GDM

GESTATIONAL DIABETES 1

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


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


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


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,


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


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


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


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


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


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


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


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


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


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, nonfasting, 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


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.


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


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.


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


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.


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


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.


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


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).


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


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:


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.


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).

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GDM

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gestational diabetessusan

prenatal care

hour glucose test

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postpartum care

nursing care

prenatal vitamins

occasional contractions