The incidence of diabetes is rising globally, attributed to factors such as changes in food systems (Monteiro et al, 2021), sedentary lifestyles resulting in reduced physical activity (Lim and Pranata, 2020) and obesity (Klein et al, 2022). Epidemiologists predict that by 2050, more than 1.5 billion people will be living with diabetes (Sun et al, 2022). The consequence of this will be shorter life expectancy for future generations, as diabetes is closely linked to renal and cardiovascular disease (Williams et al, 2020).
The worldwide prevalence of pregnant women developing gestational diabetes mellitus is also increasing (Liu et al, 2020), and has been described as ‘the most common medical complication of pregnancy’ (McIntyre et al, 2019). A woman is diagnosed as having gestational diabetes mellitus if she has any glucose intolerance that is revealed for the first time during her pregnancy (Kilgour et al, 2015), and is diagnosed after the first trimester (Egan et al, 2020). In the UK, around 5% of all pregnant women will develop gestational diabetes mellitus or have pre-existing Type 1 or Type 2 diabetes mellitus (Murphy, 2021). Other countries have reported similar numbers (Kilgour et al, 2015; Choudhury and Devi Rajeswari, 2021).
Diabetes mellitus or gestational diabetes mellitus have enormous impacts on the pregnant woman or fetus, and can cause excessive fetal growth (Mirabelli et al, 2021), adverse fetal developmental changes (Ornoy et al, 2021) and other perinatal complications (Capobianco et al, 2020). Early detection, screening, diagnosis and management reduce the risk of these complications; midwives play a vital role in recognising high-risk pregnancies and are best placed to assist with management, education and support of women with diabetes. Therefore, midwives need to maintain their education regarding the care of women with diabetes. Hospital in-services or online education packages are available to midwives, and the National Institute for Health and Care Excellence (NICE, 2015) guidelines provide excellent practical and easy-to-read information on how to care for a woman with diabetes in pregnancy, labour and birth as well as postnatally. Local organisations in various countries, such as the Joint British Diabetes Societies (JBDS, 2017) for Inpatient Care in the UK also have evidence-based guidance for healthcare professionals.
While an abundance of educational information does exist, midwives have stated that more training and education is necessary. In a survey by Dashora et al (2018), more than 85% of midwives stated that ongoing education was necessary, not just for midwives whose specific role was the care of women with diabetes, but for midwives who worked across the maternity care spectrum. This article therefore provides a brief guide to the postnatal care of women with diabetes (including Type 1/2 diabetes mellitus and gestational diabetes mellitus). First, the importance of comprehensive postnatal care will be highlighted. Challenges to contemporary delivery of postnatal care will be explored, followed by a discussion of the role that midwives play in the current NICE (2015) and JBDS (2017) postnatal diabetic guidelines.
The importance of postnatal care
Careful and continuous monitoring of women with diabetes mellitus and gestational diabetes mellitus is essential in pregnancy, labour and birth. However, postnatal follow-up is also vital because of the short and long-term sequelae. Women who develop gestational diabetes mellitus during pregnancy are at risk of recurrence in subsequent pregnancies, with ethnicity and multiparity contributing to higher recurrent rates (Schwartz et al, 2015). In addition, there is a 7-fold possibility of women with gestational diabetes mellitus developing Type 2 diabetes mellitus at a later stage (Bellamy et al, 2009; Jones et al, 2019). Around 5% of women who had gestational diabetes mellitus in pregnancy will develop Type 2 diabetes mellitus within 6 months of giving birth, and up to 60% will develop Type 2 diabetes mellitus within 20 years (Choudhury and Devi Rajeswari, 2021).
Women who develop gestational diabetes mellitus are also at risk of cardiovascular complications, such as ischaemic heart disease and hypertension, at a younger age (Daly et al, 2018; McKenzie-Sampson et al, 2018). Increased rates of depression have also been noted in women who develop gestational diabetes mellitus (Hinkle et al, 2016; Silverman et al, 2017). Women who have Type 1 diabetes are at increased risk of postnatal thyroiditis and require careful monitoring to detect this condition (Buschur and Polsky, 2021).
