Chapter I

● Objectives
● Introduction
Signs & Symptoms
Risk Factors
Complications
Chapter II
● Patient’s Profile
● History of Past and Present Illness
Past Health History
Present Health History
Lifestyle
Socio-economic Status
Familial History
● Physical Assessment
● Maslow’s Hierarchy of Needs
Physiologic Needs
Safety and Security
Love and Belongingness
Self-Esteem
Self-Actualization

Chapter III
● Anatomy and Physiology
● Pathophysiology

Chapter IV
● Diagnostic Examination ●
Management
Nursing Management
Pharmacological Management

Chapter V
● Nursing Care Plan (NCP)
● Drug Study
● Health Teachings
● Update
OBJECTIVES
 To acquire more knowledge regarding Normal Spontaneous Pregnancy, its definition,
stages, risk actors, signs and symptoms and complications.
 To know the profile information, to appraise the physical history of past and present
illness, and the Maslow's Hierarchy of needs of the client.
 To review Anatomy and Physiology of the affected system.
 To illustrate the Pathophysiology of Normal Spontaneous Delivery.
 To identify the ideal and actual Laboratory Tests and Diagnostic Examinations.
 To know the ideal and Actual Medical, Nursing and Pharmacological Management
and Treatment.
 To use the Nursing Process as the framework of care the pregnant client.
 To impact appropriate health teaching to the client and significant others.
 To update on the latest issues/ trends of treatment and management of Normal
Spontaneous Delivery.

INTRODUCTION

What is Gestational Diabetes Mellitus (NSD)?

Normal Spontaneous Delivery (NSD) is the delivery of the baby through the birth
canal without any surgery. Mother can decide to have a baby through drug-free method or
pain relief medications. NSD is the common form of delivery since it is lower risk and with a
speedy recovery.
The delivery of a full-term newborn refers to delivery at a gestational age of 37-42
weeks, as determined by the last menstrual period or via ultrasonographic dating and
evaluation. The Naegele’s rule is a commonly used formula to predict the due date based on
the date of the last menstrual period. This rule assumes a menstrual cycle of 28 days and mid-
cycle ovulation. Ultrasonographic dating can be more accurate, especially when it is
performed early in pregnancy and is used to corroborate or modify a due date based on the
last menstrual period.

Three Stages of NSD:

Stage I: Early labor and active labor: This stage starts when a regular contraction starts

leading to dilation (widening) of the cervix up to 10 cm. Contractions also lead to softening,
shortening, and thinning (effacement) of the cervix, allowing the baby to move into the birth
canal. It is the longest of all three stages. The substage of this stage includes:
Early labor: During this labor, the cervix opens and thins. The mother might feel mild
irregular contractions. As the cervix opens, the mother might notice a clear, pink, slightly
bloody discharge from the vagina, which is likely the mucus plug blocking the opening of the
cervix. The average length of this stage varies from hours to days for first-time mothers. To
promote comfort, the mother can perform these techniques:

 Go for a walk
 Listen to soothing music
 Take a warm shower or bath
 Try relaxation techniques
 Change positions
Active labor: During this stage, the cervix dilates from 6 to 10 cm. Contractions become
more powerful and come more frequently. Moreover, you might feel the following
symptoms:
 Leg cramps
 Nausea
 Increase pressure in the back
 The feeling of water break
Active labor lasts for four to eight hours or more. During this stage, the cervix dilates at
approximately 1 cm per hour. To promote comfort, the mother can perform these techniques:
 Go for a stroll
 Take a warm bath or shower
 Breathe in between the contractions
 Change positions
 Gently massage between the contractions
There’s the most painful phase called the transition phase because the cervix dilates to its
fullest at about 10 cm. The contractions are powerful and painful, which continue at intervals
of two to three minutes, each lasting for 60-90 seconds.
Stage II: Pushing and subsequent delivery of the baby: This stage starts once the cervix
dilates completely. The duration of this stage may be anywhere between a few minutes and
up to a few hours or more. The mother has to push with every contraction, which can lead
to fatigue. This stage is also characterized by the following:
 Intense pain around the vaginal opening as the child comes out
 The mother feels pressure and gets the feeling that she wants to pass motions
 The physician making episiotomy (a cut to widen the opening of the vagina)
  Continuous pushing by the mother to expel the baby out
 The baby’s head comes out first, then the shoulders, and then the butt
 Cutting the umbilical cord as a final step after the baby is completely out and has the
first cry
Stage III: Delivery of the placenta: After the child comes out, the final stage involves the
delivery of the placenta. It would take about 5-30 minutes for the doctor to take out the
placenta out through the vaginal canal. The mother will continue to have mild contractions
that will be close together and less painful. The physician might ask you to take medicines to
encourage uterine contractions and prevent bleeding. The physician may also check if the
placenta is intact and no fragments are remaining in the uterus, causing infection or bleeding.

