This case study describes the care plan that a doula may use to take care of a client who is planning a c-section and has gestational diabetes. It describes what kind of labor support a doula can give in this situation.

1. Case Study 3
Gestational Diabetes
Occasionally I will be presenting case studies separate from the lesson to help you integrate
the information you have learned as well as reinforce concepts taught. This particular case
has come from a client I had with the names changed. Her main need did not have to do with
gestational diabetes, but this definitely played a role in her choices and her goals. I begin
with my notes and assessment during the interview process, then move on to finding out her
needs and planning accordingly. At the end of this, a birth plan was made that followed her
goals and ideas.
Goals
To understand how to apply knowledge of a specific medical diagnosis to your role as a
doula.
To provide an example of how to incorporate the assessment and interview into the
birth plan and your practice as a doula.
To provide an example of the all steps in the nursing process.
Reading assignments:
Pages 244-247 in The Birth Partner by Penny Simkin.
Read the medical terminology in the lesson.
Listen to the link below:
http://obgynmorningrounds.com/blog/afternoon-lectures/2-72-medical-problems-in-pregnancy-
diabetes/
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2. The Interview,
Assessment, and
Birth Plan
Initial Interview Data
First baby During this interview
I took notes, then
She had gestational diabetes and took medication for this. She possibly
later wrote them up.
also had pre-eclampsia. At 37 weeks, she went in for a NST and found
some problems, she was then induced. She labored for a while and got I also wrote down
an epidural. Due to fetal distress, she had an emergency c-section. her own goals,
During this birth she was separated from her first husband, but he was questions, and
there along with her mother. She had a hard time with him there and didn't desires. I
want much to do with him. formulated a birth
plan from these
Second baby notes. If a woman
already has a birth
She had a normal pregnancy and had a planned c-section at 39 weeks. plan written out, I
I'm unsure if VBAC was even offered to her. She had pre-term labor that will just add my own
was controlled with medications. She had difficulty breastfeeding because
thoughts and ideas
she felt like she was not giving her baby enough milk. Baby lost weight in
the hospital and was supplemented with formula. This continued at home. to her and get her
approval.
This pregnancy
She possibly may be type 2 diabetes but it is controlled with diet. She
has seen a nutritionist for this and wants to avoid taking medications for
it. She would like a repeat c-section because she feels more comfortable
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3. with this. She already has other complications going on and her husband
also feels more comfortable with this. She is also having numerous
urinary tract infections.
Other
This interview took She has anxiety/panic attacks but is not taking medication for this. During
her births she had a few panic attacks and would like help with this.
about 2 hours. This is
Deep breathing and visualizations help with this, as well as having a
a normal amount of support person close by. She does not like the oxygen mask. It makes
time for me. her anxiety worse. She's okay with it if it is held close by, but not on.
She was frustrated with how long her baby was taken away after her last
two births and wants to make sure they are with her as soon as possible.
Care provider and place of birth
She will be delivering with Dr. X. Right now she is trying to decide which
hospital she wants to go to and would like help choosing.
Client goals or desires
She would like to have the baby with her unless there is a serious
medical reason.
Would like help with breastfeeding
Help with anxiety.
Would like to find a hospital that will support her desires.
Wants help with shoulder/gas pain after c-section.
Needs listed at this
Needs Identification, Prioritization
time are more like and Doula Actions
anticipated needs.
These are needs Physiologic Needs
that you are
expecting to Risk for imbalanced nutrition status related to
encounter during NPO status during c-section and gestational diabetes.
labor and birth. -Actions implemented: Provide clear liquids or other
food according to what is ordered or desired. Plan to
have foods that she likes available.
Risk for dehydration related to NPO status
during c-section.
-Actions implemented: Remind your client to drink.
Plan to have drinks available that she likes.
Risk for fatigue related to anxiety about birth.
-Actions implemented: Address anxiety the day before
as well as the day of her c-section.(See below for
actions taken for anxiety).
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4. Body temperature fluctuations related to c-section.
-Actions implemented: Provide warm blankets or heating pads
immediately afterwards. Provide warm fluids if desired. Request warm iv
fluids be hung right after the c-section is finished.
Impaired mobility related to epidural and c-section.
Actions implemented: Help control pain to allow movement sooner(see
actions addressing pain below).
Nausea related to c-section.
Actions implemented: Offer peppermint tea or peppermint oil for nausea.
Offer liquids and foods slowly. A fan may also be used.
Risk for shaking related to epidural use.
