Crea t i ng a patient- educ a t i on
pamphlet tor gestational diabetes
/ by
Lucille K. Steele Morrison.
Thesis Nurs. 1999 M879c

CREATING A PATIENT EDUCATION PAMPHLET FOR
GESTATIONAL DIABETES

By
Lucille K. Steele Morrison, MEd, BSN, RN

Submitted in Partial Fulfillment of the Requirements

for the Master of Science in Nursing Degree
Edinboro University of Pennsylvania

Approved by:

?//?/? 7
Jugpm Schilling, CRNP, PhD.
Committee Chairperson

Date

'A ft
np, MSN,
ariet Newcamp,
....
Committee Member

RN

Date

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CREATING A PATIENT EDUCATION PAMPHLET FOR
GESTATIONAL DIABETES

Abstract
With patient education receiving such emphasis in today’s health care

arena, multi-instructional aids are widely used to enhance the patient
education process. Printed patient education materials remain the most

common tool to supplement oral instruction (Bernier & Yasko, 1991).
Gestational diabetes mellitus (GDM) patients require education about

lifestyle modifications such as weight control, diet, exercise, and tight

glycemic control in order to lessen risks of both maternal and fetal/neonatal

complications (Ryan, 1998). These patients also need information about
prognostic considerations.

A patient education pamphlet was created following the Evaluating
Printed Education Materials (EPEM) model developed by Bernier and Yasko
(1991). This pamphlet is intended to reinforce oral instructions given to GDM

patients referred for counseling to a hospital-based diabetes education

center in northwestern Pennsylvania. The content of the pamphlet includes:
the etiology of GDM, risk factors for developing GDM, screening tests to

detect GDM, implications GDM has for the mother and the baby, maternal
and fetal complications associated with GDM, management of GDM, and
prognostic considerations of GDM. The McLauglin (1969) SMOG formula

was used to place the pamphlet at the sixth grade reading level.

Acknowledgments
No scholarly project is completed without help. I would like to say
thank you to many wonderful people.

Leading all acknowledgments must be mine to my two beautiful
children, Robert Blair and Ruth Louise Morrison, and my wonderful husband,

William. They have offered an unwavering support throughout the
development of this project.
To my wonderful sister, Anna, and her husband, Dale Hodgkinson,

who were willing to proofread the manuscript.
To my church family who have supported me in their prayers.

To Patty DiPanfilo for her computer support to illustrate the pamphlet.
To Diane Harbaugh, diabetes nurse educator, for her valuable input.
To Dr. Janet Geisel for providing critique of the first three chapters.

To Janet Newcamp, committee member, my deep gratitude for her
willingness to serve on my project committee and for providing many valuable
suggestions.

Lastly, to Dr. Judith Schilling, my deepest gratitude for acting as
chairperson of my committee and for providing me with much guidance to

bring this project to fruition.
This scholarly project received partial support from Nu Theta Chapter,

Sigma Theta Tau, Inc., on May 1, 1999.

iii

Table of Contents
Content

Page

Abstract

ii

Acknowledgments

iii

Chapter I: Introduction

1

Background of the Problem

1

Educational reform

1

Educational materials

3

Educational opportunity

4

Theoretical Framework.

4

Problem Statement

5

Statement of Purpose

6

Assumptions

6

Definition of Terms

6

Summary.

8

Chapter II: Review of the Literature
Gestational Diabetes Mellitus

9
10

Classification
Pathogenesis

12

Detection
Diagnosis

iv

Management

15

Maternal complications

19

Fetal/neonatal complications

19

Prognostic considerations

20

Education Process

21

Definition of education process

21

Steps of the education process

22

Goal of the education process

22

Patient education

23

Printed Education Materials (PEMs)

23

Research support for PEMs

24

Rationale for PEMs

24

Rationale for self-composing PEMs

26

Readability of PEMs

26

Guidelines for writing PEMs

27

Model for designing and evaluating PEMs

Summary

29

Chapter III. Methodology

Model for Evaluating Printed Education Materials
Predesign phase

Design phase....

v

Pilot test phase

30

Implementation/distribution phase

32

Evaluation phase

32

Summary

32

References

33

Appendixes

40

A. Oral Glucose Tolerance Test Results for

Screening and Diagnosing Tests

41

B. McLaughlin’s SMOG Formula

42

C. Classification of Gestational Diabetes Mellitus

44

D. Risk factors for Developing GDM

45

E. Nursing process, assure model, education process

46

F. Cover Letter Accompanying Pamphlet and Questionnaire

47

G. Questionnaire for Evaluation/Revise Phase

48

H. Pamphlet: A Guide to Understanding Gestational Diabetes

49

vi

1
Chapter 1

Introduction
This chapter provides a discussion about patient education, patient
education materials, and gestational diabetes mellitus as an opportunity for

patient education. Dorothea E. Orem’s (1995) Self-care Deficit Theory of
Nursing provided the conceptual framework for this scholarly project.
Background of the problem, the problem statement, purpose of the study,

assumptions, and pertinent definitions are provided.

Background of the Problem

Patient education is a means of improving the health status of the

American people and advanced practice nurses have a major role in this
educational process (Boyd, 1992). Today, education about preventive health

care practices and health promotion is considered an essential component of

comprehensive health care (Boyd, 1992).
Educational reform. As early as 1918, the National League of Nursing

Education advocated the importance of health teaching (Bastable, 1997). A

renewed emphasis on health education has been steadily developing over
the past 30 years and, today, education in health care is a topic of utmost

interest in both rural and urban communities (Gibson & Kapp, 1994). The
patient’s Bill of Rights, issued by the American Hospital Association in 1975

and revised in 1992, is adopted by hospitals nationwide and recognizes the
rights of patients to be informed about their health, illness, and treatment

2

(Nelson, 1997; Weinrich & Boyd, 1992).

As a result of this health consciousness, there has been federal
legislation to support health education through the National Center for Health

Education, the Centers for Disease Control and Prevention, and the

Medicare and Medicaid Programs (Nelson, 1997). The federal government
has established certain goals and objectives outlined in Healthy People
2000: National Promotion and Disease Prevention (U.S. Department of
Health and Human Services [DHHS], 1990). If these health care goals are

achieved nationally, health care costs would be dramatically reduced and

Americans could lead healthier and more productive lives (Bastable, 1997).

Health professional groups have also passed supportive statements about
health education and consumer groups have become active in promoting
consumer rights in health care (Boyd, 1992). As recently as 1993, in

recognition of the importance of patient education, the Joint Commission on

Accreditation of Health Care Organization (JACHO) delineated nursing

standards for patient education (Nelson, 1997).
Improved care outcomes and lowering health care costs are two

desirable benefits of patient education (Gibson & Kapp, 1994). In this era of

expanded knowledge, patients want to be, and are expected to be, more
active participants in their own health care (Weinrich & Boyd., 1992). By
providing patients with information and education, they can move beyond
just learning facts to making judgments in daily living (Gibson & Kapp, 1994).

3
Educational materials. Patient education materials alone do not

constitute patient education (Flavo, 1985). Patient education begins when
the nurse practitioner clearly and effectively communicates the needed

information to the patient (Flavo, 1985). However, the use of printed
educational materials (PEMs) can clarify, supplement, and reinforce oral
instruction and may be read by significant others (Weinrich & Boyd, 1992).

There is a plethora of commercially prepared written instructional
materials currently available (Bernier & Yasko, 1991; Boyd, 1992;

Hainsworth, 1997). However, there are disadvantages to using commercially

prepared PEMs (Hainsworth, 1997). These drawbacks include issues of
cost, accuracy, adequacy of content, and readability of the materials
(Bernier, 1993; Hainsworth, 1997).

