Type 1 Diabetes Research Paper
For the purpose of this essay I will explore the aspects of Type I diabetes mellitus and the effect it has upon a woman and her midwife during the antenatal period. The question I intend to explore and answer is:
“What is the role of the midwife in the management of the woman whose pregnancy is complicated by Type I diabetes?”
The rationale for concentrating on this question is to address issues and concerns raised during a recent placement in an antenatal clinical setting. I intend to explore the true role of the midwife caring for a woman with Type I diabetes during the antenatal period and the role midwives play as part of the multidisciplinary team providing the care.
The World Health Organisation (2006) defines diabetes …show more content…
as a chronic disease that occurs when the pancreas fails to produce sufficient insulin or when the body is unable to effectively use the insulin it produces. This is due to an autoimmune destruction of the insulin-yielding ß cells in the islets of Langherhans which in turn inhibits insulin production by the pancreas. This means glycolytic enzymes are inhibited and gluconeogenetic enzymes are activated, resulting in the liberation of additional glucose into the bloodstream. It is characterized by increasing levels of glucose in the blood (hyperglcaemic) and excretion of glucose in the urine (glycosuria) resulting from defects of insulin secretion, or insulin action, or both.
Blood glucose is regulated by hormones produced in the Islets of Langerhans in the pancreas. As carbohydrates are ingested glucose is absorbed through the intestine and into the bloodstream. In response to this increase in blood sugar the β cells on the pancreas produce insulin. Insulin is produced at low levels throughout the twenty four hour period; however increased blood sugar causes production to dramatically increase. Insulin is then transported via the blood to receptor sites on cells. This facilitates the glucose to be absorbed by the cells where it can be utilized for energy. In response to low blood glucose the alpha cells of the pancreas produce Glucagon. Glucagon is then transported to the liver where it stimulates the release of stored glucose into the blood stream so raising blood sugar levels. The endocrine hormones insulin and glucagons work together to regulate blood sugar in the body. Normal blood sugar levels are between 4 and 6mmol/l. This figure does not normally exceed 6.6mmol/l in pregnancy.
The classic signs and symptoms of diabetes are excessive thirst (polydipsia), excessive urinary excretion (polyuria) and unexplained weight loss (Lloyd 2003). Lloyd also states that the long term effect of diabetes mellitus are reflected in the development of macrovascular and microvascular disease producing coronary heart disease, peripheral arterial disease, kidney disease (diabetic nephropathy), loss of vision (diabetic retinopathy) and nerve damage (diabetic neuropathy). Pregnancy with additional fetal requirements places large demands on maternal metabolism. There is progressive insulin resistance, which disappears immediately after delivery of the baby. Normally the β cells increase the amount of insulin they release in the presence of insulin resistance but glucose metabolism in diabetic pregnant women becomes unstable and more insulin will be needed to achieve metabolic control (Stables 2005). The diagnosis of diabetes is by the glucose tolerance test, which challenges the body’s response to a glucose load. The World Health Organisation (2006) suggests that Type 1 diabetes (which has been previously known as insulin-dependent or childhood-onset) is characterised by a lack of insulin production and that, without daily administration of insulin, Type 1 diabetes is rapidly fatal.
Diabetes mellitus is classified into three categories, table 1.
Table 1
For the purpose of this essay I intent to explore issues relating to the midwifery management of the woman whose pregnancy and birth is complicated by type I diabetes. I also aim to consider how the care provided affects the woman, her baby and her family physically, socially and psychologically.
For this assignment, relevant information and evidence was gathered from a range of sources.
Databases such as: Academic Search Premier, CINAHL, Cochrane Library and PubMed were identified as appropriate to perform a literature search on the chosen topic. Such databases are valuable tools, providing evidence based research on multidisciplinary health professional issues. For this assignment key words and phrases selected included: ‘type I diabetes’, ‘diabetes mellitus’, ‘diagnosis of type I diabetes’, ‘antenatal care’, ‘midwife and diabetes’ and ‘management of diabetes’. Information was also gathered from the exploration of: national guidelines and publications (e.g. CEMACH, NICE and NSF), relevant textbooks, reputable consumer websites (e.g. Diabetes UK) and indicative resources suggested by the student handbook.