SIGNS AND SYMPTOMS

 Strong, frequent contractions
 Bloody show
 Belly and lower back pain
 Water breaking
 Baby drops
 Cervix begins to dilate
 Cramps and increased back pain
 Loose-feeling joints
 Diarrhea
 Weight gain stops
 Fatigue and the nesting instinct

RISK FACTORS
 Failure to progress: This is when labor slows or stops and your cervix doesn't dilate.
Your healthcare provider may give you oxytocin to stimulate contractions and
progress labor.
 Irregular fetal heart rate: This is when your baby's heart rate slows down because
their head or umbilical cord is compressed.
 Hemorrhage: This is excessive or life-threatening bleeding during or after birth.
Sometimes a person doesn't bleed until several hours after delivery (postpartum
hemorrhage).
 Vaginal tears: These are tears in the tissue around your vagina and rectum that
happen during childbirth.
 Deep vein thrombosis: These are blood clots that develop in your legs or pelvis
shortly after delivery.
 Postpartum preeclampsia: This is excessively high blood pressure in a person who
has just given birth.
COMPLICATIONS
 Labor that does not progress. Sometimes contractions weaken, the cervix does not
dilate enough or in a timely manner, or the infant's descent in the birth canal does not
proceed smoothly. If labor is not progressing, a health care provider may give the
woman medications to increase contractions and speed up labor, or the woman may
need a cesarean delivery.
 Perineal tears. A woman's vagina and the surrounding tissues are likely to tear
during the delivery process. Sometimes these tears heal on their own. If a tear is more
serious or the woman has had an episiotomy (a surgical cut between the vagina and
anus), her provider will help repair the tear using stitches.
 Problems with the umbilical cord. The umbilical cord may get caught on an arm or leg
as the infant travels through the birth canal. Typically, a provider intervenes if the
cord becomes wrapped around the infant's neck, is compressed, or comes out before
the infant.
 Abnormal heart rate of the baby. Many times, an abnormal heart rate during labor
does not mean that there is a problem. A health care provider will likely ask the
woman to switch positions to help the infant get more blood flow. In certain instances,
such as when test results show a larger problem, delivery might have to happen right
away. In this situation, the woman is more likely to need an emergency cesarean
delivery, or the health care provider may need to do an episiotomy to widen the
vaginal opening for delivery.
 Water breaking early. Labor usually starts on its own within 24 hours of the
woman's water breaking. If not, and if the pregnancy is at or near term, the provider
will likely induce labor. If a pregnant woman's water breaks before 34 weeks of
pregnancy, the woman will be monitored in the hospital. Infection can become a
major concern if the woman's water breaks early and labor does not begin on its own.
 Perinatal asphyxia. This condition occurs when the fetus does not get enough
oxygen in the uterus or the infant does not get enough oxygen during labor or delivery
or just after birth.
 Shoulder dystocia. In this situation, the infant's head has come out of the vagina, but
one of the shoulders becomes stuck.5
 Excessive bleeding. If delivery results in tears to the uterus, or if the uterus does not
contract to deliver the placenta, heavy bleeding can result. Worldwide, such bleeding
is a leading cause of maternal death. NICHD has supported studies to investigate
the use of misoprostol to reduce bleeding, especially in resource-poor settings.
PATIENT’S PROFILE
Hospital : Ilocos Training and Regional Medical Center
Name : Mrs. Ovarian
Address : Canan (Gapan), La Paz, Abra
Birthdate : April 2, 1984
Birthplace : La Paz, Abra
Age : 39 y/o
Gender : Female
Civil Status : Married
Religion : Roman Catholic
Occupation : Housewife
Citizenship : Filipino
Chief Complaints : N/A
Date & Time of Admission : 02/02/2023 (8:28 AM)
Admission Diagnosis : G1P0 38 6/7 weeks AOG, Gestational Diabetes
Mellitus (GDM)
Final Diagnosis : G1P1 (1001) PU 38 6/7 weeks, Gestational Diabetes
Mellitus (GDM)
Date & Time of Discharged : March 16, 2023 @ 9:20am
Admitting Physician : Dr. Barbero
Attending Physician : Dr. Barbero
Operation done : Cesarean section surgery
Ward : OB Gyne
 HISTORY of PAST and PRESENT ILLNESSES

PAST HEALTH HISTORY

According to the patient, she had completed her immunizations such as the BCG,
DPT, OPV, anti-measles and Hepa B vaccines when she was a child. She stated that she
acquired the usual childhood illnesses such as cough and colds, fever and chickenpox but
managed with over the counter drugs. And she was not hospitalized at her young age.
Mrs. EC had her menarche at the age of 14 with a duration of 6-7 days which
consumed 3 pads a day.

PRESENT HEALTH HISTORY

According to Mrs. EC, it was her first pregnancy and during her 24th week prenatal
check-up, she told Dra. Barbero that she’s experiencing itching and irritation in her vagina
and a burning sensation while urinating. Dra. Barbero says that it was a UTI (Urinary Tract
Infection) which is common to pregnant women. So, Dra. Barbero prescribed her medications
as follows: Metronidazole 1 tab (250mg) B.I.D for 7 days and calcium 1 tab (500mg) in
morning. And on her 28th week prenatal check-up Dra. Barbero requested a glucose
screening test and the result was 130mg/dl indicative of GDM. On the 30th week AOG was
again advised for follow-up consultation and had her oral glucose tolerance test (OGTT) and
had prescribed with the following results of fasting blood sugar was 83.15mg/dl, 1st dose was
209.84mg/dl, and 2nd dose result was 203.49mg/dl and it confirms that she had gestational
diabetes mellitus (GDM). Dr. Barbero encouraged her to have diabetic diet, fetal kick
counting, continued intake of calcium 1 tab (500mg) in the morning, Iberet 1 tab (500mg)
bedtime, light exercises and blood glucose monitoring T.I.D. Mrs. EC continued her monthly
prenatal check-up until before her admission.

