NURSEREVIEW.

ORG

POSTPARTAL DIABETES MELLITUS

(To be used in conjunction with customary postpartal plans of care.)

CLIENT ASSESSMENT DATA BASE

(Refer to CP: Diabetes Mellitus: Prepregnancy/Gestational; and CP: Intrapartal Diabetes
Mellitus.)

Activity/Rest
Fatigue, especially when labor was long or difficult (increases glucose needs)

Circulation
May have elevated BP, edema (signs of PIH that developed during prenatal, intrapartal, or
postpartal period
History of vascular changes associated with diabetes that impair circulation/kidney functioning;
venous thrombosis

Elimination
Polyuria

Food/Fluid
Polydipsia, polyphagia
Nausea/vomiting
Ketonuria, elevated serum glucose
May report episodes of hypoglycemia, glycosuria

Safety
Healing of episiotomy or cesarean incision may be delayed.
May report visual disturbances.

Sexuality
Uterus may be relaxed/boggy, and lochia may be heavy with clots present.
Current pregnancy may have involved uterine overdistension (macrosomia or hydramnios).
Labor may have been prolonged/augmented or induced.
Preterm, large-for-gestational age, or low-birth-weight infant.

Teaching/Learning
Change in stability of diabetes, adjustment of insulin therapy.
Type of infant feeding planned affects caloric needs and insulin requirements.

DIAGNOSTIC STUDIES
Fasting (Daily) or Serum Glucose: Assesses control (increased risk of hypoglycemia).
Hb/Hct: Baseline studies.
Glycosylated Hemoglobin (HbA1c): May be elevated (greater than 8.5%), indicating
inadequate control of serum glucose levels.
Urinalysis: May show glucose, ketones, or protein.
 NURSING PRIORITIES
1. Maintain normoglycemia.
2. Prevent or minimize complications.
3. Promote parent-infant bonding.
4. Provide information concerning postpartal changes and diabetic management.

DISCHARGE CRITERIA

Gestational Diabetes
1. Regains euglycemia without need of medication
2. Understands nature of condition and prognosis for future

Diabetes
Because this is a life-long condition, client’s care will be transferred to primary care provider at
completion of postpartum period.

NURSING DIAGNOSIS: NUTRITION: altered, risk for less than body

requirements
Risk Factors May Include: Inability to ingest/utilize nutrients appropriately,
increased metabolic demands (recuperation, lactation)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Maintain serum glucose levels within individually
CRITERIA—CLIENT WILL: determined parameters, free of hypoglycemia/
hyperglycemia.
Verbalize understanding of, and participate in, self-
monitoring and individual treatment regimen.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Review onset of diabetes (prepregnancy versus The client with gestational diabetes mellitus
gestational) and type of infant feeding planned. (GDM) usually requires no further insulin after
delivery; the client with prepregnancy onset must be
re-regulated based on fasting blood sugar and 1-hr
postprandial serum glucose levels. In addition,
breastfeeding has an antidiabetogenic effect because
carbohydrates are used in milk production.
Assess for hypoglycemic or hyperglycemic Because the half-life of human placental lactogen is
reactions. Note changes in mentation and behavior, 20–30 min, most of this insulin antagonist has
visual disturbances, nausea or vomiting, disappeared within 2–3 hr postpartum, rendering
tachycardia, slurred speech, or Kussmaul’s the client susceptible to hypoglycemia, if insulin
respirations. dosages are not accurately recalculated.
Monitor urine for glucose and ketones. The presence of ketones indicates inadequate
carbohydrate intake and fat breakdown and may
necessitate modifying diet or discontinuing
breastfeeding.
Advise GDM client to avoid obesity and to lose Helps reduce risk of developing insulin-dependent
weight during postpartal period if she is not diabetes (type I), although 70% of individuals who
lactating. develop GDM develop type 2 diabetes later in life,
often within 10 yr.

Collaborative
Coordinate multi-specialty care conference as Provides opportunity to determine individual
appropriate. postpartal diabetic control based on client’s specific
needs (e.g., diabetic classification, lactation).
Monitor serum glucose levels by fingerstick per Following removal of the placenta with its anti-
protocol and as indicated. insulin hormones, insulin requirements decrease in
the first 48–96 hr postpartum. Such a change results
in a glucose-insulin imbalance. Frequent assessment
(e.g., every 2 hr) is continued until serum glucose
levels stabilize and carbohydrate hemostasis occurs.
Whereas hypoglycemia is common during the first 24
hr after delivery, it may compromise wound healing,
and poor control is associated with increased
morbidity and infection.
Discontinue insulin infusion after vaginal delivery, Insulin requirements quickly decline after delivery
as indicated; continue infusion of glucose until of the placenta. Glucose infusion helps prevent
oral feedings are started. hypoglycemic response. Note: IV infusion of 5%
dextrose with insulin at 1 unit/hr via pump may be
used to maintain normoglycemic control in early
postpartal period.
Continue insulin infusion after cesarean birth until Surgical procedure/stress may increase insulin
client has resumed eating. needs.
Administer insulin subcutaneously or monitor During first 1 or 2 days postpartum, insulin
self-administration of insulin for client with dosage is usually equal to one-half to two-thirds of
prepregancy diabetes. prepregnancy levels with the resumption of a “regular”
diet.
Adjust diet to increase calories by 500–800 kcal/day Inadequate caloric intake with resulting
above pregravid requirements if client is hypoglycemia negatively affects milk supply and
breastfeeding. let-down reflex.
Reevaluate serum glucose levels at 4- to 6-wk Although temporary remission of diabetes may
checkup or when breastfeeding stops. Institute new occur, necessitating lowering insulin needs, return
dietary insulin control if fasting plasma glucose to prepregnancy doses is usually required to 6 wk
is greater than 120–140 mg/dl, or if 2-hr oral glucose postpartum, or when weaning occurs.
tolerance test (GTT) is 140–200 mg/dl and at least
one other value is greater than 200 mg/dl.