It is imperative that a comprehensive postnatal care plan is created. Healthcare providers from all health disciplines can be instrumental in encouraging and enabling change in the postnatal behaviour of women with diabetes (Ortiz et al, 2016). However, if there is a lack of coordination between the inpatient health facility and the community, uncertainty regarding the care plan and the healthcare professional responsible for overseeing that plan may result in fragmented and disjointed care. This may discourage women from attending postnatal appointments.
Challenges in postnatal care
Despite awareness of the importance of good postnatal care of women with diabetes, many women do not receive the individualised healthcare that they require (McMillan et al, 2018; Roberts et al, 2021). Postnatal women have reported that they felt ‘abandoned’ (McMillan et al, 2018) after discharge from a health facility. Pregnancy, labour and birth can be times of intense scrutiny, involving constant contact with the diabetic team, but the expert attention provided in the antenatal and intrapartum periods may be lacking once the woman goes home (McMillan et al, 2018). This can result in women lacking confidence in the healthcare system and disengaging from clinical assessments (Roberts et al, 2021).
For some women, there is confusion over which health facility will be caring for them and monitoring their diabetic status in the postnatal period (Lithgow et al, 2021). The hospital discharges women to community care; however, some women with gestational diabetes mellitus find that their GP or child health nurse is unaware of their diagnosis of gestational diabetes mellitus (Kilgour et al, 2015; Zulfiqar et al, 2017; Lithgow et al, 2021) or that the hospital recommendations for postnatal care are not clear (Kilgour et al, 2019). Sometimes, it is left to the woman to update community healthcare providers about her condition (Kilgour et al, 2019; Lithgow et al, 2021). Women have reported that their GPs concentrated on short-term, rather than a long-term, issues, despite women wanting to find out about future risks, such as development of Type 2 diabetes mellitus after gestational diabetes mellitus (Lithgow et al, 2021). Women have also criticised the purely clinical or physical focus of the postnatal appointments, which have not satisfied women seeking a more holistic or woman-centred focus (Davis et al, 2024).
Some women have reported a lack of awareness around the need for ongoing diabetic-specific healthcare following the birth of the baby (McMillan et al, 2018). Women knew that they had to attend a postnatal check up, but were less aware of the need for a diabetic test within the first 3 months of having a baby. This lack of communication has impacted multiparous women in particular (Roberts et al, 2021). The type of diabetic testing, as well as the timing of the test and the complete plan of care, is often inconsistent, resulting in dissatisfaction for women (Roberts et al, 2021). The NICE (2015) guidelines (item 1.6.11) state that postnatal women with gestational diabetes mellitus should be offered a fasting plasma glucose test at 6–13 weeks to detect those who may have developed Type 2 diabetes mellitus. However, some women have reported that they were tested using a pregnancy oral glucose tolerance test instead, and had to return on another date to have the fasting plasma glucose test (Roberts et al, 2021), which was frustrating and time wasting.
Women have many priorities after the birth of a baby, and a medical appointment may be time-consuming for a mother who is coping with the demands of a newborn (Lithgow et al, 2021). If the woman is feeling well, she may consider the medical appointment unnecessary or think that she is no longer diabetic (Lithgow et al, 2021). Financial constraints may prevent the woman from seeing her GP, and in some settings, the diagnosis of diabetes mellitus can carry stigma and the woman may be reluctant to publicly acknowledge her condition (Davis et al, 2020; Lithgow et al, 2021).
Research has demonstrated that women who have had gestational diabetes mellitus in pregnancy, or who have diabetes mellitus, require additional support in the postnatal period (McMillan et al, 2018). The intensity of scrutiny during pregnancy, labour and birth may contribute to increased anxiety and guilt, known as ‘diabetes distress’ (Buscher and Polsky, 2021). Many women with diabetes are at greater risk of postnatal depression (Buschur and Polsky 2021). The general wellbeing and mental health of postnatal women with diabetes should be considered at the postnatal check, but because of the short appointments in many GP checks, this may not be addressed (Buschur and Polsky, 2021).