On March 13, 2023 @ around 10:00am, Mrs. EC felt severe abdominal pain. Hence,
consulted APH for further management at OPD at 11:10am with the same manifestation.
Mrs. EC decided to go for admission of cesarean section delivery and was immediately
admitted by OPD staff to Dr. Barbero with the initial vital signs of T: 36.6℃, PR: 69bpm,
RR: 24cpm, BP: 110/80mmHg, 02 Sat: 96%, with a P/S: 8/10. Seen and examined by Dr.
Barbero and ordered insulin injection and laboratory tests as follows: ultrasound and urine
analysis for further management and scheduled for emergency CS. The nurse on duty
administered insulin injection and inserted aseptically an IVF of PNSS 1L @ right
metacarpal vein. Operation started on March 13, 2023 @ 7:00pm and operation finished @
8:10pm.

On March 14, 2023, the client was transferred to the Private Room 2 for the
continuity of nursing care and management.

On March 16, 2023 @ 9:20am, Mrs. EC had been discharged. Dr. Barbero prescribed
her medications as follows: Metformin HCL 500mg 1tab 3x a day for 7 days,Mefenamic acid
500mg 2x a day for 7 days, Cloxacillin 500mg 3x a day, and Iberet-folic 500mg bedtime OD
for 7 days and also encouraged to continue follow the proper diet and exercise to prevent
occurrence of Type 2 diabetes later in life.

LIFESTYLE

According to the client, she loves to eat any kinds of fruits and vegetables, processed
foods, fish and meats. Mostly, she loves to eat fries and junk foods. And she also loves to
drink soft drinks (Coke). When she was young, she was very active when it came to sports.
She was a volleyball varsity in her highschool and college days. Every morning she prepares
breakfast for her family and does some household chores before going to work that serves as
her daily activities.
SOCIO-ECONOMIC STATUS

Mrs. EC and her husband are both working and that is their source of income. They
sustained their expenses through their monthly salaries. Mrs. EC works as an Office clerk
under
TESDA at Data Center Colleges of the Philippines (DCCP) and her husband is a debt
collector of ADTEMPCO Company at Bangued Branch.

FAMILIAL HISTORY

Mrs. EC stated that they had a history of hypertension on the maternal side and a
history of diabetes mellitus on paternal side. They do not have communicable and
degenerative diseases on both paternal and maternal sides.
In addition, she has no allergy from any drugs or foods.

PHYSICAL ASSESSMENT (03-23-2023) @ 1:00pm

GENERAL PHYSICAL ASSESSMENT

● With endomorph body built

● With poor hygiene and poor grooming in appearance
● Looks appropriate with her actual age
● Conscious and coherent
● On low salt low fat diet
Vital signs as follows:
T: 36.6℃
P: 69 bpm
R: 18 cpm
BP: 110/80 mmHg
02 Sat: 96%

MENTAL STATUS

● With fair eye to eye contact

● Able to follow instructions
● Oriented to date, time and place
● With appropriate speech noted
● With good attention span
● With good judgment and insight

SKIN (INSPECTION AND PALPATION)

● Skin pinched went back immediately

● With fair complexion noted
● Uniformity of skin color noted
 ●
Skin temperature with normal range 36.6℃
● No petechiae, no pallor, no jaundice noted
● No swelling, no tenderness, no lesions noted

HAIR (INSPECTION AND PALPATION)

● Short and thick, light brown in color, evenly distributed

● Scalp is clean, smooth and firm
● No brittleness, dryness and present of dandruff noted
● No infestations noted

HEAD and SKULL (INSPECTION AND PALPATION)

● Normocephalic
● No mass, tenderness and nodules noted
● No injury
● Proportionate to body size
● Normal range of motion

EARS (INSPECTION AND PALPATION)

● Ears are aligned to the outer canthus of the eyes

● Equal in size with same color to the body and face
● With foul-smelling, sticky, yellow discharge
● Difficulty in hearing
● Pinnae recoiled and went back immediately when pinched

FACE (INSPECTION AND PALPATION)

● No involuntary muscle movements on the face

● No mass, nodule and depression noted
● Symmetrical facial movement

EYES (INSPECTION and PALPATION)

● PERRLA (Pupils Equally Round and Reactive to Light Accommodation) symmetrical

and blackish in color
● With good visual acuity 20/20 vision
● Lids closed symmetrically
 ●
● No tearing, no conjunctivitis noted
● Irises were blackish in color
● With pale palpebral conjunctivae and whitish sclera noted
● With short straight eyelashes and evenly distributed
Eyebrows were evenly distributed

NOSE AND SINUSES (INSPECTION AND PALPATION)

● Nose had the same color to the face

● No mass, no lesions, no tenderness, no nasal flaring, no redness, no swelling, no
growths and no discharge noted
● With good smelling acuity
● Nasal structure is smooth and symmetric
● Mucosa was pinkish in color
● Frontal and maxillary sinuses are nontender to palpation
● Nasal septum was in normal position
● No crepitus is evident
● Could breathe normally at atmospheric room temperature