Diabetes is the most common medical complication of pregnancy in the United Kingdom, with an incidence of around 0.4% (Stables 2005). In early pregnancy, where there has been poor glycaemic control, risks include fetal malformation and miscarriage (Confidential Enquiry into Maternal and Child Health - CEMACH 2006). As pregnancy progresses risks include Macrosomia (large baby with growth above the 90th centile), premature birth, stillbirth, infection, fetal distress, neonatal respiratory distress syndrome, neonatal hypoglycaemia and ketoacidosis (Stables, 2005). The mother also carries a greater percentage of an increased risk of instrumental/caesarean delivery, hypoglycaemia, pre-eclampsia, post-partum haemorrhage and uterine rupture (Bewley, 2004). This long list of medical risks faces professionals with the conflict between the desire for a normal vaginal delivery and the risk of poor outcome for the fetus (Mitchell, 2000).
For Diabetes sufferers, perinatal mortality rates are four times higher and congenital abnormality rates up to ten times higher (CEMACH 2006). The National Service Framework for Diabetes Standards (DoH 2001) also recognises the risks of diabetes in pregnancy and the high incidence of adverse outcome but suggests that, if the woman is empowered and involved in her own care, medicalisation need not be frightening or implicate loss of control. Mitchell (2000) suggests that, despite the prevalence of type 1 diabetes, midwives often report a lack of confidence in caring for these women.
Normal pregnancy has been characterized as a ‘diabetogenic state’ capable of causing diabetes because of the progressive increase in postprandial glucose and insulin response in late gestation (Catalano 2003). Guidelines and protocols exist for care provision for the diabetic woman and if these are adhered to in an effort to minimise risk to mother and baby, other aspects of the woman’s wellbeing may be ignored (Gould 2002). Anxiety and uncertainty play a significant part in the high risk pregnancy and the midwife plays an important role in raising the profile of normality in an otherwise abnormal situation. Through continuity and support, even in the high risk pregnancy, the midwife can facilitate some level of normality (Lindsay 2006).
Type I and Type II diabetes mellitus are complicated by the physiological changes which take place in glucose metabolism during pregnancy. In pregnant diabetic women, insulin requirements will obviously be greatly increased to cope with the relative fasting hypoglycaemia, and up to four times the usual amount of insulin will be required (Bewley 2004). Good diabetic control before, at the time of conception, as well as throughout the antenatal period greatly improves the outcome of the pregnancy. It is important therefore that that a good metabolic control is established before pregnancy. Women should ideally have access to a pregnancy counselling service and ideally meet a diabetic specialist midwife before becoming pregnant (Jardine-Brown et al 1996). Women and their partners should ideally be seen in a combined antenatal clinic by a multidisciplinary team. The team should include a physician, an obstetrician with specialist interests in diabetes in pregnancy, a specialist diabetic nurse, a specialist midwife and dietician. The woman should be seen as often as is required to maintain a good diabetic control; this normally entails fortnightly visits until twenty eight weeks gestation and then weekly until term. A dating scan should also be performed by 13 weeks gestation and blood glucose reviews and monitoring should be undertaken, along with retinal and renal function assessments (CEMACH 2006).
The diabetes team is a valuable resource to anyone providing care for women with type 1 diabetes in pregnancy. The Diabetes Specialist Midwife is available to train colleagues and provide information they also play a crucial role in antenatal care of these women, as well as providing continuity within the antenatal clinic from a midwifery perspective. The diabetes specialist midwife or nurse in particular can prove extremely useful in teaching women injection techniques for their insulin and adjustment of the dosages.
Diabetes UK (2006) recommends extra daily Folic Acid supplementation, ideally before conception and up to 12 weeks gestation to help prevent neural tube defects. The dosage recommended is 5mg for pregnant women with diabetes, as opposed to 0.4mg for non-diabetic women, and this dosage is only available on prescription. The midwife should act as the woman’s advocate in obtaining this prescription, using the evidence available.