Despite the wide variety of commercially prepared materials for
patient education, nurse practitioners may still choose to write their own.

Reasons for self-composing instructional materials include cost savings or
the need to tailor the content (Hainsworth, 1997). Bernier (1993) and

Hainsworth (1997) pointed out that tailoring written materials to reinforce
specific oral instructions will enhance efficacy and provide opportunities to

clarify concepts that have been taught. In addition, PEMs can be read again

and again by the patient which helps to reinforce teaching and answer
questions when the practitioner is not available to provide feedback (Bernier,

1993; Gibson & Kapp, 1994; Hainsworth, 1997).

4

Educational opportunity. According to Orr (1990), informed patients
are more likely to comply with medical treatment plans and are better able to
manage the symptoms with fewer complications. One nonprofit consumer

health care organization developed the philosophy that illness is an
educational opportunity and that illness can become a teachable moment

even though the patient may not be highly motivated (Orr, 1990). The

medical condition, gestational diabetes mellitus (GDM), gives rise to

educational needs for women with GDM (American Diabetic Association
[ADA], 1998; Ryan, 1998). Illness-related information includes facts about
symptoms, diagnostic tests, treatment modalities, therapeutic equipment,

and outcomes of the illness (Boyd, 1992; Orr, 1990; Ryan, 1998). GDM
patients need instructions regarding treatment modalities such as daily self­

monitoring of biood glucose, dietary modifications, and a routine exercise

program (ADA, 1998; Landon & Gabbe.,1995; Reeder, Martin & KnoniakGriffin, 1997; Ryan, 1998; Stanley, 1996).

Theoretical Framework
Dorothea E. Orem’s (1995) Self-care Deficit Theory of Nursing
provides the framework for this scholarly project. Orem (1995) described her

theory based on the belief that adult persons have developed the capabilities

to meet their own needs (self-care) and the needs of their dependents
(dependent-care) for functioning, growing and developing. The ability to

engage in self-care and dependent care activities is termed self-care agency

5

and dependent-care agency.
The total requirement for regulation of functioning, growing, and

developing is Orem’s (1995) therapeutic self-care demand. It is the deficit

between the therapeutic self-care demand and the self-care or dependent­
care agency capability that concerns the nurse practitioner. When this deficit

occurs the patient may need assistance in maintaining normal growth and
development, in prevention or cure of potentially disabling processes, in

prevention or compensation for resulting disability, or in the promotion of
well-being. The nurse practitioner provides assistance to the self-care agent

in meeting self-care requisites in one or more of the following ways: (a)
acting for or doing for another, (b) guiding and directing, (c) providing
physical or psychological support, (d) providing and maintaining an
environment that supports development, and (e) teaching.
The self-care agent that is pregnant and has developed GDM requires
education in order to become competent to manage health-deviation self-

care requisites. The goal of the nurse practitioner is to provide the support

and guidance that is needed in order to meet these requisites of the self-care
agent and to promote normal growth and development of the fetus, or

dependent-care agent, and to contribute to future normalcy.

Problem Statement
Gestational diabetes mellitus (GDM) affects approximately 4% of

pregnancies or 135,000 cases annually in the US (ADA, 1998; Ryan, 1998).

6
Women with GDM need patient education about how to make lifestyle

modifications in order to reduce risks of complications for the mother and the
fetus/neonate, and should be informed about prognostic considerations
(ADA, 1998; Ryan, 1998).
Statement of Purpose

The purpose of this scholarly project was to construct a patient

education pamphlet. This patient printed educational material is intended for
use as a teaching tool to supplement specific oral instructions delivered to
patients who have developed gestational diabetes mellitus.

Assumptions
For the purposes of this project, the following assumptions were
made:

1. The patient is capable of reading English at the sixth grade level.

2. The patient is motivated and capable to actively participate in selfcare activities.
3. Learning is related to an immediate need/deficit.
4. The patient is diagnosed with gestational diabetes mellitus.

Definition of Terms
The following terms have been defined for this study:

1 The patient is one who is in need of instructions in order to
effectively cope with a disease process (Orr, 1990).

2 The education process is a systematic, sequentially planned

7
course of action that includes two operations: teaching and learning

(Bastable, 1997; Boyd, 1992).
3. Teaching is the deliberate intervention that involves planning and

implementation to achieve identified learner outcomes (Bastable, 1997;

Boyd, 1992).
4. Learning is a change in behavior, knowledge, skill, or attitude as a

result of exposure to an environmental stimulus (Bastable, 1997; Boyd,

1992).
5. Patient education is a process of assisting a patient to learn healthrelated behaviors that can be incorporated into self-care activities with
the purpose of achieving optimal health and independence in self-care

(Bastable, 1997; Boyd, 1992; Orem, 1995).

6. Patient education materials are instruction sheets, pamphlets,

brochures, and booklets commonly used in health care settings as a means
of providing written information to patients (Bastable, 1997; Bernier & Yasko,
1991; Boyd, 1992; Hainsworth, 1997).
7. Gestational diabetes mellitus is a glucose intolerance of variable

severity with onset or first recognition during pregnancy (Appendix A) (ADA,
1998; Ryan, 1998).
8. Glucose intolerance is an abnormal metabolism of glucose, a

simple carbohydrate, that occurs when the pancreas produces an
inadequate amount of insulin or there is insulin resistance at the cellular level

8

(ADA, 1998, Ryan, 1998).

9. Lifestyle modification is the change in one's behavior as the result
of an identified health care deficit. Some examples of behavioral changes

that affect health in a positive manner are as follows: (a) a calorie restricted
diet, (b) weight control, (c) regular exercise program, (d) smoking cessation,

and (e) limited alcohol intake (ADA, 1998; Ryan, 1998).
Summary
In today’s health care arena there is a major emphasis on patient

education (Bastable, 1997; Boyd, 1992; Gibson & Kapp, 1994). The patient

is expected to be an active participant in self-care activities (Boyd, 1992;

Orem, 1995). PEMS are vehicles whereby oral instructions can be clarified
and reinforced when the nurse practitioner is not available (Bernier & Yasko,
1991; Boyd, 1992; Gibson & Kapp, 1994). Even though there are many

types of commercially prepared PEMs, the nurse practitioner may prefer to
self-compose instructional materials (Bernier & Yasko, 1991; Boyd, 1992).
Illness is an educational opportunity (Orr,1990). GDM is a medical
condition that affords an opportunity to educate the patient so that a tight

glycemic control can be achieved in order to insure optimal maternal health

and fetal/neonatal well being (ADA, 1998, Reeder et al., 1997; Ryan, 1998).
Dorothea E. Orem’s (1995) Self-care Deficit Theory of Nursing

provided the theoretical framework for this scholarly project. Assumptions

and definition of terms pertinent to this project have been provided.

9

Chapter 2

Review of the Literature

The purpose of this scholarly project was to construct a patient
education pamphlet. This patient education pamphlet will be utilized in a

hospital-based diabetes education center in northwestern Pennsylvania as a
supplement to oral instructions given to women diagnosed with gestational

diabetes mellitus (GDM). The pamphlet was written at a sixth grade reading
level, determined by the McLaughlin (1969) SMOG formula (Appendix B).

This chapter provides a review of the literature concerning the
definition, pathogenesis, detection, diagnosis, and management of GDM. In

addition, maternal and fetal complications and prognostic considerations of
GDM are addressed. Next, the process of education is discussed. Finally,

this literature review focuses on the construction of printed education
materials (PEMs) using the Evaluating Printed Education Materials (EPEM)

model developed by Bernier and Yasko (1991).
Gestational Diabetes Mellitus

Approximately 4% of all pregnancies are complicated by GDM,
resulting in 135,000 or more cases annually in US (ADA, 1998; Ryan, 1998).