MOUTH AND OROPHARYNX ((INSPECTION)

● Lips were smooth and moist without lesions or swelling

● Pinkish buccal mucosa, soft and no lesion noted
● Gums pink in color and no bleeding
● Frenulum is midline
● Tongue was pinkish in color and in central position and freely movable, had raised
papillae
● With pinkish hard and soft palate
● Had the ability to purse lips
● No angular lesions, swelling, mouth ulcer, no inflammation of tonsils noted
● With good sense of taste
● No cracking and no lesions of the lips noted
● No gingivitis noted
● Throat is without exudate or lesions

NECK (INSPECTION AND PALPATION)

● Sternocleidomastoid and trapezius were equal in size

 ●
● Head centered without bulging masses
● No enlargement or tenderness is present
● With normal range of motion
● Had the same color to the face

CHEST, THORAX, HEART and LUNGS

(INSPECTION, PALPATION, PERCUSSION, AUSCULTATION)

● Chest has evenly colored skin tone

Normal vesicular breath sound
● No chest indrawing and retraction when breathing, no masses, no lesions, no rales,
and no adventitious sound noted
● With respiratory rate 18cpm
● No tenderness, pain or unusual sensation
● Sternum is positioned midline and straight

BREAST AND AXILLAE (INSPECTION AND PALPATION)

● No localized discoloration or hyperpigmentation, mass, tenderness, swelling, nodules,

discharges and no ulcerations noted
● Had symmetrically round dark brown nipples at the center position of the areolae
noted
● No retraction, dimpling, swelling or edema noted
● Areolae had no mass and lesions noted
● No rash and infection noted

UPPER EXTREMITIES (INSPECTION AND PALPATION)

● Arms are proportionate in color of the body

● Capillary refill went back within 2 seconds
● Nails were cleaned and properly trimmed
● With complete set of fingers noted
● With symmetrical hands and arms
● Skin is warm to touch bilaterally from fingertips to upper arms
● No clubbing of fingernails noted

ABDOMEN (INSPECTION, AUSCULTATION, PALPATION AND PERCUSSION)

● Umbilical is inverted
 ●
● Presence of scars noted
● Striae gravidarum noted
● With stitches at the lower part of the abdomen
● Linea nigra
● No visible veins

LOWER EXTREMITIES (INSPECTION AND PALPATION)

● Fair complexion noted

● Capillary refill went back within 2 seconds
● Toenails were clean and properly trimmed
● Limited range of motion
● With normal angle of nail beds noted
With complete set of toes noted
MASLOW’s HIERARCHY of NEEDS

Physiologic Needs
● Can breathe with an atmospheric room temperature.
● Maintained good rest and sleep.
● Recreational habit was watching TV.
● With adequate rest and sleep. ● Hygiene is well maintained.
● Irritated due to her condition.
● Instructed to take medication on time.
● Instructed low-salt low-fat diet..
● Sexually inactive due to her present condition.

Safety and Security

● She felt safe and secured because of the presence of her husband.
● Monitored vital signs.

Love and Belongingness

● She felt loved by her husband all the time. The support given by her family and
relatives.

Self-Esteem
She manifested low self-esteem due to her present condition and being worried for her
baby.

Self-Actualization
She aimed for healing so she can go back to work and provide for their daily expenses
and have time for her family.
 ●
ANATOMY AND PHYSIOLOGY

ENDOCRINE SYSTEM
 The main function of the endocrine system is to secrete hormones directly into the
bloodstream. Hormones are chemical substances that affect the activity of another part of the
body (target site). In essence, hormones serve as messengers, controlling and coordinating
activities throughout the body.

The Endocrine System is made up of several organs called glands. These glands,
located all over your body, create and secrete (release) hormones.

Hormones are chemicals that coordinate different functions in your body by carrying
messages through your blood to your organs, skin, muscles and other tissues. These signals
tell your body what to do and when to do it.
PANCREAS

The pancreas is responsible for producing glucagon and insulin. Both hormones help
regulate the concentration of glucose (sugar) in the blood. It is a gland in the digestive and
endocrine system. It is a soft, pink, triangular gland that extends across the abdomen from the
spleen to the duodenum. It has exocrine and endocrine functions. It's exocrine functions
include secretion of pancreatic enzymes into the gastrointestinal. tract through the pancreatic
duct. Its endocrine functions include secretion. of insulin, glucagon and somatostatin.

● Islets of Langerhans.

The Islets of Langerhans, also called pancreatic islets are little masses of
hormone-producing tissue that are scattered among the enzyme-producing acinar
tissue of the pancreas. The islet of Langerhans, the endocrine part of the pancreas, are
 collections of cells embedded in the pancreatic tissue. They contain the alpha cells
which secrete the glucagon, the beta cells which secrete insulin, and the delta cells
which secrete somatostatin.

● Islet cells
Islet cells act as fuel sensors, secreting insulin and glucagon appropriately
during fed and fasting states.

● Beta cells
High levels of glucose in the blood stimulate the release of insulin from the
beta cells of the islets.

● Alpha cells
Glucagon’s release by the alpha cells of the islets is stimulated by low blood
glucose levels.

