mouth, lips, nose, throat.
Contraindications: Active cardiac, hepatic pulmonary, renal disease and pelvic inflammatory disease.
Nursing implications: monitor BP- increased risk of hypotension, respirations, lung sounds.(Saunder’s, 2010, p. 353-355).
Pitocin (Oxytocin)IV/ 2-10 milliunits /minInduction: add 10 units (1 mL) to 1000 mL IV.IV: 0.5-1 milliunit/min. Increase by 1-2 milliunit/min q 40-60 min. OR start with 1-2 milliunits/min and increase by 1 milliunt/min q 15 min.
Purpose/Action: Induction or stimulation of labor by stimulating mammary smooth muscle resulting in increased uterine contractions, helps to control postpartum bleeding. Used as adjunct to manage abortion.
Side effects: Water intoxication (Tachycardia, hypotension, nausea, vomiting); cervix/vagina/perineum tearing from rapid labor, impaired uterine blood flow resulting in fetal hypoxia.
Contraindications: uterine fails to progress, cephalopelvic disproportion (maternal pelvis is small in relation to the size of the fetal head), fetal distress without imminent delivery, grand multiparity (woman who has had five or more previous pregnancies), hyperactive or hypertonic uterus, obstetric emergencies that favor surgical intervention, unengaged fetal head, unfavorable fetal position/presentation, preterm infant, rigid unripe cervix, severe preeclampsia (HTN with protein in urine), eclampsia (convulsions and possibly coma during or immediately after pregnancy)
Nursing Implications: apply
GESTATIONAL DIABETES 25
fetal monitor,15-20 min tracings and NST to assess FHR before administering IV oxytocin.Assess baseline and monitor maternal B/P, HR, RR, FHR, contractions q15min. Notify physician of contractions that last longer than 1 min, occur more than every 2 min, or stop. Monitor I&O, be alert to potential water intoxications, check for blood loss. Monitor I&O. (Ladewig, London, & Davidson, 2010, p.542-543).
Motrin/IbuprofenDosage: PO: 800 mg (2- 400mg) tab/ q 8hrs PRN.
Max daily dose; 1200 mg/day
Purpose: Non-steroidal anti-inflammatory, analgesic, decreases fever.Action: Inhibits prostaglandin synthesis in CNS, blocks pain impulses. Acts on hypothalamus heat regulating center causing peripheral vasodilation.
Side effects: Nausea with or without vomiting, dyspepsia (heartburn), dizziness, rash. May cause diarrhea or constipation, abdominal cramps, pruritus.
Contraindications: Active peptic ulcer, chronic inflammation of GI tract, GI bleeding disorders/ulceration, history of hypersensitivity to aspirin or NSAIDS.
Nursing Implications: Monitor for nausea, dyspepsia, rash, constipation /diarrhea. Evaluate for therapeutic response of pain relief. Take with milk/ food or antacids if GI upset. Monitor CBC, hepatic/renal function (Saunder’s, 2010, p. 576 - 578).
Ferrous SulfateDosage: 325 mg tab, 2-4 times a day
Purpose: Prevention, treatment of iron deficiency anemia due to inadequate diet, malabsorption, pregnancy, blood loss.
Side effects: mild transient nausea. Rare: heartburn, anorexia, diarrhea constipation,
Contraindications:
GESTATIONAL DIABETES 26
Ferrous Sulfate
Action: Essential component in formation of hemoglobin (Hgb), myoglobin. Promotes RBC formation, transport and utilization of oxygen.
Hemochromatosis ( iron accumulates in the tissues- bronze skin, enlarged liver, DM, abnormalities of the pancreas and joints), hemosiderosis ( overload of iron in the body tissue damage) , hemolytic anemia’s, peptic ulcer disease, regional enteritis, ulcerative colitis.
Nursing Implications: Monitor serum iron, daily pattern of bowel activity and stool consistency. Assess for clinical improvement, record relief of iron deficiency symptoms (fatigue, irritability, pallor, paresthesia of extremities, headache (Saunder’s, 2010, p. 464 - 466).
Vitamin DDosage: PO/ 10mcg/ daily
Purpose: Dietary supplementAction: promotes secretion of calcium from bone to blood.
Side effects: constipation, weakness, headache, metallic taste, N&V, nocturia, HTN, itching.
Contraindications: vitamin toxicity, hypercalcemia, malabsorption syndrome.
Nursing Implications: monitor serum, urine calcium levels, BUN, Creatinine, encourage adequate fluid intake.(Saunder’s, 2010, p. 1188-1189).
IV Therapy
Lactated Ringers 125 mL/hr
Fluid replacementSide Effects: will not stay in the blood vessels and can leak out of the plasma into the tissues and cells resulting in edema.
GESTATIONAL DIABETES 27
Contraindications: none listed
Nursing Implications: Monitor for peripheral and pulmonary edema. Decreased oxygen tension may result due to dilutional effect on erythrocyte concentrations. Monitor for fluid overload (Lilley, Harrington, & Snyder, 2011, p. 419).
I pledge to support the Honor System of Old Dominion University. I will refrain from any form of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a member of the academic community, it is my responsibility to turn in all suspected violators of the Honor Code. I will report to a hearing if summoned.”
Name: SUSAN B PASCHAL
(Print Name)
“THIS IS MY OWN WORK”
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