The Department of Health (2001) published the Diabetes National Service Framework which set out a series of national standards for the management of diabetic pregnancy to be achieved by the NHS over a 10 year period.
The main aim of this framework is to “achieve a good outcome and experience of pregnancy and childbirth for women with pre-existing diabetes”. Mitchell (2000) explains that the main aim of antenatal care is to help the woman to maintain good diabetic control to contribute to the reduction of complications for the mother and fetus. The midwife’s role is to support and educate to empower the woman to take the initiative to achieve a good level of control. The existence of the medical condition must be recognised and acted upon accordingly, but the midwife can still provide a framework of continuity and normality, based on trust and understanding, within which the woman can retain control (Lindsay 2006). Aspects such as antenatal education, information on local support groups and preparation for breastfeeding should be addressed, giving the woman increased confidence both in her and in her abilities as a mother, joint decision making facilitate empowerment and control whilst still ensuring safety, a vital part of midwifery care (Page
2000).
Confidential Enquiry into Maternal and Child Health (CEMACH) (2006) states that good blood glucose control before and during pregnancy offers the best chance of decreasing the risks and suggests an HbA1c of less than 7%. HbA1c can help assess diabetic control and is an average measurement of blood glucose levels, and control, during the preceding three months. HbA1c has been found to increase in diabetes especially when the blood glucose control is poor (Bewley 2006). Levels of 10% or lower are considered a sign of good control. Levels of HbA1c correlate with development of fetal anomalies with women, with lowest levels having the least risk to the fetus (Tucker Blackburn 2003). Midwives also have an essential role in supporting the woman through early pregnancy when nausea and vomiting may be an issue, in which case blood sugar levels are always far more difficult to control.
Berg & Honkasalo (2000) describe some of the psychological effects of Type 1 diabetes in pregnant women. Some of the women described feeling that they had lost control as they were controlled by their blood glucose levels by a moral commitment for the sake of their unborn child. They felt they had little or no time to enjoy the pregnancy and acquired an acute awareness of being “at risk”, they constantly worried - feeling fear of malformations or of birthing an over-sized child. Some women felt they didn’t know their bodies anymore as the ordinary warning signs of hypo- and hyperglycaemia had transposed.
Rubin (2005) describes non-pregnant diabetes patients as “frustrated, fed up, overwhelmed or burned out by the demands of their disease”. Pregnant diabetic women are more likely to experience anxiety and depression than their non-diabetic counterparts so, these factors all taken into account, present a challenging time for the woman and her family. It is essential that the midwife has an appreciation of these factors in order to recognise any signs of anxiety or depression. Stress causes levels of cortisol to rise which makes insulin levels harder to control.
Lindsay (2006) states that midwives have a key role to play in maintaining a focus on normality in the middle of abnormal situations in very difficult times for the woman. This role calls for more than clinical skills in order to minimise and potential emotional damage caused by the “high-risk” label. It is essential to consider the holistic care of the woman and her family in order to truly offer the best care which is individualised to their needs but it is also imperative to appreciate that these women have the same needs and expectations of midwifery care as any other.
Women and midwives have reported feeling disempowered by “high-risk” pregnancies. It is sometimes felt that choices and decisions about the care are not the woman’s to make alone and she may be inclined to delegate responsibility to those she may see as “experts” although it is a crucial part of the midwife’s role to collaborate with the women and the other members of the team in implementation of the care to be given. Women should be actively involved in decisions about their care, for example plans for mode of delivery, in order to offer true informed choice. Other women may fail to accept the “high risk” label and become “uncooperative”, perhaps missing appointments, when they are often expected to comply. Not all midwives are comfortable in advocating for these women but it is essential to consider the individual’s behaviour and develop an understanding of how they may interpret the circumstances and explore their perception of the situation.