● Hormones
Two important hormones produced by the islet cells are insulin and glucagon.

● Insulin
Insulin acts on just about all the body cells and increases their ability to
transport glucose across their plasma membranes; because insulin sweeps glucose out
of the blood, its effect is said to be hypoglycemic. The major action of the insulin is
to lower blood glucose by permitting entry of glucose into the cells of the liver,
muscle and other tissues. Insulin is the primary hormone that lowers the blood glucose
level. This level is being secreted by the beta cells of the pancreas.

In those cells, insulin:

- Transports and metabolizes glucose for energy.
- Stimulates storage of glucose in the liver and muscle (in glycogen).
- Signals the liver to stop the release of glucose.
-Enhances storage of dietary fat in adipose tissue.
- Accelerates transport of amino acids (derived from dietary protein into cells)

● Glucagon
Glucagon acts as an antagonist of insulin; that is, it helps to regulate blood
glucose levels but in a way opposite that of insulin; its action is basically
hyperglycemic and its primary target organ is the liver, which it stimulates to break
down stored glycogen into glucose and release the glucose into the blood. The effect
of glucagon (opposite to that of insulin)is chiefly to raise the blood glucose by
converting glycogen to glucose in the liver. It is secreted by the pancreas in response
to a decrease in the level of blood glucose.

The somatostatin exerts a hypoglycemic effect by interfering with the release

of growth hormone from the pituitary and glucagon from the pancreas, both of which
tend to raise blood glucose levels.
 ● Glucose Metabolism

After a meal, glucose is taken up from the portal venous blood by the liver and
converted into glycogen, which is stored in the hepatocytes. Subsequently, the
glycogen is converted back to glucose (glycogenolysis) and released as needed into
the bloodstream to maintain normal levels of blood glucose. This process however,
provides a limited amount of glucose. Additional glucose can be synthesized by the
liver through a process called gluconeogenesis, the liver uses amino acids from
protein breakdown or lactate produced by exercising muscles.

ADRENAL GLANDS

The adrenal gland is made up of two glands: the cortex and medulla. These glands
produce hormones in response to stress and regulate blood pressure, glucose metabolism, and
the body's salt and water balance.

Two distinct parts:

● The adrenal cortex

The outer part of the gland produces glucocorticoid hormones that are vital to
life, such as cortisol which helps regulate metabolism and helps your body respond to
stress and mineralocorticoids, such as aldosterone which helps control blood pressure
by adjusting water and salt levels in the bloodstream.

● The adrenal medulla

The inner part of the gland produces other hormones, such as adrenaline and
noradrenaline which helps the body react to stress.
 LIVER

The organ that plays a major role in the metabolism of glucose and the regulation of
blood glucose concentration is the liver.

The liver and kidneys work together to synthesize 1,25-dihydroxyvitamin D

(calcitriol), the active form of vitamin D, which helps maintain normal levels of calcium and
phosphorus in the blood. In the skin, a molecule made from cholesterol is converted to
vitamin D by exposure to ultraviolet rays from the sun. Vitamin D undergoes further
chemical changes, first in the liver and then in the kidneys, to become calcitriol. Calcitriol
acts on the intestine, kidneys, and bones to maintain normal levels of blood calcium and
phosphorus. The liver both stores and produces sugar.

The liver acts as the body’s glucose or fuel reservoir, and helps to keep your
circulating blood sugar levels and other body fuels steady and constant. The liver both stores
and manufactures glucose depending upon the body’s need. The need to store or release
glucose is primarily signaled by the hormones insulin and glucagon.

During a meal, the liver will store sugar, or glucose, as glycogen for a later time when
the body needs it. The high levels of insulin and suppressed levels of glucagon during a meal
promote the storage of glucose as glycogen. The liver makes sugar when you need it.

When eating, especially overnight or between meals, the body has to make its own
sugar. The liver supplies sugar or glucose by turning glycogen into glucose in a process
called glycogenolysis. The liver also can manufacture necessary sugar or glucose by
harvesting amino acids, waste products and fat byproducts. This process is called
gluconeogenesis.
 TISSUE

Adipose tissue is typically known as body fat. Adipose tissue can be found all around
the
body. It is located under the skin, between muscles, and even around the organs. Adipose
tissue
is also an important endocrine-related organ. It contains many other cells that produce
hormones as a response to signals from the rest of the body’s organs. Many other hormones
are also released from adipose tissue and are responsible for different functions such as:
● Angiotensin- which helps control blood pressure
● Aromatase- which is involved in sex hormone metabolism
● Adiponectin- which helps improve the body’s sensitivity to insulin and protect against
type 2 diabetes

Having too much or too little adipose tissue can lead to other health problems.
Typically, too much adipose tissue leads to obesity, which increases the risk for type 2
diabetes, high blood pressure and cholesterol, heart disease, and stroke. Too little adipose
tissue can be a sign of other conditions such as lipodystrophy and anorexia.

Hypothalamus
The hypothalamus links our endocrine and nervous systems together. The
hypothalamus drives the endocrine system.

Stomach and Small Intestine

The digestive tract is the largest endocrine-related organ system in the body. It makes
and secretes several different types of hormones that play a role in the body's metabolism. .
Gherlin and leptin are two hormones that have been shown to regulate appetite and may be
important in obesity and weight disorders.