The prevalence could range from 1%to 14% of all pregnancies depending
on the population studied and the diagnostic tests employed (Engelgau,

Herman, Smith, German, & Aubert, 1995; Kjos et al., 1995; Solomon et al.,
1997). In a study by Engelgau et al. (1995), a multi-variant analysis of data

10

was performed with the findings and revealed that the incidence of GDM was
higher in African-Americans, Hispanics, Asians, and Native Americans,

especially those residing in the southwest. Conclusions of this study
indicated that there is a higher incidence of GDM than previously believed,

and that more frequent testing is probably responsible for this increase in the
diagnosis of GDM.

Classification. GDM is defined as glucose intolerance of variable

severity with onset or first recognition during pregnancy (Appendix A) (ADA,
1998; Moses, 1996; Landon & Gabbe, 1995; Stanley, 1996). The American

College of Obstetricians and Gynecologists ([AGOG], 1986) accepts the
White diabetes classification system that divides gestational diabetes
mellitus into class A-1 and A-2 based on fasting and post prandial blood

glucose levels (Appendix C).

Pathogenesis. As a result of hormonal changes that occur during
pregnancy, pregnancy is considered a diabetogenic state (Buchanan, 1997).
A diabetogenic state is one in which there are progressive metabolic

changes occurring that lead to increasing insulin resistance, a compensatory
hyperinsulinism, and accelerating glucose intolerance that could cause

gestational diabetes mellitus (Buchanan, 1997; Reeder et al., 1997).
Buchanan (1997) wrote that pregnancy can be viewed as a stress test for the

pancreatic beta cells. GDM occurs when the beta cells of a woman’s

pancreas are stressed by this diabetogenic state and consequently cannot

11

adequately meet the increased demands for endogenous insulin (Buchanan,
1996; Landon & Gabbe, 1995; Ryan, 1998).
During the first trimester of pregnancy, maternal insulin needs are
decreased due to low levels of the insulin antagonist, human placental
lactogen (Reeder et al, 1997; Stanley, 1996). This insulin antagonist is

produced by the placenta and promotes lipolysis, the break down of fats.
This lipolysis accounts for the increased amount of circulating fatty acids

needed for maternal metabolic use while glucose, a simple carbohydrate and
one of the most important fuels for fetal growth, is spared for fetal use.

There are physiologic changes occuring in the kidneys during the first
trimester of pregnancy that lead to a decreased renal threshold resulting in
the excretion of glucose and ketones (Landon & Gabbe, 1995; Reeder et al.,

1997). This may result in glycosuria and ketonuria. The physiologic changes

that occur in the kidneys, the potential decreased nutritional intake due to
anorexia or loss of appetite and vomiting, and the increased transfer of

glucose to the fetus may cause the diabetic mother to experience
hypoglycemia (Landon & Gabbe, 1995; Reeder et al., 1997);

Hormonal changes that occur during the early stages of pregnancy,
which include rising levels of estrogen and progesterone hormones,

influence a woman's metabolic state by stimulating the beta cells in the
pancreas to increase insulin production and secretion (Reeder et al., 1997).

This increased insulin production, associated with decreased insulin

12
sensitivity at the cellular level, results in the liver mobilizing hepatic stores of

glycogen (Landon & Gabbe, 1995). As the pregnancy progresses, maternal
hyperinsulinism continues (Reeder et al., 1997).

During the second and third trimesters of pregnancy, rising levels of
several hormones: human placental lactogen, estrogen, progesterone,
cortisol, prolactin, and insulinase, an enzyme that accelerates insulin

degradation, accelerate the increased insulin resistance (Reeder et al.,
1997). This is a glucose-sparing mechanism that allows for an increased
blood level of glucose or hyperglycemia to provide for fetal growth (Reeder et

al., 1997). During this time, maternal insulin requirements increase
dramatically. Persistent elevations of glucose and amino acids may stimulate
the fetal pancreas which results in beta cell hyperplasia and fetal

hyperinsulinism (Reeder et al., 1997).

Fetal glucose levels are normally maintained within narrow limits

because the maternal glucose level is well regulated in a healthy,
normoglycemic pregnancy state (Landon & Gabbe, 1995; Stanley, 1996).

However, if a pregnant patient has a borderline pancreatic reserve, the

endogenous insulin may be inadequate to overcome the effect of the
placental hormones, and gestational diabetes mellitus is manifested (Landon

& Gabbe, 1995; Stanley, 1996).
Detection. The risk factors for GDM (Appendix D) are obesity, family
history of diabetes mellitus. weight gain during pregnancy of more than 25

13
pounds, previous history of GDM or macrosomia, advanced maternal age,

multipanty, unexplained pregnancy wastage, presence of hydramnios,
previous newborn with congenital anomaly, hypertension, history of

glucosuria, and being a member of an ethnic group with high prevalence of

diabetes mellitus (ADA, 1998; Naylor, Phil, Sermer, Chen, & Farine, 1997;
Reeder et al, 1997; Solomon et al., 1997). Excess risks for gestational

diabetes and impaired glucose intolerance have been documented In ethnic
groups such as African-American, Hispanic- and Latino-Americans, and

Native-American women, as well as women from the Indian subcontinent

and the Middle East (Homko, 1998).
Until 1997, the ADA recommended that all pregnant women be

routinely screened for GDM. If all risk factors are absent, the likelihood of
GDM is so low that it may not be economical to do universal screening (ADA,

1998; Homko, 1998; Ryan, 1998). The new and current recommendation is

that women between the 24th and 28th weeks gestation be screened only if
they have one or more risk factors. Low risk women who do not need to be
screened were identified as women younger than 25 years, of normal body

weight, who do not have a first-degree relative with diabetes, and are not a

member of a high risk ethnic group (ADA, 1998; Bashoff, Johnson,
Jovanovic, LaRosa, & O’Brien, 1998; Genuth, Palmer, Zimmerman, & Glass,

1998).
Solomon et al. (1997) wrote that there may be justification for

14

universal screening because approximately 3% of women with GDM have no
identifiable risk factors. Several private practices of obstetricians and

gynecologists in northwestern Pennsylvania continue to do universal
screening between the 24th and 28th gestational weeks (P. Duda, H.
Jackson, S. Patrick, personal communication, November 2, 1998).

Diagnosis. The oral glucose tolerance test (OGTT) is specifically
recommended for use in pregnant women in order to screen for and to make

the diagnosis of GDM (ADA, 1998; Carpenter & Coustan, 1982). Screening

and diagnosis of GDM is a two step approach: screening test and diagnostic

test (ADA, 1998; Carpenter & Coustan, 1982). The screening test is a

nonfasting 50 g oral glucose challenge test followed by a venous plasma
glucose measurement 1 hour later (ADA, 1998). If a venous plasma glucose

value of 140 mg/dL or greater is found on the screening test then a full
diagnostic 100 g 3-hour OGTT is performed in the fasting state following 3
days of an unrestricted diet of 150 g or more of carbohydrate per day (ADA,
1998; Landon & Gabbe, 1995). A fasting venous glucose is drawn and 100 g

of glucose is administered orally. A venous plasma glucose is drawn at 1,2,

and 3 hours following the ingestion of the glucose (ADA, 1998). The
diagnosis of GDM is made, after the 100 g 3-hour OGTT, when two out of
four venous plasma glucose levels equal or exceed the levels listed in
Appendix A (ADA, 1998).