There may be social or economic factors influencing the woman and her family during these times. If there are many hospital appointments in different departments on different days for assessments, antenatal appointments, scans etc, this can result in significant stress, both financially and psychologically for the woman and her family. There may be issues in finding appropriate childcare for existing children in the family, fears of coming to hospital for many reasons, difficulties in actually getting to the hospital or being able to afford bus fares, for example. These should be taken into account as much as is achievable and measures should be taken to try and co-ordinate some of these appointments, if at all possible. Midwives require a warm, open manner and should demonstrate knowledge and skill in order to facilitate an open, honest relationship in which trust can develop between the women, family and midwife with the ability to express feelings and encourage self esteem, confidence and knowledge.
It is important that the midwife is familiar with the clinical details of diabetes in order to allow her to interpret the medical picture and explain the relevance and important of required actions to the woman and her family. However, as stated by Mitchell (2000), much of the research related to type 1 diabetes and pregnancy is published in specialised diabetic journals which are not always easily accessible.
Parent craft classes and antenatal education groups should also be promoted as for any other woman. Lindsay (2006) suggests that these particular groups of women miss out, as they are seen mostly in the hospital setting and not community. The midwife may also be able to recommend appropriate peer support groups in the local area to help to prevent isolation of the woman and her family. It is very important that the midwife works closely with the woman’s family, with her consent, in order to help them to provide vital support.
References
Berg M & Honkasalo, 2000, Pregnancy and diabetes – a hermeneutic phenomenological study of women’s experiences: Journal of Psychosomatic Obstetrics and Gynaecology, 21, p39-48.
Bewley C, 2004, 13th ed. Medical Disorders of Pregnancy: Henderson C & Macdonald S, eds. Mayes’ Midwifery: A Textbook for Midwives. Edinburgh: Balliere Tindall.
Catalano P, 2003, Maternal metabolic adaptation to pregnancy: Textbook of Diabetes and Pregnancy, Martin Dunitz, London
Confidential Enquiry Into Maternal and Child Health, 2006, Pregnancy in women with Type I and Type 2 Diabetes in 2002-2003 in England, Wales and Northern Ireland. London: CEMACH
Department of Health, 2001, National Service Framework for Diabetes: Standards. London: DOH.
Diabetes UK, 2006, Care Recommendations – Folic Acid Supplementation in Pregancy http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Folic_acid_supplementation_in_pregnancy/ - accessed 23/01/09.
Gould D, 2002, One-to-one midwifery – making it happen, British Journal of Midwifery. 10(1) 17-22.
Jardine-Brown C, Dawson A, Dodds R et al, 1996, Report of the pregnancy and neonatal care group, Diabetic Medicine, 13:p43-53
Jordan S, 2002, Diabetes Mellitus and Pregnancy: Pharmacology for Midwives, Palgrave, Hampshire
Lindsay P, 2006, Creating normality in a high-risk pregnancy, Practising Midwife. 9(1) p16-18.
Lloyd C, 2003, Common Medical Disorders Associated with Pregnancy: Myles Textbook for Midwives, chpt. 19, Churchill Livingstone, Edinburgh
Mitchell M, 2000, Improving maternity care for pregnant diabetics, British Journal of Midwifery, 8(9) p560-564.
Page L, 2000, Putting science and sensitivity into practice: Page L A ed. The New Midwifery: Science and Sensitivity in Practice. Edinburgh: Churchill Livingstone, 45-70.
Rubin R, 2005, Counselling and Psychotherapy in Diabetes Mellitus: Psychology in Diabetes Care – Second Edition, John Wiley & Sons Ltd, Chichester, 8
Stables D, 2005, Diabetes mellitus and other metabolic disorders in pregnancy: Physiology in Childbearing, chpt. 35, Elsevier, Edinburgh
Tucker Blackburn S, 2003, Maternal Fetal & Neonatal Physiology A Clinical Perspective, Elsevier Science, USA, p613
World Health Organisation, 2006, Diabetes – Fact sheet No 312, http://www.who.int/mediacentre/factsheets/fs312/en/ – accessed 22/01/2009
“What is the role of the midwife in the management of the woman whose pregnancy is complicated by Type I diabetes?”