Skeletal Muscle
In addition to being required for bodily movements and participating in the regulation
of body temperature, skeletal muscle commonly uptakes over 70% of glucose after a meal.
After a meal, blood glucoses rises, which leads to the release of insulin. Insulin is the
hormone that stimulates the uptake of glucose into skeletal muscle for energy or storage
purposes. The actions of insulin result in the return of blood sugar back to normal levels. In
people with type 2 diabetes, tissues such as skeletal muscle are no longer responsive to the
actions of insulin, which leads to abnormally high blood sugar levels, or hyperglycemia.

Every cell in the human body needs energy in order to function. The body's primary
source of energy is glucose, a simple sugar resulting from the digestion of foods containing
carbohydrates (sugars and starches).
 PATHOPHYSIOLOGY of GESTATIONAL DIABETES MELLITUS

As we learn more about the pathophysiology of gestational diabetes mellitus, we find that
there is more yet to be discovered. It is a syndrome with disordered metabolism due to beta-
cell dysfunction/impairment which leads to increased insulin resistance that occurs when
excess glucose in the blood reduces the ability of the cells to absorb and use blood sugar for
energy. It is caused by developing insulin sensitivity that causes increased insulin resistance
including excess

body weight, too much belly fat, lack of exercise, and smoking. As insulin resistance
increases, the body fights back by producing more insulin that makes decreased insulin
secretion due to a decline in the cellular secretory rate (that is, in individual B-cell function).
And that makes the client experience signs and symptoms such as blurring of vision, fatigue,
nausea and vomiting, frequent urination and vaginal infection which leads to gestational
diabetes mellitus. If it is treated with the necessary management then the client will recover
from this disorder. If left untreated,when glucose builds up in the blood instead of going into
cells, it can cause far- reaching possible complications such as: for mother; preeclampsia,
heart disease, neuropathy and for the baby; shoulder dystocia, macrosomia, hypoglycemia
and respiratory distress syndrome. And if neglected, then the client might die.

Normal Pathology of the human body in people that are healthy, the pancreas, an
organ located behind the liver and stomach, secretes digestive enzymes and the hormones
insulin and glucagon into the bloodstream to control the amount of glucose in the body. The
release of insulin into the blood lowers the level of blood glucose (simple sugars from food)
by allowing glucose to enter the body cells, where it is metabolized. If blood glucose levels
get too low, the pancreas secretes glucagon to stimulate the release of glucose from the liver.
Right after a meal, glucose and amino acids are absorbed directly into the bloodstream, and
blood glucose levels rise sharply. The rise in blood glucose levels signals important cells in
the pancreas, called beta cells, to secrete insulin, which pours into the bloodstream. Within 20
minutes after a meal insulin rises to its peak level.

Insulin enables glucose to enter cells in the body, particularly muscle and liver cells.
Here, insulin and other hormones direct whether glucose will be burned for energy or stored
for future use. When insulin levels are high, the liver stops producing glucose and stores it in
other forms until the body needs it again. As blood glucose levels reach their peak, the
pancreas reduces the production of insulin (about 2-4 hours after a meal both blood glucose
and insulin are at low levels).

DIAGNOSTIC EXAMINATION

IDEAL

● Glucose Challenge Test (GCT)

The Glucose Challenge Test or also known as glucose screening test measures
the body’s response to sugar (glucose). It is done during pregnancy to screen for
gestational diabetes mellitus that develops during pregnancy. The results indicate
whether there might have gestational diabetes mellitus. If the test results are above
normal, you’ll need to have further testing to determine the diagnosis. The test is
generally done between 24 to 28 weeks of pregnancy.
 ● Oral Glucose Tolerance Test (OGTT)

Oral Glucose Tolerance Test identifies abnormalities in the way your body
handles glucose after a meal-often before your fasting blood glucose level becomes
abnormal. It is commonly used during pregnancy for diagnosing gestational diabetes.
With an OGTT, the client receives a dose of oral glucose (the dose depends upon the
length of the test).

● Ultrasound

The Doctor recommends close monitoring of the baby’s growth, typically

through ultrasound. It is done in the following instances like for monitoring of fetal
growth, assessing evolution of any detected fetal anomaly, or determining fetal
position before delivery, as well as to confirm presence of a normal fetal heartbeat if
the fetal movements become reduced or absent.

● Urine analysis

Doctor will ask to collect urine for 24 hours, for measurement of the amount
of protein in urine. A single urine sample that measures the ratio of protein to
creatinine-a chemical that’s always present in the urine-also may be used to make the
diagnosis.

● Complete Blood Count (CBC) Test

To examine the effect of gestational diabetes mellitus (GDM) in the third

trimester on the maternal blood count in nonanemic women with singleton
pregnancies. The development of GDM is associated with significant changes in
blood counts beyond the effect of advancing gestation alone, probably related to the
pathologic effect of diabetes.