Midwifery care of postnatal women with diabetes
While midwifery care guidelines are often divided into preconception and antenatal, labour/birth and postnatal care, it is important to remember that the woman herself does not necessarily view each stage as separate. Indeed, most women experience pregnancy, labour, birth and the postnatal period as a continuum (Vedeler et al, 2022). Postnatal guides should therefore be read together with information regarding other stages of pregnancy and childbirth. Davis et al (2024) stated that excellent care in the postnatal period is vitally important and highlighted the need for holistic care that includes the woman as a partner. Postnatal women with gestational diabetes mellitus have identified feelings of abandonment by healthcare professionals, as well as a lack of attention to longer-term health issues. A holistic and comprehensive approach to postnatal care will contribute to the ‘coherence’ (Vedeler et al, 2022) of the woman's journey.
Women with diabetes are usually referred to a diabetic team in healthcare facilities, and an agreed plan is formulated. Midwives can reiterate the guidance provided to the woman by the diabetic team, and thereby effect positive change. It is important that midwives repeat information that was provided antenatally to postnatal women, to stimulate recall and promote and improve understanding (Zulfiqar et al, 2020). When midwives continue to talk about diabetic care after birth, women prioritise that care and attempt to implement recommendations (Evans et al, 2021). Woman-centred care by a midwife has been shown to improve outcomes for women, increase their satisfaction and experiences of healthcare, and result in lower overall costs (Jonas and Rosenbaum, 2021). Despite the specific management of women with diabetes being the remit of a diabetic team, midwives are the coordinators of maternity care (Nursing and Midwifery Council, 2019), and when midwives are included as equal partners in a broad multidisciplinary team, they can make a positive contribution to all aspects of maternity care (Consultant Midwives Cymru, 2017). Indeed, when midwives collaborate with medical specialists in the care of women with complications, such as diabetes mellitus, morbidity and mortality is reduced (Renfrew et al, 2014).
The postnatal care plan drawn up by the diabetic team will follow the health facility and NICE (2015) or JBDS (2023) guidelines. The NICE guidelines were amended in 2015 and again in 2020, and it is possible that some midwives may not be aware of the changes made. In the following section, some of the NICE guidelines are explained in more detail, with emphasis on the role of the midwife.
For women who had gestational diabetes mellitus in pregnancy, blood glucose levels should be monitored every 4 hours, up until the first meal (NICE, 2015). Thereafter, blood glucose levels are monitored before and 1 hour after meals for the first 24 hours after the birth (NICE, 2015). While this may seem unusual, as gestational diabetes mellitus is associated with pregnancy, it is possible that blood glucose level monitoring may uncover unknown pre-existing or new onset diabetes mellitus. Blood glucose levels should be between 6 and 10mmol/L (JBDS, 2017). If blood glucose levels are higher than 7mmol/L pre-meal, or higher than 11.1mmol/L post-meal, the woman should be referred to the diabetic team (NICE, 2015). It is possible that oral anti-diabetic drugs or insulin may be prescribed.
If a woman with diabetes mellitus is breastfeeding or expressing, she is at risk of hypoglycaemia, because metabolic requirements increase, causing a fall in circulating blood sugar levels (Surendran et al, 2019; Buschur and Polsky, 2021). Many women worry about this risk (Buschur and Polsky, 2021). Women should be advised to have a snack of 10–15g of carbohydrates as well as a drink close at hand each time they breastfeed or express (JBDS, 2023), including for night feeds. To achieve satisfactory lactation, women require additional carbohydrates, and the JBDS (2023) advises that an additional 450 calories may need to be added to a woman's diet to establish and maintain lactation.
It is important for midwives to hold meaningful conversations with women regarding their diet; women have reported receiving vague advice regarding their postnatal diet and sometimes no dietary education or support is provided (Eades et al, 2018; Davis et al, 2024). Midwives can connect the woman with a community dietician who can reinforce dietary advice. As the woman adjusts her carbohydrate intake, her insulin dose may also need adjustment (JBDS, 2023). Careful, clear conversations regarding calorific intake should be held with the woman. If a woman is using formula to nourish her baby, there is no need for extra carbohydrates or calories, and the woman should be advised to resume her pre-pregnancy carbohydrate intake regime (JBDS, 2023).