NURSING DIAGNOSIS: INJURY, risk for

Risk Factors May Include: Biochemical or regulatory complications (e.g., uterine
atony/hemorrhage, hypertension [PIH], hyperglycemia)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
 DESIRED OUTCOMES/EVALUATION Display vital signs, reflex response, lochial
CRITERIA—CLIENT WILL: discharge, and WBC count WNL, with uterus well
contracted.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Monitor contractility and location of uterus. Uterine atony and hemorrhage may occur, owing to
overdistension associated with a large (macrosomic)
infant, hydramnios, or oxytocin stimulation.
Gently massage uterus, as indicated. Increases uterine tone and myometrial contractility,
reducing risk of hemorrhage.
Assess amount and type of lochial flow with each Increased or heavy flow may indicate developing
check of the fundus. (Refer to CP: Postpartal complications.
Hemorrhage; ND: Fluid Volume, risk for deficit.)
Assess bladder fullness; encourage voiding within Polyuria (increased urine output) associated with
6–8 hr following delivery. Monitor intake and output. diabetes occurs as a means of excreting excess
glucose and retained fluids. A full bladder may
interfere with uterine involution.

Monitor BP and pulse. Note location and extent of With hemorrhage, BP decreases and pulse
edema and presence of proteinuria, visual increases. Elevated BP, proteinuria, and extensive
disturbances, hyperreflexia, or RUQ/epigastric pain. edema may indicate PIH or potential eclampsia.
Institute seizure precautions. (Refer to CP: Danger of eclampsia exists for up to 72 hr
Pregnancy-Induced Hypertension.) postpartum, but can actually occur for up to 1 wk
postpartum, depending on severity of hypertension,
fluid retention, and organ involvement.

Monitor temperature and WBC count. Assess lochia Infection is indicated by elevated temperature and
and episiotomy or abdominal incision. Note WBC count; redness, erythema, or exudate at site
progressive rate of uterine involution. of episiotomy or abdominal incision; and foul-
smelling lochia. Infection may occur in diabetic client
owing to poor healing associated with vascular
involvement and hyperglycemia. (Refer to CP:
Puerperal Infection.)