A study of 514 patients

at the University of Miami/Jackson Memorial

15
Hospital concluded that a 1 -hour glucose screen value greater than 185

mg/dL was sufficient to diagnosis GDM without the inconvenience of the 3hour OGTT (Landy, Gomez-Marin, & O’Sullivan, 1996). Coustan et al. (1989)
collected demographic and historical data on 6214 pregnant women

representing a population of universally screened individuals and found a

95% probability of GDM in women with glucose results of 183 mg/dL or
higher on the 1-hour glucose screening test. They recommended that the

diagnosis of GDM be made using this upper limit. A second testing of
women with an initial negative glucose tolerance test is recommended when
the patient is over 33 years, has a first-degree relative with diabetes, and/or

weighs more than 120% of ideal body weight (Bashoff et al., 1998; Naylor et

al., 1997).
Management. The management of GDM varies across the country
but the common goal is to reduce the perinatal morbidity and mortality

associated with GDM through the control of maternal plasma glucose levels

(Fagan, King, & Erick, 1995). Medical nutrition therapy (MNT) is considered
the cornerstone of treatment (Fagan et al., 1995; Gunderson, 1997). MNT

should provide for adequate calories and nutrients to meet the demands of

pregnancy and maintain maternal plasma glucose levels consistent with
goals established (ADA, 1998). The goals of MNT are to keep maternal

fasting plasma glucose levels below 95 mg/dl and 2-hour postprandial
plasma glucose levels below 120 mg/dl (ADA, 1998; Homko, Sivan, &

16
Reece, 1998). Nutritional counseling should be done by a registered

dietician, a licensed specialist in nutrition (Gunderson, 1997; Reeder et al.,
1997). Women with GDM are started on approximately 2000 to 2500 calories

daily excluding simple carbohydrates (ADA, 1998). Simple carbohydrates
such as those found in candy, soft drinks and sweetened desserts should be

avoided (ADA, 1998; Ryan, 1998). Limitation of total amount of

carbohydrate, careful distribution of carbohydrate at several meals, and
snacks throughout the day is the strategy used to prevent hyperglycemia,
meet metabolic demands, and prevent starvation ketosis, an accumulation of

ketones in the blood as a result of fat lipolysis (ADA, 1998; Gunderson,

1997; Ryan, 1998). Fagan et al. (1995) emphasized that until the optimal
treatment of GDM is defined, dietary recommendations must be
individualized to each patient. According to Gunderson (1997), GDM follows

a pathological continuum that results in worsening glucose tolerance as

gestation progresses; therefore, during the third trimester of pregnancy, MNT
may need to be more restrictive than during the second trimester of
pregnancy.

Self-blood glucose monitoring (SBGM) is the second most important
intervention in helping to maintain tight glycemic control for the GDM patient
(ADA, 1998; Gunderson, 1997; Landon S Gabbe, 1995; Ryan, 1998). If MNT

does not consistently maintain a fasting plasma glucose under 95 mg/dL and

2-hour postprandial plasma

glucose level under 120 mg/dL on two or more

17
occasions within a 1 to 2 week interval, insulin therapy should be initiated
(ADA, 1998; Homko, 1998). Repetitive fasting self-blood glucose levels
above 95 mg/dL and 2-hour postprandial plasma glucose levels above 120

mg/dL mandate insulin therapy in order to prevent the fetal complication of

macrosomia, a baby whose birth weight is greater than 9 pounds (ADA,
1998; Homko, 1998; Landon & Gabbe, 1995; Ryan, 1998). Coustan et al.

(1989) recommended insulin therapy as soon as GDM is diagnosed. Human
insulin is advocated to minimize the transplacental transport of anti-insulin

antibodies and the risk of future allergic reactions to insulin in women who
develop diabetes after pregnancy (Homko, 1998). Oral hypoglycemic agents

are contraindicated during pregnancy because of their teratogenic effects on
the fetus (ADA, 1998; Conrad, 1988; Ryan, 1998).

One prospective study used 334 GDM patients who were taught to
achieve euglycemia using a memory-based reflectance meter. These 334
subjects were matched for control of obesity, race, and parity. The results of
this study suggested that a relationship exists between the level of glycemic

control and neonatal weight and optimal pregnancy outcome in GDM

(Langer et al., 1994). Fetal pancreatic beta cells are thought to be highly
sensitive to maternal metabolism thus suggesting the need for tight glycemic
control throughout pregnancy (Keller et al., 1990; Langer et al. 1994). The

Fourth International Workshop on GDM advocated the use of reflectance

meters that store results electronically for review by the health care provider

18
(Homko, 1998).
The treatment regimen for GDM women requiring insulin therapy

involves fetal ultrasonographic examinations beginning at 32 weeks

gestation (Gunderson, 1997; Keller et al., 1990; Landon & Gabbe, 1995).
These examinations include abdominal circumference (AC) and biparietal
diameter (BPD) measurements (Gunderson, 1997; Keller et al., 1990;

Landon & Gabbe, 1995). All women should be taught to perform fetal

movement counting for at least the last 8 to 10 weeks of pregnancy (Homko,
1998). Weekly non-stress tests starting at 32 weeks gestation for women

requiring insulin therapy, and at or near term for women controlled by MNT,
are performed to confirm the well-being of the fetus (Homko, 1998). Most
women with GDM can complete their pregnancy and begin labor
spontaneously unless a complication develops (ADA, 1998; Homko, 1998;

Landon & Gabbe, 1995). In the event of a complication, the physician may
elect to do a cesarean delivery, a delivery of the fetus by means of a surgical

incision into the uterus (Knuppel & Drukker, 1993).
According to the ADA (1998), women with an active lifestyle should be

encouraged to continue their usual activities. Pregnancy is not the optimun
time to begin a strenuous exercise program; however, low to moderate

intensity or aerobic exercise is thought to be safe (Reeder et al., 1997).
During exercise there

is an increased affinity for the binding of glucose:

peripheral insulin sensitivity increases and maternal blood glucose

19

concentration is lowered (Homko, 1998; Zinman, 1997).

Maternal complications. Maternal complications of GDM include an
increased rate or cesarean delivery (Knuppel & Drukker, 1993). Other

potential complications are pregnancy-induced hypertension (blood
pressure of 140/90 mm Hg or higher) and proteinuria (protein in the urine

above 0.5gm/24hr) (ADA, 1998; Ryan 1998; Reeder et al., 1997).

E?.tel/neontal complications. Two significant complications associated
with GDM are macrosomia and neonatal hypoglycemia (Ryan, 1998). The

major determinants of macrosomia are maternal weight, maternal weight
gain, parity, gestational age, and fluctuating and elevated maternal plasma

glucose levels (Ryan, 1998). Rey, Monier, & Burns (1996) reported that

macrosomia occurs in 20% of GDM pregnancies that are undiagnosed and

untreated until late in pregnancy. Although macrosomia is linked to GDM,
maternal obesity is a prominent and inseparable cofactor (Helton, Arndt,

Kebede, & King, 1997). Neonatal hypoglycemia is related to fetal pancreatic
hyperplasia (Ryan, 1998). Although in the neonate normal plasma glucose

level can drop as low as 30 mg/dL, some neonates of mothers with GDM can
drop below this level, and the neonate is susceptible to serious neurologic
long-term consequences (Ryan, 1998). Other neonatal complications that

are associated with GDM are: (a) hyperbilirubinemia (elevation of bilirubin in
the blood), (b) respiratory distress syndrome (severe impairment of

respiratory function), (c) shoulder dystocia causing difficult passage through

20

the birth canal, (d) birth trauma, (e) hypocalcemia (low level of calcium in

blood), and (f) polycythemia (increased number of red blood cells) (Reeder
et al.,1997; Ryan, 1998), The likelihood of stillbirth in a woman with

appropriately managed GDM is no different than for the general population

of pregnant women (Reeder et al., 1997).