The rationale for concentrating on this question is to address issues and concerns raised during a recent placement in an antenatal clinical setting. I intend to explore the true role of the midwife caring for a woman with Type I diabetes during the antenatal period and the role midwives play as part of the multidisciplinary team providing the care.
The World Health Organisation (2006) defines diabetes …show more content…
as a chronic disease that occurs when the pancreas fails to produce sufficient insulin or when the body is unable to effectively use the insulin it produces. This is due to an autoimmune destruction of the insulin-yielding ß cells in the islets of Langherhans which in turn inhibits insulin production by the pancreas. This means glycolytic enzymes are inhibited and gluconeogenetic enzymes are activated, resulting in the liberation of additional glucose into the bloodstream. It is characterized by increasing levels of glucose in the blood (hyperglcaemic) and excretion of glucose in the urine (glycosuria) resulting from defects of insulin secretion, or insulin action, or both.
Blood glucose is regulated by hormones produced in the Islets of Langerhans in the pancreas. As carbohydrates are ingested glucose is absorbed through the intestine and into the bloodstream. In response to this increase in blood sugar the β cells on the pancreas produce insulin. Insulin is produced at low levels throughout the twenty four hour period; however increased blood sugar causes production to dramatically increase. Insulin is then transported via the blood to receptor sites on cells. This facilitates the glucose to be absorbed by the cells where it can be utilized for energy. In response to low blood glucose the alpha cells of the pancreas produce Glucagon. Glucagon is then transported to the liver where it stimulates the release of stored glucose into the blood stream so raising blood sugar levels. The endocrine hormones insulin and glucagons work together to regulate blood sugar in the body. Normal blood sugar levels are between 4 and 6mmol/l. This figure does not normally exceed 6.6mmol/l in pregnancy.
The classic signs and symptoms of diabetes are excessive thirst (polydipsia), excessive urinary excretion (polyuria) and unexplained weight loss (Lloyd 2003). Lloyd also states that the long term effect of diabetes mellitus are reflected in the development of macrovascular and microvascular disease producing coronary heart disease, peripheral arterial disease, kidney disease (diabetic nephropathy), loss of vision (diabetic retinopathy) and nerve damage (diabetic neuropathy). Pregnancy with additional fetal requirements places large demands on maternal metabolism. There is progressive insulin resistance, which disappears immediately after delivery of the baby. Normally the β cells increase the amount of insulin they release in the presence of insulin resistance but glucose metabolism in diabetic pregnant women becomes unstable and more insulin will be needed to achieve metabolic control (Stables 2005). The diagnosis of diabetes is by the glucose tolerance test, which challenges the body’s response to a glucose load. The World Health Organisation (2006) suggests that Type 1 diabetes (which has been previously known as insulin-dependent or childhood-onset) is characterised by a lack of insulin production and that, without daily administration of insulin, Type 1 diabetes is rapidly fatal.
Diabetes mellitus is classified into three categories, table 1.
Table 1
For the purpose of this essay I intent to explore issues relating to the midwifery management of the woman whose pregnancy and birth is complicated by type I diabetes. I also aim to consider how the care provided affects the woman, her baby and her family physically, socially and psychologically.
For this assignment, relevant information and evidence was gathered from a range of sources.
Databases such as: Academic Search Premier, CINAHL, Cochrane Library and PubMed were identified as appropriate to perform a literature search on the chosen topic. Such databases are valuable tools, providing evidence based research on multidisciplinary health professional issues. For this assignment key words and phrases selected included: ‘type I diabetes’, ‘diabetes mellitus’, ‘diagnosis of type I diabetes’, ‘antenatal care’, ‘midwife and diabetes’ and ‘management of diabetes’. Information was also gathered from the exploration of: national guidelines and publications (e.g. CEMACH, NICE and NSF), relevant textbooks, reputable consumer websites (e.g. Diabetes UK) and indicative resources suggested by the student handbook.
