Gestational Diabetes Mellitus (GDM): Treatment (Nursing)

00:02 So, now, let's talk about what our goals are for management.

00:05 So what are we hoping to prevent? So when we talk about improving the outcomes, what are we actually doing? So, if we exercise and we diet and we provide medications, what are we going to get from that? Well, we can prevent fetal macrosomia, so we can prevent some of the birth injuries that happen because we prevent the cause which is a big baby.

00:27 We can also avoid ketosis, so that DKA that we talked about, those toxins floating around as the liver helps to ingest some of that extra glucose, we can avoid that.

00:37 We can also detect complications that we might experience.

00:41 So one of the things that we're going to be doing during that antepartum period is making sure that these complications aren't developing.

00:48 Specifically, we're talking about hypertension, we're talking about intrauterine growth restriction or a small baby which can happen, in addition to having a large baby, and fetal distress because if the baby's blood sugar is elevated or if we have issues with vascularity and that's compromised in some way, and we have IUGR or growth restriction, all of those things together can lead to fetal distress.

01:14 We want to avoid that, so that's what we're doing during the antepartum period.

01:18 So those are our goals for treatment. Now, let's talk about what we actually do.

01:23 So we mentioned diet and exercise already.

01:26 We'll break those down in just a second, and then we're also going to add to that the medication.

01:31 So we have a couple of types of medications, oral medication and also insulin.

01:36 So we'll look at those in just a minute.

01:38 Let's also talk a little bit more about how we determine fetal well-being.

01:43 Some of that's going to be things that we do as providers, but there are actually some things the client can do as well.

01:49 One of those things is called daily fetal movement counting or kick counts for short.

01:55 We begin this around 32 weeks.

01:58 Now you may be asking yourself, doesn't the baby move long before 32 weeks? Absolutely, they do. But at this point, the baby sort of got a pattern like they might be up all night or during the day, and it's easy to really figure out when the baby normally moves and also begin to count the number of movements.

02:16 We can also do an ultrasounds.

02:18 So this is something the provider would do and so we can do a couple of things.

02:23 We can look at the fluid.

02:24 Ahh, remember polyuria, exactly, and that produces excess fluids so we can measure that and that gives us some indication about how the baby's doing.

02:36 And we can also do a biophysical profile.

02:39 So the biophysical profile also includes the amniotic fluid index, but it looks at the baby, is the tone good? So is the baby moving around? Do they has respiratory effort so these are all things we can look at to make sure the baby is doing okay.

02:54 So if the baby is lying there like this or the tone is not very good or we have polyuria and we have then polyhydramnios, or we have low fluid, oliguria, and then we have low amniotic fluid index, then that would be an indication that things are not going well.

03:12 So this test is typically done twice a week, and depending on how the diabetes is managed, will give us some indication about the best time to start doing this test.

03:23 So if the client has been prescribed insulin as a way to manage their diabetes, typically we'll begin this testing around 32 or 34 weeks, because this is going to be your more severe cases of gestational diabetes.

03:36 If their diet controlled, however, that means it's a less serious case and so we can start the testing a little bit later, around 34 to 36 weeks.

03:46 So, twice a week, the client will come in, we'll do these test, and if the result is good, we have an indication that fetus is doing pretty well in there and we can continue with the pregnancy.

03:58 Now, some clinicians are going to manage diet-controlled gestational diabetes without doing some of these tests, but these are some of the recommendations, meaning, not mandates, but recommendations of how to manage that.

04:11 Now, let's look at nutritional considerations in more detail.

04:15 So what are our goals of changes in diet? We want to avoid ketosis, we want to achieve normal blood glucose levels, and we want to make sure that our nutritional compositions, so the carbohydrates and the proteins, are in good balance.

04:31 And we want to make sure that the weight gain is pretty normal, so that curve of gaining around 25 to 35 pounds for someone with a normal BMI would be our goal.

04:43 We don't want to lose too much weight, we don't want to gain too much weight.

04:47 So when we think about eating foods that create a low glycemic index, we want to avoid things that have a lot of sugar and things that are really heavy in carbohydrates, because if we can do that, then we can decrease the need for insulin in order to maintain euglycemia, or a normal glucose, okay.

05:07 Now, things that might affect how well we manage our glucose and can tell us that we're managing it well, is that we're not hungry all the time.

05:17 So, if we're eating and we're eating snacks all throughout the day, we won't have a period of being super hungry and eating, too much.

05:24 We'll find that our blood sugars are staying pretty stable and we don't have these dips like this.

05:29 We can also think about weight gain, so if we're doing well, we're going to keep our weight at a steady state, and that's what we're after.

05:38 Now, remember, we want to use these characteristics and these outcomes to really determine how many carbohydrates someone can eat.