Prognostic considerations. The primary maternal considerations are

that gestational diabetes mellitus will recur and that the patient will develop
type 2 diabetes in the future (Buchanan, 1997). According to Reeder et al.
(1997), approximately 60% of women with GDM will eventually develop type
2 diabetes. Buchanan (1997) indicated that the most useful clinical

predictors that a woman will develop overt diabetes is the severity of
maternal hyperglycemia during pregnancy, the gestational age at which
GDM developed, and the oral glucose tolerance test result 1 to 4 months

after delivery. In a study conducted by Greenberg, Moore, and Murphy
(1995) with 238 patients, there was no single maternal, intrapartum, or
neonatal variable that predicted postpartum glucose intolerance in all cases.

However, their study concluded that a patient requiring at least 100 U/day of

insulin has a 100% incidence of postpartum glucose intolerance. Conrad

(1988) believed that women with GDM have a 30% to 40% chance of
developing diabetes mellitus within 1 to 25 years while Basholf et al. (1998)

and Reeder et al. (1997) estimated that as high as 60% will develop type 2

diabetes. The Fourth International Workshop Conference on GDM

21
recommended long-term, annual follow-up for women with a history of GDM

(Homko, 1998). Women with GDM should be evaluated in the postpartum
period using the 2-hour OGTT with a 75 g glucose load (ADA

, 1998; Bashoff

et al.,1998; Conrad, 1988; Homko, 1998; Reeder et al., 1997; Ryan, 1998).
Counseling should be provided for women with a history of GDM about the

use of lifestyle changes such as weight control and regular exercise to

reduce the risk of developing type 2 diabetes (ADA, 1998; Homko, 1998).

Scientists, from the Northwestern School of Medicine in Illinois,
conducted a study of 90 children born to mothers with GDM and 80 children

born to those who did not have GDM (Kahn, 1995). This study found that the

children born of mothers with GDM had higher mean arterial pressure, higher
systolic and diastolic pressure, higher body mass index, and higher insulin

levels.
Education Process
When an individual becomes dependent upon the health care system
for diagnosis, treatment, or rehabilitation she/he is exposed to health

information that is focused upon the disease or condition and its implications

(Boyd, 1992). Disease management techniques and other health promoting
strategies can also be included in the patient education (Orr, 1990).
Definition of education process. The education process according to

iquential planned course of action that
Bastable (1997) is a systematic, se'

consists of two interdependent operations. teaching and learning. Teaching

22

is a deliberate intervention that involves assessing the learner’s deficits,
creating the teaching plan, and implementing instructional activities using

aids such as PEMs to reach established learner outcomes (Bastable, 1997).
Learning is a change in behavior, knowledge, skill, or attitude that can occur
at any time as a result of the teaching operation (Bastable, 1997). Bernier

and Yasko (1991) related that a great deal of health education is done using
oral communication and one-to-one teaching with PEMs given to the learner
to reinforce teaching. Boyd (1987) wrote that people forget about one-half of

all oral instructions within 5 minutes of receiving them, and lay persons often

do not understand medical jargon.

Steps of the education process. The steps of the educational process
and the steps of the nursing process run parallel to each other but with a
slightly different slant (Appendix E) (Bastable, 1997). A paradigm to assist

the nurse practitioner in organizing and carrying out the education process is
the ASSURE model (Rega, 1993). The acronym stands for (a) analyze the

learner’s capabilities and deficits; (b) state objectives, both teachers and
learner’s; (c) select instructional methods and tools; (d) use teaching

materials (e) require learner performance, and (f) evaluate/revise the
teaching and teaming process (Bastable, 1997; Rega, 1993).

Goal of the education process. Patient education occurs when the
nurse practitioner assists

individuals in learning health-related behaviors in

order to incorporate them into

everyday life with the goal of achieving optimal

23

health and independence in self-care (Bastable, 1997; Orem,1995). The

ultimate outcome of patient education in keeping with ideals of self-care is to

transfer the responsibility for learning from the nurse practitioner to the
patient (Bastable, 1997).
Patient education. Patient education is considered an essential

component of quality health care (Gibson & Kapp,1994). With the increasing

emphasis on disease prevention, people are coming to understand that
knowledge about illness and medical care is not the exclusive property of the
health care professionals (Close, 1988). It is the responsibility of the primary

care practitioner to provide patients with the necessary information and
education so that they can become active participants in self-care (Close,
1988; Doak & Doak, 1980; Gibson & Kapp, 1994). Patient education

provides the primary care practitioner and the patient an opportunity to form
a partnership for improved health outcomes. (Gibson & Kapp, 1994).
Printed Education Materials (PEMs)
Bernier & Yasko (1991) described PEMs as the most economical and

effective instructional mediums available. PEMs help Increase understanding
of health problems and self-care regimens and are Important lor quality
patient care (Bernier S Yasko, 1991). Patient education using PEMs has
been an integral part of care for orthopedic patients, diabetic patients,

gynecological patients, cardiovascular patients, and cancer patients (Bernier,
1993; Mahon, 1996).

24
Research support for PEMs In a randomized controlled trial, a
package of educational materials was given to

one group of 108 patients

identified by their primary care provider as being depressed (Robinson et al.,

1997). One week later these patients were surveyed by telephone and
reported that the written materials were somewhat helpful: medication

booklet 81%, behavioral health booklet 82%, and video 69%. This study

concluded that educational materials may play a significant role in improving

depression treatment outcomes (Robinson et al., 1997). A study by Rice and
Johnson (1984) used a sample of 130 presurgical cholecystectomy and
herniorrhaphy patients. One experimental group was given preadmission

self-instruction booklets on specific exercise techniques, and the other

experimental group was given booklets that had no specific instructions. The
controlled group was given no instructions and no booklets. The two
experimental groups required less post-surgery teaching time than did the
controlled group that received no preadmission instruction (Rice & Johnson,

1984). Rice & Johnson (1984) also wrote that providing patients with
booklets for self-care at home may allow them to have an increased sense of
self-control. In a literature review to examine the role of nurses as patient

teachers, Close (1988) expressed that giving information to patients and
educating them will enable them to cope better with the stress of illness,
reduce complications, and accelerate recovery.

Rationale for PEMs. PEMs are often considered to be the backbone

25

of a comprehensive patient education program. They provide the nurse
practitioner with ready access to information in a consistent and presentable

manner, reinforce oral instruction, enhance the learning process, and
provide a resource for the patient to find answers to questions when the

nurse practitioner is not available (Farrell-Miller & Gentry, 1989; Hainsworth,
1997). PEMs have the following advantages: (a) consistency of message, (b)

flexibility of delivery, (c) portability and usability, (d) economical to produce

and update, and (e) permanence of information (Bernier, 1993).
Various instructional tools can be employed to facilitate learning:

written materials, displays, graphics, models, games, demonstrations,
overhead transparencies, slides, cassettes, videos, television, and computer-

assisted instruction (Boyd, 1992; Krishna, Balas, Spencer, Griffin & Boren,

1997). These teaching tools are intended to be used as adjuncts to teaching,
not a replacement (Pohl, 1981).