Diabetes is the most common medical complication of pregnancy in the United Kingdom, with an incidence of around 0.4% (Stables 2005). In early pregnancy, where there has been poor glycaemic control, risks include fetal malformation and miscarriage (Confidential Enquiry into Maternal and Child Health - CEMACH 2006). As pregnancy progresses risks include Macrosomia (large baby with growth above the 90th centile), premature birth, stillbirth, infection, fetal distress, neonatal respiratory distress syndrome, neonatal hypoglycaemia and ketoacidosis (Stables, 2005). The mother also carries a greater percentage of an increased risk of instrumental/caesarean delivery, hypoglycaemia, pre-eclampsia, post-partum haemorrhage and uterine rupture (Bewley, 2004). This long list of medical risks faces professionals with the conflict between the desire for a normal vaginal delivery and the risk of poor outcome for the fetus (Mitchell, 2000).
For Diabetes sufferers, perinatal mortality rates are four times higher and congenital abnormality rates up to ten times higher (CEMACH 2006). The National Service Framework for Diabetes Standards (DoH 2001) also recognises the risks of diabetes in pregnancy and the high incidence of adverse outcome but suggests that, if the woman is empowered and involved in her own care, medicalisation need not be frightening or implicate loss of control. Mitchell (2000) suggests that, despite the prevalence of type 1 diabetes, midwives often report a lack of confidence in caring for these women.
Normal pregnancy has been characterized as a ‘diabetogenic state’ capable of causing diabetes because of the progressive increase in postprandial glucose and insulin response in late gestation (Catalano 2003). Guidelines and protocols exist for care provision for the diabetic woman and if these are adhered to in an effort to minimise risk to mother and baby, other aspects of the woman’s wellbeing may be ignored (Gould 2002). Anxiety and uncertainty play a significant part in the high risk pregnancy and the midwife plays an important role in raising the profile of normality in an otherwise abnormal situation. Through continuity and support, even in the high risk pregnancy, the midwife can facilitate some level of normality (Lindsay 2006).
Type I and Type II diabetes mellitus are complicated by the physiological changes which take place in glucose metabolism during pregnancy. In pregnant diabetic women, insulin requirements will obviously be greatly increased to cope with the relative fasting hypoglycaemia, and up to four times the usual amount of insulin will be required (Bewley 2004). Good diabetic control before, at the time of conception, as well as throughout the antenatal period greatly improves the outcome of the pregnancy. It is important therefore that that a good metabolic control is established before pregnancy. Women should ideally have access to a pregnancy counselling service and ideally meet a diabetic specialist midwife before becoming pregnant (Jardine-Brown et al 1996). Women and their partners should ideally be seen in a combined antenatal clinic by a multidisciplinary team. The team should include a physician, an obstetrician with specialist interests in diabetes in pregnancy, a specialist diabetic nurse, a specialist midwife and dietician. The woman should be seen as often as is required to maintain a good diabetic control; this normally entails fortnightly visits until twenty eight weeks gestation and then weekly until term. A dating scan should also be performed by 13 weeks gestation and blood glucose reviews and monitoring should be undertaken, along with retinal and renal function assessments (CEMACH 2006).
The diabetes team is a valuable resource to anyone providing care for women with type 1 diabetes in pregnancy. The Diabetes Specialist Midwife is available to train colleagues and provide information they also play a crucial role in antenatal care of these women, as well as providing continuity within the antenatal clinic from a midwifery perspective. The diabetes specialist midwife or nurse in particular can prove extremely useful in teaching women injection techniques for their insulin and adjustment of the dosages.
Diabetes UK (2006) recommends extra daily Folic Acid supplementation, ideally before conception and up to 12 weeks gestation to help prevent neural tube defects. The dosage recommended is 5mg for pregnant women with diabetes, as opposed to 0.4mg for non-diabetic women, and this dosage is only available on prescription. The midwife should act as the woman’s advocate in obtaining this prescription, using the evidence available.