-Actions implemented: Make sure that warm iv fluids are used
intraoperatively and immediately afterwards. Request warmed blankets
during the operation and afterwards Request warm blankets while being
before, during, and after the surgery. Diffuse peppermint in the air
afterwards or rub some on the feet.
Risk for itching related to epidural use.
-Actions implemented: Find something to distract your client from the
itching while it wears off.
Safety Needs
Desires control related to birthing place.
Actions implemented: Research the hospitals in the area to see what their
protocols are regarding infant care afterward, particularly as it relates to
babies born by c-sections and from mothers who have gestational
diabetes.
Desires control related to infant bonding.
Actions implemented: Make sure staff knows that your client wants the
baby with her as much as possible. Encourage skin-to-skin.
Pain related to should/gas pain after c-section.
Actions implemented: Hot packs to shoulders. Distraction techniques.
Get your client up and moving quickly.
Pain related to incision after c-section.
Actions implemented: Ice packs for the first 24 hours, then heat packs.
Pain related to iv
Actions implemented: Use heat or ice(whichever feels better). Before the
iv is put in, warm the hand where is is going to be placed.
Information seeking behavior related to breastfeeding as
manifested by desire for more knowledge and difficult past experiences.
Actions implementd: Find the closest LLL group. Make sure your client is
able to see a lation consultant. Encouragement. Reassurance. Place a
sing on babies crib that says not to give this baby anything else by mouth.
Anxiety related to c-section.
Actions implemented: Reflexology. Lavender oil. Music therapy.
Encouragment. Make sure spouse is close by. Teach spouse light tough
to use during c-section.
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5. Anxiety related to gestational diabetes.
Actions implemented: Point out what your client is able to control(i.e. Food
choices). Focus on signs of good health. Connect them to a nutritionist if
possible. Make sure your clients have any medical questions answered
by their chosen care providers and provide information they are unablet to
obtain.
Social Needs
Opportunity for enhanced parent/infant bonding.
Actions implemented: Provide resources on breastfeeding. Provide
resources and information on bonding.
Risk for impaired parent/infant bonding related to c-section and
complications from gestational diabetes.
Actions implemented: Research hospitals to find one that is committed to
mom and baby staying together. Make sure the staff understands that
your client wants her baby with her as much as possible.
Opportunity for enhanced relationships.
Actions implemented: Discuss plan of care with spouse or significant
other. Make sure spouse is doing all that he wants to do. Discuss what
your clients spouse can do to be involved.
Isolation related to c-section policies.
Actions implemented: Make sure that someone is always with your client
afterward. Get the majority of the prep work done before your client goes
into the operating room.
Opportunity to enhanced connection to the birthing process.
Action implemented: Allow your client to see as much as she desires of
the c-section birth. Ask to do skin to skin as soon as possible afterward.
Esteem Needs
Risk for body image disturbance related to physical changes and
c-section.
Actions implemented: Mirror therapy.
Opportunities for enhanced feelings of empowerment.
Actions implemented: Make sure your client understands her choices and
is given choices.
Opportunities for keeping environment focused.
Actions implemented: Request music that your client would like. Make
sure choices made are in accordance with your clients wishes. Speak in
soft tones. Dim lights as much as possible. Be aware of your clients
privacy needs and ask that those be respected as much as possible.
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6. Written Birth Plan
Birth Plan for C-section/gestational diabetic client
To my care providers and hospital staff:
I would like to express my appreciated of your care for me and let you know of my
desires for this birth.
Written birth plans are
done to allow your
I have chosen to have a repeat c-section, but have some specific desires related to
client to communicate
this. I would like to have all preliminary preparation done before I go into the OR.
her wishes to her
This would include the epidural and catheter placement, as well as medications.
medical provider and
hospital staff. It is
After the birth, I would like to have my baby with me unless there is a medical reason
based off of the plan
not to. Please discuss with me any reason for this not being possible.
you come up with
together and express
During the surgery, I would like to have my own music playing and I would like to
the exact desires of
use some essential oils that I have found useful for anxiety.
your client.
I am also concerned about breastfeeding and would like to make sure that nothing
else is given to my baby besides my own breast milk unless it is deemed medically
necessary. I would like to be able to discuss any questions about this with a
pediatrician should a question arise.
Thank-you again for your care and making sure that me and my baby are safe.
Stacey
Because of the birthing environment we have in our culture, birth plans are
viewed as unuseful and sometimes hostile by some medical personnel.
Therefore, I do not always recommend giving one to the medical
personnel at the hospital, but leave it up to you and your clients discretion.
In the absence of hostility, a birth plan can be a good way to let your care
providers know what your desires and wishes are, so that they can be
prepared to offer you the care that you desire.
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