ACTUAL
LABORATORY RESULTS (PRENATAL CHECK-UP)
March 14,2023

ABRA PROVINCIAL HOSPITAL

Bangued, Abra

CLINICAL LABORATORY REPORT

Name: Mrs. EC Date Reported: Requesting Physician:

03-14-2023
Age/Sex: 33/F TEST: 75g Oral Glucose Tolerance Test

Result Normal Result Normal Urine Significance

Values Values (Glucose)

mmol/l mmol/l mg/dl mg/dl

Fasting Blood 4.61 3.89-5.83 83.15 70-105 Negative Non-significant

Sugar

After 1hour 11.65 4.67-8.63 209.84 84-155 Negative Diabetes

After 2hour 11.29 3.85-6.71 203.49 69-120 Positive(++) Diabetes

MANAGEMENT
NURSING MANAGEMENT
POST-OP (March 23, 2023)
IDEAL
● Establish a good client-nurse relationship.
Rationale: To ensure the client’s physical and psychological safety.

● Assess, report, and record signs and symptoms and reactions to treatment. Rationale:
To ensure that aren’t any medical risks that would predispose the client to a medical
emergency.

● Monitor and record vital signs.

Rationale: To measure the body’s basic function and to assess the well-being of the
client.

● Provide client and family education in nutritional requirements.

Rationale: To get the client to eat a diet that promote health and decreases the risk of
nutrition-related disease.

● Provide reassurance and emotional support to patient and family.

Rationale: To improve the healing process and help client feel safe and more
empowered with managing her own recovery.
ACTUAL
● Established a good client-nurse relationship.
● Assessed, reported, and recorded signs and symptoms and reactions to treatment.
● Monitored and recorded vital signs.
● Provided client and family education in nutritional requirements. ● Provided
reassurance and emotional support to client and family.

Non-Pharmacological Management
IDEAL (PRE-OP)
● Diet
The client might need to consume adequate energy, protein, and minerals. The client
needs adequate nutrition and weight gain, plus prevention of ketosis and postprandial
hyperglycemia.

● Physical Activity
The client might need physical activities to lower the glucose level and reduce the risk
of adverse perinatal outcome.

ACTUAL
● Diabetic diet
The client provided adequate calories for maternal needs, fetal growth and adequate
weight gain.
FRUITS RICE & EQUIVALENTS DRINKS

1pc banana ½cup rice(white &/or brown) Safest drink-WATER

1pc apple ½cup pasta ● No milk, yogurt, nor

fruits during
1pc ponkan/orange 1pack noodles breakfast
1pc atis/chico* 1cup oatmeal ● Snacks should be:
*½ glass of milk as
1pc pear 1cup corn am snack (9-10am)
½ pc dragon fruit 2pcs potato, yam, sweet potato *½ glass of milk as
pm snack (3-4pm)
½ pc mango 2slices bread *1glass of milk at
bedtime (9-10pm)
¼ pc avocado* 3pcs pandesal
● NO SUGARFREE
1slice papaya 1slice pizza to diet.

1in thick pinya 2pcs dipping saba

*1 glass= 3 scoops of any
1in thick melon Milk formula
*If used as snack-take half of the
serving size
1in thick watermelon 9-inch plate (Diabetic plate)
7pcs lanzones

7pcs rambutan

7pcs longgan
7pcs grapes/dates*

*avoid if possible

Shortcut: 1/2cup of any fruit

slices

1 palm/dakulap/palad
● Exercise
Exercised 30min/day or 1 hour 3x/week

Pharmacological Management
IDEAL (PRE-OP)

● Multivitamin Supplements
Multivitamins used to treat or prevent vitamin deficiency due to poor diet, or
certain illnesses. Vitamin and iron are important building blocks of the body and help
keep you in good health.

● Calcium
Calcium lowers the risk of developing conditions involving high blood
pressure/preeclampsia during pregnancy.

● Anti-bacterial infection drug

The client might need anti-bacterial infection tablets to treat infection.

ACTUAL

● Iberet-folic 500mg 1tab OD bedtime

● Calcium carbonate 500mg 1tab after breakfast
● Metronidazole 500mg 1tab 2x daily for 7days

IDEAL (POST-OP)
● Anti-diabetic drug
 The client might need anti-diabetic medication to lower the glucose level and
to prevent for having Type 2 diabetes later.

● Nonsteroidal anti-inflammatory drug (NSAID)

To reduce hormones that cause inflammation and pain in the body.

● Antibiotic drug
To prevent/treat wound infection.

● Multivitamin Supplements
Multivitamins used to treat or prevent vitamin deficiency due to poor diet, or
certain illnesses. Vitamin and iron are important building blocks of the body and help
keep you in good health.

ACTUAL
● Metformin HCL 500mg 1tab 3x a day for 7 days
● Mefenamic acid 500mg 2x a day for 7 days
● Cloxacillin 500mg 3x a day
● Iberet-folic 500mg bedtime OD for 7 days
HEALTH TEACHINGS

POST-OP

● Advised client to continue monitoring blood glucose level using a glucose monitoring
device(glucometer) wherein the recommended time is 1-2 hours after a meal and at
bedtime.

Rationale: The measurement of blood glucose provides information on the

effectiveness of blood glucose metabolism and guides interventions to
achieve optimal glucose control within the body.

● Instructed the client to use pain medication as ordered. Oral intake of mefenamic acid
500mg B.I.D x 7 days.

Rationale: To reduce the effect of pain on client function and quality of life. The
ability to resume activity, maintain a positive affect or mood, and sleep
are relevant functions for the client.

