Midwifery is one of the few health care professions that primarily cares for a healthy population. Since we care mainly for well women the focus in my profession is on prevention and early diagnosis of illness and/or disease and then referral to the appropriate specialist. This does not mean that everyone under a midwife’s care is completely healthy or free from disease and every health care discipline is challenged with caring for an increasingly unwell population.
In my practice the three most common chronic diseases that I treat are hypertension, diabetes and mental health issues often accompanied by SSRI use. In my opinion, diabetes and gestational diabetes in particular is the most common chronic disease that midwives routinely diagnose and treat in collaboration with endocrinology and diabetes education counselors. According to the CDC presently approximately 6-9% of pregnant people will develop gestational diabetes during their pregnancy and 1-2% enter pregnancy with pre-existing diabetes either type 1 or type 2 worldwide. In Canada, the rate of type 1 diabetes has remained relatively stable, while rates of type 2 diabetes and gestational diabetes continue to creep up with the highest rates of gestational diabetes found in British Columbia (73.4 per 1,000) and the lowest rates found in Nunavut (11.7 per 1000). Rates of gestational diabetes were also highest in older women (Maternal Diabetes in Canada, 2014).
It is not surprising to find rates of type 2 and gestational diabetes are climbing and certainly this matches my anecdotal experience as a clinician. Age and weight are two significant contributing risk factors to the development of both type 2 and gestational diabetes and with a significant percentage of the population being either overweight or obese and with many women delaying pregnancy until later in life, it appears that gestational diabetes rates will continue to climb for the foreseeable future (Berger et. Al, 2016).
Treating women with gestational diabetes is always a delicate balancing act between ensuring the women’s well-being and that of her developing fetus. Guidelines and recommendations are always evolving. Currently the recommendations for diabetes management in pregnancy are largely derived from the research and clinical practice guidelines provided by the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the current guideline for best practice recommends induction of labour between 38-39 weeks gestation depending on the patient’s glycemic control. The risks of diabetes in pregnancy include delivery of a macrosomic infant, higher rates of shoulder dystocia, assisted vaginal delivery, perineal trauma and caesarian section largely attributed to macrosomia, higher risk of stillbirth and higher rates of placental dysfunction. In an attempt to mitigate these risks induction of labour by 39 weeks is recommended in order to deliver at term but with less time for the fetus to become too large and before the delivery becomes too problematic (Berger et. Al, 2016). Achieving a euglycemic state in labour is also an important part of the treatment plan so that the transition to extrauterine life is less stressful for the neonate as they begin to regulate their own sugars and insulin levels (Reproductive Health-Diabetes in Pregnancy,2018).
Chronic diseases are here to stay and rates of diabetes are going to continue to rise if current health trends persist. All health care disciplines are faced with treating this disease and clinical practice guidelines will continue to evolve as more research becomes available. It is my job to ensure I am diagnosing and treating the needs of my diabetic patients by following the clinical practice guidelines that are in line with my community’s resources and based on the recommendations of my consultants, the College of Midwives of BC and the SOGC.
References:
Living with Gestational Diabetes. (n.d.). Retrieved from
Berger, H., Gagnon, R., & Sermer, M. (2016). Diabetes in Pregnancy. Journal of Obstetrics and Gynaecology Canada, 38(7), 667-679.
What is Gestational Diabetes. (n.d.). Retrieved from www.diabetes-pregnancy.ca/gdm/overview/
Reproductive Health - Diabetes in Pregnancy. (2018, June 12). Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/diabetes-during-pregnancy.htm
Maternal Diabetes in Canada. (2014, October 09). Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/maternal-diabetes-canada.html
Comments