GESTATIONAL DIABETES

Childbearing Clinical Case Study: Gestational Diabetes Susan B. Paschal Student UIN# 00799934 Sentara Leigh Hospital

Submitted in partial fulfillment of the requirements in the course N331 Clinical Management of the Childbearing Family in the School of Nursing Old Dominion University NORFOLK, VIRGINIA Spring, 2011

GESTATIONAL DIABETES Childbearing Clinical Case Study: Gestational Diabetes

The purpose of this paper is to discuss one womans 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 Womens 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

GESTATIONAL DIABETES 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 patients 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 patients 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 Ringers 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 patients 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

GESTATIONAL DIABETES

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. Patients 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,

GESTATIONAL DIABETES 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 infants head facing away from the spine. Patient did not require an episiotomy. The infants 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, Homans 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 Homans 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

GESTATIONAL DIABETES 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 infants 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 infants 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

GESTATIONAL DIABETES 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 patients initial experiences with breastfeeding (Association of Womens 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 patients 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 infants 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 Womens 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 babys latching on and

GESTATIONAL DIABETES 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 Womens 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 ringers), perform a

GESTATIONAL DIABETES 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 infants 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

GESTATIONAL DIABETES sessions to ensure proper positioning and latching on, avoid supplemental feedings, promote

10

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 patients 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 patients 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

GESTATIONAL DIABETES

11

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

GESTATIONAL DIABETES reactive fetal rates 69% of the time (Alus, Okumus, Mete & Guclu, 2007). From this study we

12

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 wasnt 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

GESTATIONAL DIABETES consequences later in life for both the mother and the infant (Fink, 2010). I chose gestational

13

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 bodys 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 mothers 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 insulins 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

GESTATIONAL DIABETES 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

14

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, Erbs 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

GESTATIONAL DIABETES 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.

15

Diabetes is diagnosed if the patients 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 quicksugar foods available (Fink, 2010, p 29). A final and essential intervention is to support and listen to the patients concerns and to assess her stress and coping ability.

GESTATIONAL DIABETES After the birth of the infant and delivery of the placenta the mothers blood sugar levels return to prepregnancy levels. Women with gestational diabetes usually do not need insulin

16

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 infants 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 infants blood glucose after delivery was tested at 54 mg/dL, which is with the normal limits of 20 -80 mg/dL. Infant displayed no

GESTATIONAL DIABETES respiratory distress or other adverse effects of mothers diabetes and had a one minute and five

17

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 References

18

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 Womens 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

GESTATIONAL DIABETES

19

Prenatal Course Age Ethnic Background Educational Level GTPAL Past Pregnancies Date of Delivery Outcomes (SVD or C/S) Risk factors Current Status of children LMP/EDC Planned pregnancy? 24 African American Completed high School G1,T1,P0,A0,L1 None

LMP: 4/21/2010 EDC: 1/26/2011 Not planned.

Prenatal Care Group For Women (Where, when started, number July 16, 2010 at 11 weeks of visits) gestation Number of ultrasounds/ 10 prenatal visits significant findings 4 ultrasounds Other testing 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.

GDM positive HSV- Bacterial vaginitis culture positive Iron and vitamin deficiencies.

Iron deficiency noted on 11/ 9/2010, pt given low iron information sheet. RX iron on 12/6/2010.

GESTATIONAL DIABETES Gynecological History (Menarche onset, duration and frequency, PAP smears, problems, sexual partners, history of rape or abuse Medical or Surgical History Any traumas? Normal childhood diseases? Psychological History Postpartum Depression? Evidence of Bonding? Social/Cultural Factors Employment/insurance/living quarters Religious or spiritual beliefs Support System/ Marital Status Community Resources Risk Factors or complications with this pregnancy Gestational diabetes Herpes- vaginitis Genetic history of spina bifida Toxoplasmosis Intrapartal Course Asthma Smoking Vitamin D and Fe deficiency. No psychological history. No sign of post partum depression. African American Cashier at store Living in apartment Christian. Bonding with infant enface, holding close. Onset: age 8 Duration: 3- 5 days Frequency:30 day cycle Pap: 7/13/2010 no abnormal findings. Osteoarthritis, asthma, degenerative joint disease, sciatica. HSV lesion on labia, bacterial vaginitis. Declined number of sexual partners question. No history of rape/abuse.