● Instructed the client the proper technique in doing perineal care that is wiping the
perineum with a soft washcloth from front to back. And perform wound care as
needed.

Rationale: To prevent contamination that can cause infection.

● Emphasized the importance of doing light activities. Both aerobic and resistance
exercise at a moderate intensity, a minimum of three times a week for 30-60 min each
time.

Rationale: In order to prevent occurrence of Type 2 diabetes later in life.

● Instructed the client to follow a proper diet as directed such as eat protein with every
meal, include daily fruits and vegetables in diet, limit or avoid processed foods and
pay attention to portion sizes to avoid overeating.

Rationale: To control the amount of carbohydrates (such as bread, cereal, and fruit)
you eat at each meal and snack.

● Advised not to take any extra vitamins or other medicines without talking to the
healthcare provider first and emphasized the importance of compliance of
medications. Oral intake of prescribed medications, such as:
*Cloxacillin 500mg T.I.D x 7 days (anti-infection),
*Metformin 500mg T.I.D x 7 days (anti-diabetic)
*Iberet 500mg bedtime OD x 7 days (multivitamins)
 Rationale: It's important to talk with the physician/healthcare provider before taking
supplements to discuss the risks, effectiveness, and inform client of any
potential interactions and also help to find the right supplement for the
patient.

● Emphasized the importance of breastfeeding. Encouraged the client to breastfeed her

baby every two hours or each time the baby cries, and put the baby on her breast to
suck. To help him figure out where lunch is coming from, rub his cheek with the
nipple or finger to get him to turn toward the breast. Newborns may nurse for up to
15-20 minutes or longer on one or both breasts.

Rationale: To keep the baby healthy. It protects against allergies, sickness, and
obesity. It protects against diseases, like diabetes, cancer, and infections
like ear infections. It is easily digested – no constipation, diarrhea or upset
stomach.

● Emphasized the importance of compliance of the vaccination of the baby. The baby
already received BCG and 1st dose of Hep B vaccine.

Rationale: To protect the baby from deadly diseases.

● Emphasized the importance of follow-up check up to the physician or diabetes care

team as directed.

Rationale: In order for client to have screening tests for Type 2 diabetes 4 to 12
weeks after giving birth. And may also need to have tests for diabetes
every 1 to 3 years for life.

Abstract
Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder with
onset during pregnancy and is associated with increased feto-maternal morbidity as well as
long-term complications in mother and child. Women who fulfill the criteria of a manifest
diabetes in early pregnancy (fasting plasma glucose >126 mg/dl, spontaneous glucose level
>200 mg/dl or HbA1c > 6.5% before 20 weeks of gestation) should be classified as having
manifest diabetes in pregnancy and treated as such. Screening for undiagnosed type 2
diabetes at the first prenatal visit (evidence level B) is particularly recommended in women at
increased risk (history of GDM or prediabetes, malformation, stillbirth, successive abortions
or birth weight >4500 g in previous pregnancies, obesity, metabolic syndrome, age >35 years,
vascular disease, clinical symptoms of diabetes, e. g. glucosuria, or ethnic groups with
increased risk for GDM/T2DM, e.g. Arabian countries, south and southeast Asia and Latin
America). A GDM is diagnosed by an oral glucose tolerance test (OGTT) or a fasting glucose
concentration ≥92 mg/dl. Performance of the OGTT (120 min, 75 g glucose) may already be
indicated in the first trimester in high risk women but is mandatory between 24-28 gestational
weeks in all pregnant women with previous non-pathological glucose metabolism (evidence
level B). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome
(HAPO) study and following the recent WHO recommendations, GDM is present if the
fasting plasma glucose level exceeds 92 mg/dl, the 1 h level exceeds 180 mg/dl or the 2 h
level exceeds 153 mg/dl after glucose loading (OGTT international consensus criteria). A
single increased value is sufficient for the diagnosis and a strict metabolic control is
mandatory. After bariatric surgery an OGTT is not recommended due to the risk of
postprandial hypoglycemia. All women with GDM should receive nutritional counseling, be
instructed in self-monitoring of blood glucose and to increase physical activity to moderate
intensity levels, if not contraindicated. If blood glucose levels cannot be maintained in the
therapeutic range (fasting <95 mg/dl and 1 h postprandial <140 mg/dl) insulin therapy should
be initiated as the first choice. Maternal and fetal monitoring is required in order to minimize
maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with
GDM have to be re-evaluated by a 75 g OGTT (WHO criteria) 4-12 weeks postpartum to
reclassify the glucose tolerance and every 2 years in cases of normal glucose tolerance
(evidence level B). All women have to be informed about their (sevenfold increased relative)
risk of developing type 2 diabetes (T2DM) at follow-up and possible preventive measures, in
particular weight management, healthy diet and maintenance/increase of physical activity.
Monitoring of the development of children and recommendations for a healthy lifestyle are
necessary for the whole family. Regular obstetric examinations including ultrasound
examinations are recommended. Within the framework of neonatal care, neonates of GDM
mothers should undergo blood glucose measurements and if necessary appropriate measures
should be initiated.

Keywords: Diabetic fetopathy; Gestational diabetes mellitus; Pregnancy; Pregnancy

complications; Type 2 diabetes mellitus.

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https://www.unionwomancare.org/pdf/ONG-09e.pdf