05:47 So, typically, a minimum of 175 grams of carbohydrates is what we want, and that's going to be distributed throughout about 5 to 7 meals a day.

05:56 So, 5 to 7 meals is a lot, which doesn't mean that you eat 5 to 7 full meals, but that you space these very small meals out in order to maintain and even blood sugar.

06:06 We want to avoid the waves.

06:09 Now, let's talk about exercise, because, again, exercising can prevent, can delay, or reduce the need for insulin and that's what we want.

06:19 If we end up on insulin that lets you know that we have a more severe case and so therefore outcomes could be more severe as well.

06:27 So we use something called the FITT principle.

06:30 So this is a way we can make an exercise prescription for our clients to let them know what they need to do.

06:37 So F stands for frequency and typically we recommend about three times a week of some sort of exercise.

06:43 The intensity meaning it's moderate, meaning you can't really carry on a normal conversation while you're doing it.

06:48 You can talk, but maybe not like I'm doing right now.

06:52 We want to think about the time, so 30 to 60 minutes, most days, is what we're after.

06:58 And then, we want to think about the type, so we're going to mix a little bit of cardiovascular, cardio workout, with a little bit of resistance, so a little weight training in there to strength training.

07:08 So we don't want to do anything that's going to put the client at risk.

07:11 We're not going to ask them to go out and start lifting heavy weights, but we definitely want to get some resistance in because that really does a great job of helping to use up some of the glucose.

07:21 So those are our diet and exercise consideration.

07:24 Now, if diet and exercise doesn't work, then we might need to move on to medication.

07:30 So glyburide is an oral medication that has been recommended for pregnancy, so we can give that. We'll start usually with glyburide.

07:38 Now, remember, this is a gestational diabetic, not someone who's type 2 with a preexisting disease.

07:44 We can also use insulin if we try the oral and it doesn't work.

07:49 So when we use insulin therapy, we're going to use this to actually, hopefully, help maintain normal blood glucose.

07:57 So we've exhausted all our other efforts and now we're going to try the insulin.

08:01 Now when we use insulin, we really have to monitor the blood sugar, because the blood sugar fluctuations can be much more dramatic when we us insulin.

08:10 So this is going to be, this is going to require someone to check their blood sugar several times a day, usually four times, so we get a fasting and then a two hour postprandial after breakfast, after lunch and after dinner.

08:23 Sometimes, we'll need to order a fifth, right before someone goes to bed.

08:28 So we're going to check our glucose levels.

08:30 We're also going to monitor their meal choices, because what you eat can affect how much insulin you need at any particular time, okay.

08:40 Also, exercise. So see how you don't get out of exercising or eating well, even if you take medication, it's a really important way that we can really manage our glucose.

08:50 We want to decrease the amount of insulin that we need and we can do that by making some different choices in our day, okay? So let's talk about what happens at the intrapartum period.

09:02 So, remember, this is when the client reports to the labor suite. So what are our goals? Well, our goals are going to avoid a caesarean birth.

09:11 So we don't want to have complications that lead to an unstable blood sugar, or anything like that, or a traumatic birth for the baby, and then we end up needing a caesarian birth in order to be safe.

09:21 We don't want to have a shoulder dystocia, so that's when the head delivers and the shoulder get stuck and caught on the symphysis pubis, likely because of macrosomia or fat distribution.

09:31 We also want to avoid any of the trauma that could happen as a result of the fetal macrosomia.

09:37 We also remember at postpartum, blood sugar drops on the baby, if we can keep the client euglycemic throughout the labor, then we'll be less likely to have a situation where we have a baby that drops their blood sugar right after birth.

09:52 So these are going to be our goals.

09:54 So during the intrapartum period in terms of management, checking the pregnant person's blood sugar fairly frequently is going to be part of the practice.

10:03 So depending on the protocol and the severity of their gestational diabetes, checking the blood sugar every 1 to 2 hours is going to be the recommendations.

10:12 Often, clients who had gestational diabetes will need more support for maintaining their blood sugar during the labor period.

10:19 They may be on an insulin drip or we may be able to use a sliding scale, but we have to make sure that we maintain euglycemia as much as possible during the laboring period.

10:31 Now a couple of things I want to remind you of that we talked about in other lectures in terms of preterm labor management.

10:38 So remember that one of the things that we give when we are concerned about fetal lung maturity are corticosteroids.

10:47 Now corticosteroids, steroids, steroids lead to increase blood sugar.

10:55 They do that anyway, so if you have a client who's also experiencing a preterm birth, then if, if, if, which is not typical, a corticosteroid is given, we're going to absolutely have to manage that blood sugar because it's naturally going to go up and then we've got someone who is insulin resistant and so it's going to make it even worse, so we have to be really, really careful in those periods.

11:19 So, again, our goal during the intrapartum period is to keep that blood sugar at a steady state.