The Department of Health (2001) published the Diabetes National Service Framework which set out a series of national standards for the management of diabetic pregnancy to be achieved by the NHS over a 10 year period.
The main aim of this framework is to “achieve a good outcome and experience of pregnancy and childbirth for women with pre-existing diabetes”. Mitchell (2000) explains that the main aim of antenatal care is to help the woman to maintain good diabetic control to contribute to the reduction of complications for the mother and fetus. The midwife’s role is to support and educate to empower the woman to take the initiative to achieve a good level of control. The existence of the medical condition must be recognised and acted upon accordingly, but the midwife can still provide a framework of continuity and normality, based on trust and understanding, within which the woman can retain control (Lindsay 2006). Aspects such as antenatal education, information on local support groups and preparation for breastfeeding should be addressed, giving the woman increased confidence both in her and in her abilities as a mother, joint decision making facilitate empowerment and control whilst still ensuring safety, a vital part of midwifery care (Page
2000).
Confidential Enquiry into Maternal and Child Health (CEMACH) (2006) states that good blood glucose control before and during pregnancy offers the best chance of decreasing the risks and suggests an HbA1c of less than 7%. HbA1c can help assess diabetic control and is an average measurement of blood glucose levels, and control, during the preceding three months. HbA1c has been found to increase in diabetes especially when the blood glucose control is poor (Bewley 2006). Levels of 10% or lower are considered a sign of good control. Levels of HbA1c correlate with development of fetal anomalies with women, with lowest levels having the least risk to the fetus (Tucker Blackburn 2003). Midwives also have an essential role in supporting the woman through early pregnancy when nausea and vomiting may be an issue, in which case blood sugar levels are always far more difficult to control.
Berg & Honkasalo (2000) describe some of the psychological effects of Type 1 diabetes in pregnant women. Some of the women described feeling that they had lost control as they were controlled by their blood glucose levels by a moral commitment for the sake of their unborn child. They felt they had little or no time to enjoy the pregnancy and acquired an acute awareness of being “at risk”, they constantly worried - feeling fear of malformations or of birthing an over-sized child. Some women felt they didn’t know their bodies anymore as the ordinary warning signs of hypo- and hyperglycaemia had transposed.
Rubin (2005) describes non-pregnant diabetes patients as “frustrated, fed up, overwhelmed or burned out by the demands of their disease”. Pregnant diabetic women are more likely to experience anxiety and depression than their non-diabetic counterparts so, these factors all taken into account, present a challenging time for the woman and her family. It is essential that the midwife has an appreciation of these factors in order to recognise any signs of anxiety or depression. Stress causes levels of cortisol to rise which makes insulin levels harder to control.
Lindsay (2006) states that midwives have a key role to play in maintaining a focus on normality in the middle of abnormal situations in very difficult times for the woman. This role calls for more than clinical skills in order to minimise and potential emotional damage caused by the “high-risk” label. It is essential to consider the holistic care of the woman and her family in order to truly offer the best care which is individualised to their needs but it is also imperative to appreciate that these women have the same needs and expectations of midwifery care as any other.
Women and midwives have reported feeling disempowered by “high-risk” pregnancies. It is sometimes felt that choices and decisions about the care are not the woman’s to make alone and she may be inclined to delegate responsibility to those she may see as “experts” although it is a crucial part of the midwife’s role to collaborate with the women and the other members of the team in implementation of the care to be given. Women should be actively involved in decisions about their care, for example plans for mode of delivery, in order to offer true informed choice. Other women may fail to accept the “high risk” label and become “uncooperative”, perhaps missing appointments, when they are often expected to comply. Not all midwives are comfortable in advocating for these women but it is essential to consider the individual’s behaviour and develop an understanding of how they may interpret the circumstances and explore their perception of the situation.
