Care of Mother and Child at Risk or with

Problems (Acute and Chronic)

Module #2

Lesson Title: CARE OF THE HIGH-RISK PREGNANT CLIENT Materials:

(PRE-GESTATIONAL CONDITIONS- MANAGEMENT OF
DIABETES MELLITUS) Pen, paper, index card, book, and class List

Learning Targets:
At the end of the module, students will be able to: References:
1. Define diabetes mellitus in relation to pregnancy, including pre-
existing factors that contribute to its development. Pilliteri, Adele and Silbert-Flagg, JoAnne
2. Integrate knowledge of diabetes mellitus in relation to pregnancy (2018) Maternal and Child Health Nursing, 8th
and nursing process to achieve quality maternal and child health Edition. USA: Lippincott Williams and Wilkins
nursing care.

A. LESSON PREVIEW/REVIEW

Instruction: Identify the classification of heart disease based on the given description.

Description Answer
1. Ordinary physical activity causes no discomfort. No symptoms of cardiac insufficiency
and no anginal pain. Class I

2. During less than ordinary activity, woman experiences excessive fatigue, palpitations,
dyspnea, or anginal pain. Class III

3. Ordinary physical activity causes excessive fatigue, palpitation, and dyspnea or anginal
pain. Class II

4. Woman is unable to carry out any physical activity without experiencing discomfort.
Even at rest, symptoms of cardiac insufficiency or anginal pain are present. Class IV

B. MAIN LESSON
The instructor should discuss the following topics. Instruct students to take down notes.

DIABETES MELLITUS Risk factors of DM

 Family history
Description:  Rapid hormonal changes in pregnancy
 An endocrine disorder in which the pancreas cannot  Tumor/infection of the pancreas
produce adequate insulin to regulate body glucose  Obesity
levels  Stress
 Disorder in CHO, CHON, and fat metabolism
 Pregnancy is a diabetogenic state due to the profound
effect of hormones (HPL), which increases insulin-
resistance

Normal Metabolic changes in Pregnancy that Affect DM

1. Increase insulin antagonistic hormones: cortisol, estrogen, progesterone and human placental lactogen
2. Lowered renal threshold for sugar, increased Glomerular Filtration Rate is link to GLYCOSURIA
3. Excess glucose crosses placenta is link to LGA
4. Vomiting decreases CHO intake link to metabolic acidosis
5. Labor activity requires increased CHO intake
6. Hypoglycemia postpartum due to involution & lactation

Gestational Diabetes Mellitus (GDM)

 This is DM that develops during pregnancy and spontaneously resolves after delivery.

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #2

MATERNAL COMPLICATIONS OF GDM FETAL COMPLICATIONS:

 Predisposes to PIH, UTI,  Macrosomia---birth injuries
 Infections: candidiasis, UTI  Intrauterine Growth Restriction due to placental
 Uteroplacental insufficiency insufficiency
 Dystocia due to large infant ----CS delivery  Fetal hypoxia, IUFD, stillbirths
 Preterm Labor and Cephalopelvic Disproportion  1st trimester: spontaneous abortion or fetal
 Postpartum hemorrhage due to uterine atony anomalies
 More difficult to control DM-hypo/hyperglycemia  Hydramnios
 Maternal mortality  Prematurity
 Diabetic retinopathy  Neonatal hypoglycemia as soon as 1 hr postpartum
 Diabetic nephropathy  Respiratory Distress Syndrome
 Hyperbilirubinemia
 Hypocalcemia
 Birth defects: heart, brain & spine, kidney, GIT
Assessment Findings
 Family hx of DM, previous GDM
 Previous LGA (4k or more)
 Previous infant with congenital defects, hydramnios
 Spontaneous abortion, fetal deaths, stillbirth
 Obesity
 Frequent candidiasis
 Marked abdominal enlargement (hydramnios & LGA)

Signs of Hypoglycemia: SIGNS & SYMPTOMS of Hyperglycemia(N=80-

 Sweating with cold, clammy skin 120mg/dL)
 Pallor  Glycosuria-blood glucose>150mg/dL
 Tremors, shakiness  Polyuria
 Hunger & nausea  Polydipsia
 Irritability or impatience, anger  Polyphagia
 Confusion, indicating delirium  Weight loss: CHON & Fat stores are used for
 Tachycardia energy
 Nervousness, anxiety  ketoacidosis
 Sleepiness
 Blurred vision
 Seizures
 unconsciousness
Diagnosis Treatment of Hypoglycemia
1. SCREENING TEST  Consume 15-20 g glucose or simple CHO
 At 26-28 wks. for high-risk women  Glucose tabs, 2 tbsp raisins, 4 oz (1/2 c juice or
 50g oral glucose challenge (if >140 mg/dl, needs 3-hr soda), 8 oz nonfat milk, 1 Tbsp sugar, honey or
GTT) corn syrup, hard candies, jellybeans or
2. GLUCOSE TOLERANCE TEST(GTT) gumdrops
 100 g GTT between wks. 28-34  Recheck blood glucose after 15 mins.
 Glucose levels at 1,2 & 3 hrs.  Emergency drug: GLUCAGON IM into buttock,
 Results: Gestational Diabetes Mellitus if FBS>95 or 2 arm or thigh to stimulate liver to release stored
results are high glucose into the bloodstream
 Normal: 
 FBS (95 mg/dl) DO NOT:
 1h (180 mg/dl)  Inject insulin
 2h (155 mg/dl)  provide food or fluid if unconscious
 3h (140 mg/dl)  put hands in mouth

