Gestational diabetes mellitus (GDM) is a silent disease defined as any degree of glucose intolerance with onset, or first recognition, during pregnancy and affects approximately 4% of all pregnancies (Moore, 2010). GDM may increase the risk of developing type 2 diabetes mellitus (T2DM) and also recurrent GDM in future pregnancies. Children born to mothers with GDM have greater risks of obesity, impaired glucose tolerance and diabetes mellitus. These pregnancies are at risk of fetal complications such as macrosomia and traumatic births such as shoulder dystocia (Moore, 2010; Kim, 2009).
A literature search was undertaken using Medline, CINAHL, NHS Evidence and PubMed. Knowledge of women’s experiences may enable midwives to empower them to adopt better lifestyles, preventing further complications. Blood sugar self-monitoring, and the midwife’s role in this, will be considered.
Current literature suggests there is a lack of relevant information and regular updates for health professionals on the management of GDM (Moore, 2010). Some clinicians recommend that women monitor blood glucose one hour after the start of the meal and others say one hour after the end of the meal. This causes major confusion for women and healthcare providers. Women receive little information and end up being cared for by too many different specialists.
Hanna et al (2008) surveyed members of the Association of British Clinical Diabetologists, asking them to describe how patients were screened for GDM, the diagnostic criteria, subsequent management and their clinical targets. Their study confirmed that there is a wide variation in policies and practice and they recommend an urgent need for guideline development (Hanna et al, 2008).
Midwives are mainly guided by their trust’s protocol, as well as their initiative, in their care of women with GDM, which can be challenging, especially with screening and management.
Random blood glucose (RBG) testing between 24 and 28 weeks is recommended, for screening purposes, for women with a body mass index (BMI) of more than 30 or a family history of diabetes and previous GDM.
The 75g oral glucose tolerance test (OGTT) is the ideal way of diagnosing and is currently the gold standard method in the UK (NICE, 2008). However, controversy continues in the screening, diagnosing and management of women with GDM. Health professionals treat GDM and antenatal care as separate entities, which frustrates women as they end up with too many appointments with very little information and lack of understanding of their condition.
Screening for postpartum diabetes is recommended for women with a history of GDM and is emphasised, particularly at the six-week postpartum visit, because abnormal glucose levels during this period are likely to indicate pre-conception glucose intolerance (NICE, 2008). However, the primary debate is whether screening should consist of postpartum fasting, glucose only or whether to conduct an OGTT. Regular advice updates for staff working with GDM clients is urgently needed in order for them to assist women with coping strategies and to better manage the condition.
Women’s views As qualitative data is often personal, Hjelm et al (2008) made use of participants’ quotes to demonstrate their involvement and personal views on the care they received. They conclude that: ‘Respondents expressed satisfaction with the present healthcare model, but emphasised the importance of being given adequate, non-alarming information about GDM’ (Hjelm et al, 2008: 178).
Women like to be involved in their healthcare decisions and management (Witkop et al, 2009; Hjelm et al, 2008; Harrison et al, 2003), thus some women could view blood sugar self-testing as a positive thing. However, it can have a negative impact on others, especially if they are not well-educated on how to test. Managing GDM is challenging and quite demanding for women, so support is needed throughout pregnancy.
Witkop et al’s 2009 study comparing active with expectant delivery management in women with GDM reported that women are satisfied with being involved in decision-making, but they recommend further studies in order to gain sufficient evidence to inform clinical practice. NICE is committed to producing guidance that involves the patients and carers and has produced a document,
Patient and public involvement policy, to reflect this (NICE, 2010).
The midwife’s role The midwife’s role is paramount in the care of women with GDM. As Rees (2003) states: ‘Women want choice and control and it is the midwife’s job to empower them.’ Midwives screen, inform and refer women with GDM to different practitioners. However, not every midwife knows how to manage the disease effectively, and this can bring about negative reactions and feelings from the women. One person’s assumptions and understanding is different from another’s, and an individual and holistic response to these differences should always be addressed. Appropriate knowledge and accountability should be demonstrated by the midwife, which means further training and updates where needed.
The controversy is ongoing, therefore more studies are recommended. These should include women’s satisfaction with their care and a midwife’s experience of managing GDM. This research may bridge gaps and educate midwives to maintain consistency and lead to better outcomes and experiences for women.
RCM CommunitiesDo you feel confident in your understanding of how to advise women in managing GDM? Join the discussion at:
http://communities.rcm.org.uk
ReferencesHanna FWF, Peters JR, Harlow J, Jones PW. (2008) Gestational diabetes screening and glycogenic management: national survey on behalf of the Association of British Clinical Diabetologists.
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Harrison MJ, Kushner KE, Benzies K, Rempel G, Kimak C. (2003) Women’s satisfaction with their involvement in healthcare decisions during a high-risk pregnancy.
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Hjelm K, Berntorp K, Frid A, Åberg A, Apelqvist J. (2008) Beliefs about health and illness in women managed for gestational diabetes in two organisations.
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Moore LE, Clokey D, Rappaport VJ, Curet LB. (2010) Metformin compared with glyburide in gestational diabetes: a randomized controlled trial.
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NICE. (2010) Patient and public involvement policy. See:
http://www.nice.org.uk/getinvolved/patientandpublicinvolvement/patientandpublicinvolvementpolicy/patient_and_public_involvement_policy.jsp (accessed 16 June 2011).
NICE. (2008)
Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. See:
http://www.nice.org.uk/nicemedia/live/11946/41342/41342.pdf (accessed 16 June 2011).
Rees C. (Ed.). (2003)
Introduction to research for midwives (second edition). Books for Midwives: Edinburgh.
Witkop CT, Neale D, Wilson LM, Bass EB, Nicholson WK. (2009) Active compared with expectant delivery management in women with gestational diabetes: a systematic review.
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