There may be social or economic factors influencing the woman and her family during these times. If there are many hospital appointments in different departments on different days for assessments, antenatal appointments, scans etc, this can result in significant stress, both financially and psychologically for the woman and her family. There may be issues in finding appropriate childcare for existing children in the family, fears of coming to hospital for many reasons, difficulties in actually getting to the hospital or being able to afford bus fares, for example. These should be taken into account as much as is achievable and measures should be taken to try and co-ordinate some of these appointments, if at all possible. Midwives require a warm, open manner and should demonstrate knowledge and skill in order to facilitate an open, honest relationship in which trust can develop between the women, family and midwife with the ability to express feelings and encourage self esteem, confidence and knowledge.
It is important that the midwife is familiar with the clinical details of diabetes in order to allow her to interpret the medical picture and explain the relevance and important of required actions to the woman and her family. However, as stated by Mitchell (2000), much of the research related to type 1 diabetes and pregnancy is published in specialised diabetic journals which are not always easily accessible.
Parent craft classes and antenatal education groups should also be promoted as for any other woman. Lindsay (2006) suggests that these particular groups of women miss out, as they are seen mostly in the hospital setting and not community. The midwife may also be able to recommend appropriate peer support groups in the local area to help to prevent isolation of the woman and her family. It is very important that the midwife works closely with the woman’s family, with her consent, in order to help them to provide vital support.
References
Berg M & Honkasalo, 2000, Pregnancy and diabetes – a hermeneutic phenomenological study of women’s experiences: Journal of Psychosomatic Obstetrics and Gynaecology, 21, p39-48.
Bewley C, 2004, 13th ed. Medical Disorders of Pregnancy: Henderson C & Macdonald S, eds. Mayes’ Midwifery: A Textbook for Midwives. Edinburgh: Balliere Tindall.
Catalano P, 2003, Maternal metabolic adaptation to pregnancy: Textbook of Diabetes and Pregnancy, Martin Dunitz, London
Confidential Enquiry Into Maternal and Child Health, 2006, Pregnancy in women with Type I and Type 2 Diabetes in 2002-2003 in England, Wales and Northern Ireland. London: CEMACH
Department of Health, 2001, National Service Framework for Diabetes: Standards. London: DOH.
Diabetes UK, 2006, Care Recommendations – Folic Acid Supplementation in Pregancy http://www.diabetes.org.uk/About_us/Our_Views/Care_recommendations/Folic_acid_supplementation_in_pregnancy/ - accessed 23/01/09.
Gould D, 2002, One-to-one midwifery – making it happen, British Journal of Midwifery. 10(1) 17-22.
Jardine-Brown C, Dawson A, Dodds R et al, 1996, Report of the pregnancy and neonatal care group, Diabetic Medicine, 13:p43-53
Jordan S, 2002, Diabetes Mellitus and Pregnancy: Pharmacology for Midwives, Palgrave, Hampshire
Lindsay P, 2006, Creating normality in a high-risk pregnancy, Practising Midwife. 9(1) p16-18.
Lloyd C, 2003, Common Medical Disorders Associated with Pregnancy: Myles Textbook for Midwives, chpt. 19, Churchill Livingstone, Edinburgh
Mitchell M, 2000, Improving maternity care for pregnant diabetics, British Journal of Midwifery, 8(9) p560-564.
Page L, 2000, Putting science and sensitivity into practice: Page L A ed. The New Midwifery: Science and Sensitivity in Practice. Edinburgh: Churchill Livingstone, 45-70.
Rubin R, 2005, Counselling and Psychotherapy in Diabetes Mellitus: Psychology in Diabetes Care – Second Edition, John Wiley & Sons Ltd, Chichester, 8
Stables D, 2005, Diabetes mellitus and other metabolic disorders in pregnancy: Physiology in Childbearing, chpt. 35, Elsevier, Edinburgh
Tucker Blackburn S, 2003, Maternal Fetal & Neonatal Physiology A Clinical Perspective, Elsevier Science, USA, p613
World Health Organisation, 2006, Diabetes – Fact sheet No 312, http://www.who.int/mediacentre/factsheets/fs312/en/ – accessed 22/01/2009