Pohl (1981) pointed out that learners’ concepts can be more fully
developed using PEMs and learning is improved. Hainsworth (1997)

emphasized that having a brochure that can be reread at the patient’s
convenience and pace can reinforce earlier learning and minimize confusion

involving oral instructions.
Rationale for self-composing^EMs. The perfect pamphlet is rare,
perhaps nonexistent; therefore, the nurse practitioner may decide to self­
compose written materials using the same criteria that should be availabie in

26
commercial prepared materials: accuracy, clarity, appropriateness, reader

appeal, and appropriate reading level (Gibson & Kapp, 1994) Other reasons
for self-composing PEMs are cost savings and the need to tailor the content

in order to reinforce specific oral instructions that will enhance the efficacy of
instructions and provide opportunities to clarify difficult concepts (Bernier &

Yasko, 1991; Hainsworth, 1997).
Readability of PEMs. Mathis (1989) reported that most patients read
on or below eighth grade level. Consequently, a primary concern, in patient

education, is the readability of PEMs to insure that the patients can read and
understand the information (Bermier& Yasko, 1991; Hainsworth, 1997;

Weinrich & Boyd, 1992). The readability of PEMs is recommended at or
below seventh grade level, and medical jargon should be avoided unless

fully explained (Gibson & Kapp, 1994; Hainsworth, 1997; Weinrich & Boyd,

1992). The patient education center at one northwestern Pennsylvania
medical center selects PEMs that are at or below the sixth grade reading
level (B. Magee, personal communication, November 17, 1998). Boyd (1992)

and Mathis (1989) recommended that the nurse practitioner determine the
average grade in school completed by the targeted population and write the
patient education materials two to four grades below that level. There are a

number of available formulas including Fog, SMOG, Flesch, and Fry that the
nurse practitioner can employ to determine the readability of patient

educational materials (Bernier & Yasko, 1991; Hainsworth, 1997;

27

McLaughlin, 1969), The McLaughlin SMOG formula

was used in this project

(Appendix B).
GMJdelinejLfo^^

Of utmost concern, in designing or

selecting PEMs, is the content accuracy and the readability level (Mathis,

1989). The following are guidelines for decreasing the reading level and
increasing the ease of reading: (a) keep sentences short, (b) express one

idea per sentence, (c) avoid complex grammatical structures, (d) write in
conversational style using the active voice, (e) write using the second

person, (f) use one or two syllable words, (g) limit the number of three or

more syllable words, (h) limit column width to less than 60 to 70 letters, (i)

present the most important information first, (j) use adequate spacing, and
(k) avoid use of all capital letters (Farrell-Miller et al., 1989). Hanafin (1993)

suggested employing the KISS formula when self-composing PEMs: Keep It
Simple and Smart. Bernier (1993) suggested that if there is a lot of

information to be given to the patient, it is better to construct several
pamphlets rather than trying to put a lot of information into one pamphlet.

Model for designing and evaluating PEMs. The Evaluating Printed
Education Materials (EPEM) model is a standard that can be used to guide
the development and evaluation of PEMs (Bernier 8 Yasko, 1991). This

model has five phases that parallel the nursing process, the education

process, and the ASSURE model (Appendix E). Just as the nursing process
follows a circular path from assessment to evaluation, the phases of the

28
EPEM model follow a circular path: predesign, design, pilot test,
implementation/distribution, and evaluation (Bernier & Yasko, 1991).

Summary

This literature review has discussed gestational diabetes mellitus.

Implications that GDM has for the mother and the fetus/neonate have been
presented. The prognostic considerations for the patient with GDM have also
been detailed. The education process and the Assure model were described.

Finally, the development and evaluation of PEMs using the EPEM model

developed by Bernier and Yasko (1991) was presented.

29
Chapter 3

Methodology
The purpose of this si■cholarly project was to construct a patient

education pamphlet that can be used to supplement specific oral instructions
delivered to women diagnosed with gestational diabetes mellitus (GDM).

This chapter discusses the development of the pamphlet using as a standard
the Evaluating Printed Education Materials (EPEM) model developed by
Bernier and Yasko (1991).

Model for Evaluating Printed Education Materials
Bernier and Yasko’s EPEM model is composed of five phases:

predesign, design, pilot test, implementation/distribution, and evaluation.

The phases of the EPEM model parallel the steps of the nursing process,

education process, and the Assure model (Appendix E).
Predesiqn phase. During the predesign phase, the need for a

pamphlet on GDM that would include information about prognostic
considerations was determined through discussion with one of the diabetes

nurse educators in a hospital-based diabetes educational center in
northwestern Pennsylvania. The purpose of the pamphlet is to supplement
specific oral instructions delivered by diabetes nurse educators to patients

who have been diagnosed with GDM. The pamphlet reinforces oral
instructions furnished to GDM patients seen in the diabetes education

center. The content of the pamphlet Includes: the etiology of GDM, risk

30

factors for developing GDM, screening tests to detect GDM, implications

GDM has for the mother and the baby, maternal and fetal complications
associated with GDM, management of GDM, and prognostic considerations

of GDM.
Design phase. During the design phase, the most essential
information was selected based on a review of the literature. As the content

was organized, information points were presented in a logical sequence so

that the flow of the pamphlet was smooth and readability was enhanced.
Careful attention was given to expressing one idea per sentence, using one

or two syllable words, avoiding medical jargon, and keeping sentences short
and simple. A personal, conversational writing style was used in the
pamphlet. Questions were used as headings to encourage active learning.
The readability of the pamphlet was determined at the sixth grade level using

McLaughlin’s SMOG formula (Appendix B).
Pilot test phase. The pilot test phase of this project involved testing
the first draft of the pamphlet with a random sample group of GDM patients

and two health professionals at a hospital-based diabetes education center

in northwestern Pennsylvania. The health professionals were asked to
provide feedback on the clarity and accuracy of the content. The pamphlet

ire for evaluation (Appendix G), and a cover letter
(Appendix H), questionnaire
accompanying the questionnaire (Appendix F) were distributed to five GDM

patients. The patients were asked to read the pamphlet and to complete the

31

questionnaire. Feedback from the two heaith care professionals and the four
GDM patients who returned the questionnai

re was used to evaluate and

revise the first draft of the pamphlet.
The diabetes nurse educator stated that the purpose of the pamphlet

was clear and that the content was accurate. The educator did suggest

including that GDM usually goes away within 48-72 hours after delivery of
the baby, and only if diabetes continues after the delivery, does the mother

need to monitor more frequently her blood sugars while breast feeding. The
suggestion that the dietician offered was that the word “temporary” be added

to clarify that the newborn’s low blood sugar level is a temporary state rather
than a permanent state. These revisions were made to the pamphlet.

All four GDM patients felt that the purpose of the pamphlet was clear

and that the information was helpful. The personal style in which the

pamphlet was written was clear and understandable to all four patients. They
all stated that the questions used in the headings were helpful. None of the
four patients identified any unfamiliar words. Two patients suggested that

information about the symptoms of type 2 diabetes be included in the

pamphlet, and this revision was made. One patient suggested that additional
information be included about the diet. Since the purpose of this pamphlet is

to supplement oral instructions that are delivered to GDM patients, and a diet
plan is tailored by a dietician to fit each patient's individual needs, no

additional information about the diet was included in the pamphlet.

32
The comp|eted pa(ient educat.on

pamphlet (Appendix H) was delivered to a hospital-based diabetes education

center in northwestern Pennsylvania. The pamphlet will be included in an
information packet that is distributed to all new GDM patients who are

referred for diabetes education in this hospital-based diabetes education

center.
Evaluation phase. The final phase in the development of PEMs is the

evaluation phase. The evaluation of this completed patient education
pamphlet can be accomplished by asking a small number of GDM patients to
participate in the evaluation phase. A similar questionnaire, used in the pilot

phase, could be employed to receive verbal or written feedback. Answers to
these questions can serve as a useful gauge in evaluating the quality of the

pamphlet and the effectiveness of reaching desired outcomes, and for
providing direction for future revisions of the pamphlet.

Summary
In summary, the purpose oif this scholarly project was to construct a

patient education pamphlet that can

be used to reinforce specific oral

Instructions delivered to women who have developed gestational diabetes

mellitus. The EPEM model developed by Bernier and Yasko (1991) was

adopted as the standard for developing this patient education pamphlet.

McLaughlin's SMOG formula was used to determine the readability of the

pamphlet.