Nursing Implementation Management

1. Participate in early detection. 1. Maintain normal FBS, Hba1c(N=6%)
2. Encourage early prenatal mgt. & supervision

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #2
 Regular prenatal check-up  Glycosylated hemoglobin measures the
 Record dietary intake & monitor glucose levels amount of glucose attached to the RBC &
 Insulin when FBS is not consistent at < 105 mg/dL reflects average measurement of the
or 2-hr PPBS is not <120mg/dL glucose levels over the past 4-6 wks.
 Serial UTZ- from 28-34 wks. if DM poorly controlled  Good test to assess effectiveness of
or with complications treatment
 Hospitalization- if DM is poorly controlled, with HPN  Abnormal: >7% of total hemoglobin
and infection. 2. Clinic visit every 2 wks up to 36 wks
3. Provide teaching: 3. Exercise lowers glucose levels
 Nature, effects of DM  Ingest protein or complex Carbohydrates
 Signs & symptoms of hypo/hyperglycemia prior to exercise
 Exercise to regulate glucose levels 4. Diet:
 Insulin regulation/self-administration  1800 to 2,200 cal/day or 35 kcal/kg BW
 Prompt reporting of danger signs and signs of  12%-20& CHON, 40%-45% CHO, 40%
infection from PUFAs
4. Promote control of DM  Use Diabetic food exchange list
5. Diet: 1800 to 2,200 calories/day or 35 kcal/kg BW  Weight gains not > 24 lbs.
 12%-20& CHON, 40%-45% CHO, 40% from 5. Instruct on signs of hypoglycemia (dt
Polyunsaturated Fats excessive insulin, exercise, or insufficient
 Use Diabetic food exchange list dietary intake):
 Weight gains not > 24 lbs.  Pallor
 Weakness, numbness
6. Exercise: decreases need for insulin but may cause  Headache
hypoglycemia if excessive:  Confusion or irritability
 No exercise when glucose levels are low or stomach  Blurred vision
is empty  Perspiration
 Don’t administer insulin in extremity used in exercise  Hunger
 Don’t exercise alone  Convulsions, coma
 always carry diabetic ID
“cold and clammy, need some candy”
7. Insulin Therapy Mgt: Give CHO foods like fruit juice, cola, sugar,
 No OHA candy
 Insulin requirements drops during 1st trimester,
increased in 2nd & 3rd tri(tripled); increased chance 6. Self-monitoring of Blood glucose at least TID
of ketoacidosis  Desired values:
 Regular & NPH(Isophane) insulin; only regular  before meal: 95 mg/d
insulin  1 hr. after meal: <140 mg/d
 IV during labor to prevent ketoacidosis  2 hrs. after meal <120 mg/dl
 Humulin (DOC) - least allergenic 7. Fetal Well-being Monitor
 Split-dose therapy: regular & intermediate combi;  Alpha-fetoprotein level at 15-17 wks.
2/3 daily dose before breakfast at 2:1 ratio  Ultrasound at 18-20 weeks and monthly to
(intermediate to regular);1/3 30 mins before dinner rule out deformities, hydramnios,
(1:1)  NST starting at 34 wks. (if abnormal, CST,
BPP)
8. Prevention of infection, stress, which leads to  Daily kick counts from wk. 28(N=10/hr.);
hyperglycemia, which increases the need for insulin report if less
 Encourage assessment of fetal well-being: ultrasound,  L/S Ratio starting 34-36 weeks (N=2.5-3:1)
amniocentesis (L/S ratio), phosphatidyl glycerol (fetal  Creatinine clearance to monitor perfusion
lung maturity), NST, CST, BPP
 Early labor induction or CS in the presence of fetal
distress (36-37 weeks)
Care During Labor and Delivery Newborn Care
Plan to deliver birth weight 36-40 wks when fetus is mature 1. Keep warm.
enough but not too large to cause CPD 2. Observe respiration since hydramnios inflates
 L/S ratio should be 2.5-3.5:1 stomach and may interfere with lung expansion
 Vaginal delivery is preferred 3. Observe for hypoglycemia (shrill cry, tetany,
tremors), BF or give glucose water

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #2
 Regular insulin on Labor Day because need for insulin 4. Observe for hypocalcemia (tetany, tremors), give
drops immediately pp and may not need insulin in the 1st Calcium gluconate
24 hrs. post-partum 5. Observe for congenital anomalies: esophageal
 Monitor glucose levels. atresia, NTD

Contraception
1. No IUD- high incidence of PID
2. No COCs- P interferes with insulin and Estrogen raises lipid, cholesterol levels & affect blood coagulation
3. Norplant or progestin only pills(minipills) may be used safely by diabetic women

CHECK FOR UNDERSTANDING

The instructor will prepare 10 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.