20

No surgical history/traumas. Chicken pox as a child

Family in vicinity for support. Married in August to babys father WIC.

GESTATIONAL DIABETES 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. External FHR 140-145 Reactive accelerations Variable decel x1 at 1200.

21 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. Early decel at 1630 Bradycardia - FHR below 100bpm at 1744 and 1820

Fetal Monitoring External or Internal or Both FHR Baseline Reactive/Nonreactive Accels Early/Late/Variable Decels. Neonatal Course Delivery Summary Gestational 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. Cord results not available due to bad sample. Infant glucose 54 mg/dL = within normal level.

Sex, Length/Weight Apgar score Resuscitation

Male, 20 in. /50.8 cm, 7lb 8 oz. Apgar: 1 min 8, 5 min -9. Nares and mouth suctioned.

GESTATIONAL DIABETES 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, Erbs palsy.

22

Laboratory Findings Blood type Rubella titer VDRL/RPR

Pregnancy 7/13/2010

Postpartum 7/20/2011

AB+ immune Not documented

HBsAg (<1.00index) GBS HIV Chlamydia GC Glucose- after delivery

.25 Not documented Not documented negative negative 11/9/2010 1 hr 154 mg/dL 11/17/2010 3hr fasting 100 mg/dL non fasting = 204 mg/dL

Infant 58 mg/dL Normal: 20 -80 mg/dL Pt postpartum: not performed

BUN

Not documented

GESTATIONAL DIABETES Uric Acid WBC (4.5 -13.0 k/uL) RBC (4.0 -5.0 M/uL) Hct (36.0 46.0 %) Hgb (12-16 g/dL) Urinalysis

23

Not documented 4.3 k/uL 3.87 M/uL Low 33.3 % Low 11.2 g/dL low 6/15/2010 - Negative for glucose, pregnancy positive, <1.005 specific gravity Purpose Purpose: Relief of moderate to moderately severe pain. Action: Inhibits prostaglandin synthesis in CNS, blocks pain impulses. Side effects /Contraindications/ Nursing Implications 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 (Saunders, 2010, p. 9- 11). Side effects: Abdominal pain, diarrhea, nausea, flatulence, dyspepsia, headache. Contraindications: Pregnancy (produces uterine contractions) Nursing Implications: Avoid magnesium-containing antacidsminimizes potential for diarrhea. (Saunders, 2010, p. 755, 762 763). 6.7 k/uL 3.5 M/uL Low 27% Low 9.1% Low

Medications/Dosage/Route Percocet (Acetaminophen Oxycodone) Percocet - 325mg/5mg PO: 325 mg q 4hrs PRN. Maximum- 4 g/day.

Cytotec (misoprostol) Dosage: 400mcg rectally. 1 application.

Purpose: Control excessive bleeding. Action: produces uterine contractions.

GESTATIONAL DIABETES 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.

24

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. (Saunders, 2010, p. 353-355).

Pitocin (Oxytocin) IV/ 2-10 milliunits /min Induction: 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 12 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/Ibuprofen Dosage: PO: 800 mg (2400mg) 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 (Saunders, 2010, p. 576 - 578).

Ferrous Sulfate Dosage: 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 Action: Essential component in formation of hemoglobin (Hgb), myoglobin. Promotes RBC formation, transport and utilization of oxygen.

26 Hemochromatosis ( iron accumulates in the tissuesbronze skin, enlarged liver, DM, abnormalities of the pancreas and joints), hemosiderosis ( overload of iron in the body tissue damage) , hemolytic anemias, 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 (Saunders, 2010, p. 464 - 466). Purpose: Dietary supplement Action: 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. (Saunders, 2010, p. 1188-1189).

Ferrous Sulfate

Vitamin D Dosage: PO/ 10mcg/ daily

IV Therapy

Lactated Ringers 125 mL/hr

Fluid replacement

Side 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