33

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40

1

Appendixes

41

Appendix A
Oral Glucose Tolerance Test Results for
Screening and Diagnosis of GDM

Plasma Glucose mg/dL

Time

50-gram screening

OGTT

OGTT

>105

Fasting

1-hour

100-gram diagnostic

>140

>190

2-hour

>165

3-hour

>145

Diagnosis of gestational diabetes mellitus. After 100 gram oral

glucose load, diagnosis of GDM may be made if two venous plasma glucose
values equal or exceed the above values (American Diabetes Association,
1998).

42

Appendix B
Me Laughlin Smog Formula
The SMOG formula was originally developed by G. Harry Me Laughlin

in 1969. It will predict the grade-level difficulty of written material within 1.5

grades in 68% of the written passages tested. It is simple to use and faster
than most other measures. The procedure is presented below:

Instructions

1 ■ You will need 30 sentences. Count out 10 consecutive sentences
near the beginning, 10 consecutive from the middle, and 10 from the end.

For this purpose, a sentence is any string of words punctuated by a period
(.), and exclamation point (!) or a question mark(?).

2. From the entire 30 sentences, count the words containing three or
more syllables, including repetitions.

3. Obtain the grade level from Table on the next page, or calculate
the grade level as follows: Determine the nearest perfect square root of the

total number of words of three or more syllables and then add a constant of

3 to the square root to obtain the grade level
Example.
Total number of multi-syllabic (3 or more syllables) words....67

Nearest perfect square
Square root
Add constant 3

43
Grade 11 is the grade level.

Smog Conversion Table

Word Count

Grade Level

0-2

4

3-6

5

7-12

6

13-20

7

21-30

8

31-42

9

43-56

10

57-72

11

73-90

12

91-110

13

111-132

14

133-156

15

157-182

16

183-210

17

211-240

18

McLaughlin, G. H. (1969). SMOG-grading: A new readability formula.

ournal of Reading, 12. 639-645.

44

Appendix C

Classification of Gestational Diabetes Mellitus

Class

A-1

A-2

Fasting Plasma Glucose

Less than 105 mg/dL

Postprandial Plasma Glucose

and

Less than 120 mg/dL

More than 105 mg/dL and/or More than 120 mg/dL

Therapy

Diet only
Insulin

From the American College of Obstetricians and Gynecologists

(1986). Classification of diabetes in pregnancy, Technical Bulletin No. 92.
Washington, DC: U.S. Printing office.

45

Appendix D

Risk Factors for Developing GDM

* Obesity-weight > 200 lb
* Positive family history of diabetes mellitus

Previous history of GDM or macrosomia (newborn, 9 lbs or more)
* Advanced maternal age

Glucosuria on two successive occasions
* Excessive weight gain > 25 pounds during pregnancy

* Unexplained pregnancy wastage (spontaneous abortions, stillbirths)
* Multiparity

* Presence of hydramnios

Previous newborn with a congenital anomaly
* Hypertension

Member of high risk ethnic group:
Hispanic- and Latino-Americans
African Americans

Native American Indians
Asian Indians

Risk factors for developing GDM- From Reeder, S., Martin, L, a
Knoniak-Griffin D. (1997), MalsmiS^^
health care (18» ad. >, Philadelphia: Lippincott,

gnd ”men's

46
Appendix E
Nursing Process

Appraise physical and

ASSURE Model

-A- ASSESSMENT

Education Process

Ascertain learning needs

psychosocial

readiness to learn, and

needs

learning styles

Develop care plan based -S- PLANNING

Develop teaching plan to

on mutual goal setting to -S-

meet desired outcomes

meet individual needs.

Carry out nursing care

- IMPLEMENTATION-

Perform the act of teach

interventions using

-U-

ing specific instructional

standard procedures

-R-

Determine physical and

-E- EVALUATION

methods and tools

Evaluate behavioral
changes (knowledge,

psychosocial outcomes

attitudes, and skills.
The education process, the ASSURE model, and the nursing process
parallel each other. The ASSURE model: A= analyze the learner’s

capabilities and deficits, S

state the objectives, both the teacher’s and the

learner's, S= select instructional methods and tools, U= use teaching
materials, R= require learner performance, E= evaluate/revise the teaching

and learning plan (Bastable, 1997, Rega, 1993).

47

Appendix F

Cover Letter Accompanying Pamphlet and Questionnaire

Dear Patient,
I am a graduate student at Edinboro University of Pennsylvania. I am

working on creating a pamphlet to give to women who develop Gestational
Diabetes Mellitus. Creating this pamphlet is part of the requirements for me
to graduate.

I would like to request your help in revising this draft of the pamphlet.

Would you take a few moments of your valuable time and read the entire
pamphlet? After you have read the pamphlet, would you complete the
questionnaire attached to the front of the pamphlet?

I thank you in advance for your fine cooperation in reading the

pamphlet and completing the questionnaire.
Sincerely yours,

Lucille K. Steele Morrison
EUP Graduate student

48

Appendix G
Questionnaire For Evaluation/Revise Phase

1. Is the purpose of the pamphlet clear to you?

2. Is the information new and helpful?

3. Is the pamphlet written in a style that is clear and understandable?

4. Are the questions in the headings helpful?

5. Are there any unfamiliar words?

6. Is there any other information that you think should be included in
the pamphlet?

49

A Guide to Understanding
Gestational Diabetes

50

What is
gestational
diabetes
mellites?

Your body gets sugar from the food you eat. This sugar

goes into your blood and then into the cells of your
body.

ou then make energy from this sugar in your

body’s cells.

Insulin is a hormone
made by your body’s
pancreas. Insulin helps

sugar leave the blood and go into your body’s cells.
When this happens the way it should, the level of sugar

in your blood goes down. Your body’s cells can then
make all the energy you need to do things.
When you have diabetes, your body does not make as

much insulin as it needs. The sugar cannot leave your
blood like it should. Instead, the sugar stays in your
blood, and the level gets higher and higher. You also

cannot make enough energy in your body’s cells.

51

Gestational diabetes mellitus (GDM) is a kind of
diabetes that you can only develop when you are going

to have a baby. (Gestation is another word for
pregnancy.) GDM develops between the 24th and 28th

weeks of pregnancy.

Who can

If you are over 30 years old, are overweight, have a

get GDM?

family history of diabetes, or have a previous history of

GDM or delivery of a baby over 9 pounds, you have a

greater chance of developing GDM. Any pregnant
woman can get GDM, but it is
more common in:
♦ Hispanic Americans

♦ African Americans
Native Americans

♦ Middle Easterners

52

How will
I know if I
have GDM?

Y ou may not feel any differently if you have GDM, and
that is why all pregnant women should be checked. A

blood test is the only way to be sure if you have it.
♦ If you have had GDM before, your doctor may

do the blood test at your first visit.

♦ If you have never had GDM before, your
doctor may do the blood test between the 24th

and 28th week of your pregnancy.

How is the test done?
When you are tested for GDM, you will be asked to
drink a sugary drink. You will then have a blood test

one hour later. If the result of the test is above a certain
level, you will then be asked to take a three-hour test.
You should do this test as soon as you can and you

cannot eat before it. The results from this test will tell

your doctor if you have GDM. If you end up having
GDM, you will need to start treatment right away.

53

What does
having
GDM mean
to me and
my baby?

When you are pregnant, everything your baby needs to

grow and be healthy comes from you. Vitamins,
minerals, and sugar are carried in your blood to your

baby. If everything works as it should during your
pregnancy, you will be able to give your baby all that
it needs.

When you have GDM, this process does not work as
well. Instead of sugar being used to make energy, sugar
stays in your blood. A

high level of sugar in
your blood is not healthy

for you or your baby.