1. A 36-year-old female is currently 18 weeks pregnant. You’re collecting the patient’s health history. She has the
following health history: gravida 5, para 4, BMI 28, hypertension, depression, and family history of Type 2 diabetes. Select
below all the risk factors in this scenario that increases this patient’s risk for developing gestational diabetes?
1. 34-years-old
2. 16 weeks pregnant
3. Gravida 5, para 4
4. BMI 28
5. Hypertension
6. Depression
7. Family history of Type 2 diabetes

A. 1,2,3 and 4
B. 1,3,4 and 5
C. 1,2,3 and 6
D. 1,3,4 and 6

2. A pregnant client is currently diagnosed with Gestational Diabetes at 30 weeks ask you when do most pregnant women
develop gestational diabetes?
A. usually during the 1-3 month of pregnancy
B. usually during the 2-3 month of pregnancy
C. usually during the 1-2 trimester of pregnancy
D. usually during the 2-3 trimester of pregnancy

3. You are having your duty in the out-patient department and you are providing an educational class for pregnant
women about gestational diabetes. You discuss the role of insulin in the body. Select all the CORRECT statements about
the roleand function of insulin:
A. “Insulin is a type of cell that provides glucose to the body from the blood.”
B. “Insulin is a hormone secreted by the beta cells of the pancreas.”
C. “Insulin does influences cells by causing them to uptake glucose from the blood.”
D. “Insulin is a protein that helps carry glucose into the cell for energy.”

4. Michelle, a 32-year-old female is diagnosed with gestational diabetes. As the nurse you know that what test below is
used to diagnose a patient with this condition?
A. 1 hour glucose tolerance test
B. 24-hour urine collection

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #2
C. Hemoglobin A1C
D. 3-hour glucose tolerance test

5. Erina, a 25-year-old pregnant female is diagnosed with gestational diabetes at 28 weeks gestation. You’re educating
Tara Jing about her condition. Which statement by the patient demonstrates they understood your teaching about
gestational diabetes?
A. “Once I deliver the baby, it will go away, and I will not need any further testing.”
B. “It is important I try to get my fasting blood glucose around 70-95 mg/dL and <140 mg/dL 1 hour after meals.”
C. “There are no risks or complications related to gestational diabetes other than hyperglycemia.”
D. “I’m at risk for delivering a baby that is too small for its gestational age due to this condition.”

6. The following are true regarding contraception in Diabetes Mellitus, EXCEPT:

A. Diabetic Women can use Intrauterine Device
B. Clients can use COC type of oral contraceptives
C. Norplant or progestin only pills(minipills) may be used safely by diabetic women
D. Diabetic Women cannot use Intrauterine Device

7. Glaiza, a 36 week pregnant woman and has gestational diabetes. As a part of her prenatal check-up, her doctor
requested to check her blood glucose level. Which of the following lab results is below normal?
A. Blood glucose 55 mg/dL
B. Blood glucose 82 mg/dL
C. Blood glucose 148 mg/dL
D. Blood glucose 325 mg/dL

8. A client with gestational diabetes and is currently 34 weeks pregnant came to the hospital for her prenatal check-up.
Which assessment findings below should you immediately report to the physician?
129 mg/dL
B. Blood pressure 190/102
C. Proteinuria
D. Linea nigra

9. Kris a 35 week pregnant woman has gestational diabetes and uncontrolled hyperglycemia. Her current blood glucose is
290 mg/dL. You administer insulin per physician’s order and recheck the blood glucose level per protocol. It is now 135
mg/dL. Which statement by the patient requires you to notify the physician?
A. “It burns when I urinate.”
B. “My back is hurting.”
C. “I feel tired.”
D. “I feel the baby kick about 10 times an hour.”
10. Jenny, a mother with gestational diabetes gave birth to a baby at 37 weeks gestation. As the nurse you know at birth
that the newborn is at risk for. SELECT ALL THAT APPLY
A. Hyperglycemia
B. Hypoglycemia
C. Respiratory distress
D. Jaundice
E. Hyperthermia

C. LESSON WRAP-UP

AL Activity: Minute Paper

Instruction:
1. Reserve a few minutes at the end of class session. Leave enough time to ask the questions, to allow students to
respond, and to collect their responses.
2. Pass out slips of paper on index cards for students to write on. You may also ask students to bring out and write on a
half sheet of paper instead.
3. Collect the responses as or before students leave. One way is to station yourself at the door and collecting “minute
papers” as student file out.
4. Respond to students’ feedback during the next class meeting or as soon as possible.

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 Care of Mother and Child at Risk or with
Problems (Acute and Chronic)

Module #2

1) What was the most useful or the most meaningful thing you have learned this session?

2) What question(s) do you have as we end this session?

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