Some women may need to resume oral glucose lowering drugs once the baby has been born. Metformin is safe to use if the woman is breastfeeding, as it will not cause hypoglycaemia and is the oral glucose lowering drug recommended by NICE (2015). Glibenclamide continues to be listed as a possible oral glucose lowering drug for breastfeeding women in the JBDS (2017) guidelines, but this option was removed from the NICE (2015) guidelines in 2015.
For all women who developed gestational diabetes mellitus in pregnancy, a fasting plasma glucose test is required at 6–13 weeks in the postnatal period (NICE, 2015), to detect if women have developed diabetes mellitus. As most women attend a 6-week postnatal check with their GPs, this is the ideal time for this test. However, it is important that midwives emphasise the need for this test and remind women to ask their GPs for it. Sufficient time to complete the test needs to be factored into the 6-week postnatal check, and midwives can advise women to ask for this extra time in the postnatal appointment. Some GPs may be unaware of women's diabetic status, especially if she developed gestational diabetes mellitus, and so may not offer the fasting plasma glucose test. In addition, women may not feel unwell in the postnatal period, and because the fasting plasma glucose test has not been raised by the GP, women may assume that the impact of diabetes has ceased (Kilgour et al, 2015). However, midwives should remind women with gestational diabetes mellitus that they need lifelong follow-up, becaues of the ongoing risk of developing cardiovascular disease and diabetes mellitus (Egan et al, 2020).
The postnatal education of all women with diabetes should include discussions around contraception and plans for future pregnancies. A women with diabetes mellitus or gestational diabetes needs time to achieve control of her blood glucose levels, and adjust to her own and her baby's healthcare. Midwives can advise women that appropriate spacing between pregnancies will enable them to adjust to motherhood. Long-acting contraceptive options, such as an intrauterine device, are usually recommended (JBDS, 2017). However, for women with diabetes who have vascular complications, progesterone-only contraceptives are the best option (Buschur and Polsky, 2021). Midwives can reassure women that neither the intrauterine device nor progesterone-only contraceptives interfere with lactation.
Women who have Type 1 diabetes mellitus should be screened for postnatal thyroiditis, as their risk of this condition is 3–4 times higher (Buschur and Polsky, 2021). Postnatal thyroiditis is the development of hypothyroidism or thyrotoxicosis (or both) in the first 12 months after the birth of the baby (Smith et al, 2017). Testing for postnatal thyroiditis involves assessing the level of thyroid stimulating hormone at 3 and 6 months postnatally. If postnatal thyroiditis is diagnosed, women will require annual thyroid stimulating hormone tests for 5–10 years (Smith et al, 2017). Postnatal thyroiditis occurs in 7–10% of postnatal women (Smith et al, 2017), and midwives should counsel women with Type 1 diabetes about this possibility.
All women who are diabetic or who had gestational diabetes mellitus in pregnancy should receive in-depth and practical counselling about diet, behaviour and lifestyle modifications. These have been shown to have major impacts on the chances of developing further complications later in life (Ringvoll et al, 2023), and emphasis on these issues is therefore warranted. Midwives should go through these aspects of care in great detail, ensuring that women have good understanding of how to adjust their diets and lifestyles.
Conclusions
The incidence of diabetes mellitus and gestational diabetes mellitus are increasing worldwide. Diabetes can have serious consequences for both mother and baby. Midwives have the important role of working in partnership with women, ensuring that they have a safe and positive experience during their maternity care, from pre-conception through to the postpartum period. Comprehensive assessment of women with diabetes enables midwives to implement and evaluate care for each woman on an individual basis. This practice entails applying preventative measures, recognising complications in the mother, promoting health and education and working in collaboration with other healthcare professionals to ensure the best possible outcome for the woman. Up-to-date knowledge of how to care for women with diabetes is therefore very important for midwives.