54

Will GDM
hurt
my baby?

GDM will not cause your baby to have diabetes after it

is bom. In fact, if you keep your blood sugar level in the
normal range during your pregnancy, you have a very
good chance of having a healthy baby. If you do not

keep your blood sugar level in the normal range, your
baby can have some problems.

Large birth size
When you have a higher than normal blood sugar level,
a lot of the extra sugar goes to your baby. Your baby

makes extra insulin to try and lower this blood sugar

level, but this extra insulin and sugar causes your baby
to grow very big. This makes it harder for you to give

birth to your baby. Sometimes an operation called a
cesarean section is needed to help deliver your baby.

55

Low blood sugar in your baby after birth
If you have high blood sugar levels during your
pregnancy, your baby will continue to make extra
insulin. After birth, your baby will still make extra

insulin even though it does not need to. This extra
insulin will cause your baby’s blood sugar level to drop

very low temporarily, and a low blood sugar level can

hurt your baby. For

several hours after
delivery, your baby’s

blood sugar level will be checked often.

Jaundice
A slight yellow skin color (jaundice) is normal in a new

baby. Usually the yellow skin color goes away by itself.
When you have GDM, jaundice in your baby may be
more severe. Your baby might even need a special kind

of light treatment to help the jaundice go away.

56

Other problems
High blood sugar levels can cause your baby to be bom
early, which in turn gives your baby the possibility of

having breathing problems. It is rare that a life­

threatening problem develops, because now there are

easy ways to check your baby before and during birth.

Labor and delivery
How can
GDM affect Most women with GDM can have a regular vaginal
ma?
delivery, but you need to keep your blood sugar levels in
the normal range so your baby will not grow too big. If
your baby grows too large, you may need to have a

cesarean delivery.

Greater risk for infection
With GDM, you have a greater

WIWI

chance of getting vaginal, bladder and

PILLS

kidney infections. You may have to
take medicine to treat the infections.

57

High blood pressure

|C

When you have GDM. your blood pressure can go up.
This is not healthy for you or your baby and you will

need treatment to bring your blood pressure down. This

could mean that you would have to stay in bed most of
the time until your baby is bom. It could also mean your
baby will have to be delivered early.

Diabetes after your baby is born
The most serious problem for you if you have GDM is
that your diabetes may not go away after pregnancy.

You also have a greater chance of developing type 2

diabetes when you are older. Being overweight puts you
at an even higher risk of developing diabetes later in life.

You should have an oral glucose tolerance test at your

six-week check-up after your baby is bom to make sure
that your blood sugar level has returned to normal. After

that, you should have your blood sugar level checked

once each year.

58

If you have GDM, you may develop it again the next
time you are pregnant. Because of this, you will need to
have your blood sugar level checked as soon as you

know that you have become pregnant.

What can I By keeping your blood sugar levels normal, you do the
do to take best you can to keep yourself and your baby healthy.
care
There are several things you can do.
of my
baby and
Work with your health care team
myself?
Before you knew you had GDM,

your regular doctor cared for you.

Now you may also need others to
help you. The best way to get this help is from a health

care team. Your health care team may include:

• a doctor who treats diabetes (an endocrinologist)

• a nurse who will help you learn how to control your
blood sugar levels (diabetes nurse educator)
• a person who can teach you about the foods you

should eat (a dietician)

59

Follow your meal plan
You will need to eat healthy. It is important to include
all of the basic food types in your meal plan. A dietician

will help you come up with a meal plan that will keep
your blood sugars normal and keep your baby healthy.

You should stay away from:

A

alcohol
V caffeine

V foods high in
sugar, such as candy, soft drinks,

and sweetened desserts

Test your blood sugar
You may need to test your blood sugars several times

each day. You will need to do this before you eat in the

morning and two hours after you eat. Your blood sugar
goals are the same as in normal pregnancy. The nurse

will show you how to test your blood sugar level.

Ideal Blood Sugar Values
Before Breakfast
2 hours after meals

....................... less than 95 mg/dL
...less than 120 mg/dL

60

You will also be asked to keep a written record of your
blood sugar levels. You will need to bring this record

with you whenever you go to visit your doctor.

Testing your urine for ketones
Your body’s cells use sugar to make energy. Sugar
cannot be used if your body does not make enough

insulin. When you do not make enough insulin, your
body will start to break down fat to make energy. When
your body uses fat to make energy, ketones are left over.

Ketones in your blood may harm your baby. Ketones
can also leave your body through your urine.
Your body may make ketones if
you go too long without eating.
You should eat a snack before

you go to bed at night. You should not skip meals. You

should eat your meals at regular times and eat everything
that is on your meal plan.

61

You will need to check your urine each morning for

ketones, and record the results in a logbook. The nurse
will show you how to do this.

Exerciso
Exercise helps you feel better and helps you control your
weight. Exercise also helps keep your blood sugar levels

in the normal range. Good forms of exercise are:
fast walking

V swimming
"V stretching exercises

Ask your doctor about the kinds of exercise that you
should do.

If you need more help
If your meal plan and exercise plan does not keep your
blood sugar levels in the normal range, you may have to
take insulin shots. If you need to take insulin shots, you

will be taught how to give yourself the shots.

62

Keeping written records
T ou need to keep a written record of:
V Your blood sugar test results
V Your urine ketone test results
V Any change in your diet

"V Any change in your exercise
V Any change in your insulin

What tests
will my
doctor do?

you have GDM) your doctor wil1 want t0 see y°u
often. Starting around the 34th to 36th week of

pregnancy, your doctor will do tests to see how well

your baby is growing. Some of the tests are:
• ultrasound (sonogram) - This is a safe and painless

test. It checks to see how big your baby is.
• baby movement counts - You will be asked to count

the number of times your baby moves during a
specific amount of time each day. Call your doctor at
once if you think your baby’s movements have

slowed down.

63

• non-stress test - This test is also painless. This is a

test to find out how fast your baby’s heart is beating
o

every time your baby moves.

After my Breast-feeding
baby is
It is okay for you to breast-feed your baby. Breast milk
born, what is good for your baby, and it helps to keep your baby
should I do?
healthy. Breast-feeding can also help you with weight
control. If your diabetes does not go away after your
Y

baby is bom and you choose to breast-feed, you will

need to check your blood sugar levels more often.

7\

After your baby is born
You should have a glucose tolerance test six weeks after

your baby is bom. This will let you and your doctor
know for sure if your diabetes is gone. In most women

with GDM, the diabetes goes away within 48 hours after

the baby is bom.

64

If your blood sugar level does not return to normal, you

will need to see your doctor for medical care. Even if

your blood sugar level returns to normal, you still need
to watch your weight. You need to be careful what you
eat and you still need to eat using a healthy meal plan.

You also need to have a regular exercise program.
You should have your blood sugar level checked every
year to make sure you are not developing type 2

diabetes.

What if I
gat
pregnant
again?

Once you have GDM, you are more likely to develop it
again with your next pregnancy. With each future
pregnancy, you should ask your
doctor to test you for diabetes at your
first visit. If the test is normal, then

\ you should be checked again at 24th to
28th weeks of pregnancy.

65

What about
my future
health?

About one-half of all women who have GDM will

develop type 2 diabetes. It may happen right after your

baby is bom or years later.

It is important that you have a blood sugar test each year.
You should also learn the symptoms of type 2 diabetes.
You will need to watch for symptoms, such as increased

thirst, hunger, frequent urination, fatigue, blurred vision,

yeast infections, or numbness in your hands or feet.

You should have your blood sugar tested before you get

pregnant again.
V You should always eat using a healthy

meal plan.
V You should not gain a lot of weight.
V You should exercise regularly.