NURSING DIAGNOSIS: KNOWLEDGE deficit [LEARNING NEED], regarding

condition, prognosis, and treatment needs
May Be Related To: Lack of exposure/recall, misinterpretation, unfamiliarity
with resources
Possibly Evidenced By: Verbalization of concerns/misconceptions, inadequate
performance of procedures, development of
preventable complications
DESIRED OUTCOMES/EVALUATION Verbalize understanding of physiological changes,
CRITERIA—CLIENT/COUPLE WILL: individual needs, possible outcomes.
Perform necessary activities/procedures correctly and
explain reasons for actions.
 Select family planning method prior to discharge.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Discuss dietary needs based on individual weight Calorie needs will be determined by desired
gain and choice of infant feeding. weight goal and whether client is breastfeeding.
(During lactation, glucose is used as energy in milk
production, thus lowering glucose levels in client.)
Stress importance of home monitoring of condition Although the demands of pregnancy are
and maintenance of log of dietary intake, medication, concluded, postpartal demands of healing/return
exercise, and signs/symptoms of serum glucose to nonpregnant state and needs of infant
fluctuation. (including lactation) and family will affect diabetic
control. Keeping a log provides insight to individual
needs/responses to therapy. Note: Increased
sensitivity to insulin during first few weeks following
delivery places client at high risk for hypoglycemia.
Evaluate client’s eyesight and ability to provide Approximately 15% of diabetic clients will incur
infant care in client with long-standing diabetes. an increase of retinopathy during the prenatal period,
negatively affecting client’s independence and
requiring additional teaching/support.
Provide information for class A diabetic client About 18% of class A diabetic clients manifest
(White’s classification) about the need to return for carbohydrate intolerance at 6 wk postpartum.
a 3-hr GTT at 6–8 wk postpartum or at cessation Greater than 70% of clients with GDM eventually
of breastfeeding. If tests results are normal, annual develop type 2 diabetes, many within 10 yr
follow-up testing is recommended. following delivery.
Identify signs/symptoms requiring notification of Prompt evaluation and intervention may prevent
healthcare provider; e.g., continued oozing or lack or limit development of complications such as
of progression of lochia, fever, or foul-smelling hemorrhage and infection.
urine/vaginal drainage.
Discuss client’s/couple’s plans for future Diabetes, if well controlled, does not alter or
pregnancies and the impact of diabetes on fertility. reduce fertility rate. Uncontrolled diabetes and
Review the critical importance of obtaining elevated HbA1c levels during organogenesis
metabolic control of diabetes prior to conception. greatly increase incidence of malformations. Good
metabolic control started before conception and
continued during these critical weeks may prevent
such malformations.
Determine client’s/couple’s plans for selecting a Choosing a method of contraception involves
contraceptive method. some compromise between benefits and risks,
especially with the diabetic client. Risk of using oral
contraceptives or the intrauterine device (IUD) in
diabetic clients must be weighed against the risk of
pregnancy with other forms of contraception. Note:
Cultural/religious beliefs may limit options.
Provide information and review side effects
associated with contraceptive choices:
Oral contraceptives; Side effects include elevated BP and acceleration of
blood vessel disease (thrombophlebitis, vascular
 complications). Estrogen increases the production
of cholesterol and triglycerides, and progesterone
interferes with insulin activity, accelerating the
subclinical diabetic process and creating
deterioration in the diabetic state. Note: Progestin-
only or triphasic products are considered safer
than combined oral contraceptives.
IUD; Some studies indicate an increased risk of pelvic
salpingitis (especially during first 20 days after
insertion).
Barrier methods (i.e., condom, diaphragm, No side effects or contraindications of these
cervical caps, sponges, or spermicidal methods are specific for diabetic client, although
creams); these methods are not as effective in preventing
unwanted pregnancies, in part because of
inconsistent use. When a device such as the
diaphragm is used in conjunction with a
spermicidal cream, effectiveness is significantly
increased.
Tubal ligation. May be desirable for diabetic client with
complications of nephropathy, retinopathy, or
vascular disease, rather than risk the possibility of
future pregnancies with negative maternal/fetal
outcomes.

Provide information about effects of diabetes on Heredity contributes to the risk of diabetes. Type 1
future offspring. (insulin-dependent) diabetes mellitus appears to
be transmitted less frequently to offspring of
diabetic women than to offspring of diabetic men,
although this phenomenon may be caused by
perinatal loss of affected offspring by diabetic
mothers. If a parent develops type 2 diabetes
mellitus, the children are at a greater risk than the
general population for developing this type of
diabetes.
(Refer to CP: The Client at 4 Hours to 2 Days Postpartum; ND: Knowledge deficit [Learning need], for
additional actions.)

NURSING DIAGNOSIS: PARENT/INFANT ATTACHMENT, risk for altered

Risk Factors May Include: Interruption in bonding process, physical
illness/changes in physical abilities
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Demonstrate positive attachment behaviors.
CRITERIA—CLIENT/COUPLE WILL: Verbalize fears and concerns about infant’s condition.
Participate optimally in infant contact and care.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine current status of infant. The special needs of the infant of the diabetic mother
include hypoglycemia, hypocalcemia, prematurity,
and respiratory distress syndrome, possibly
necessitating a short- or long-term stay in the
neonatal intensive care unit (NICU). Such separation,
with diminished physical contact coupled with
excessive parental anxiety, may interfere with
positive bonding and may create a high-risk
parenting situation.
Provide information concerning condition of infant. Information helps reduce fears and emphasizes the
reality of the infant’s presence.
Determine client’s/couple’s feelings concerning Provides baseline for future comparison; identifies
infant. Observe contact with infant. (Refer to CP: needs and potential concerns.
The Parents of a Child with Special Needs.)
Assess effectiveness/use of support systems by Strong system of support from family/friends or
client/couple. community facilitates positive adaptation to stress.
Encourage frequent interaction with infant and Couple may be extremely anxious if infant is in
participation in infant care tasks as client’s/infant’s NICU and may be fearful of touching or holding
condition allows. the infant.
Facilitate communication between couple and Staff can reduce fears, act as role models, and
nursery staff. Point out normal and positive facilitate bonding, especially in caring for preterm
aspects of infant. infant.
Refer parents to other couples who have had Increases parents’ sense of support and helps them
similar experiences with their newborn infants or to feel that they are not alone. Provides
to the appropriate support groups. opportunity for creative problem solving.

Collaborative
Refer to visiting nurse services or parenting classes, Client/couple may need additional assistance to
as indicated. promote family integration.

(Refer to CP: Maternal Assessment: 4 to 6 Weeks Following Delivery; ND: Parenting, risk for altered.)