Acute effect of exercise on blood glucose and insulin levels in women with gestational diabetes.

OBJECTIVE: To evaluate the effect of a single session of exercise (cycling), at rest (control condition) and at two intensity levels (low- and moderate-intensity exercise conditions), on blood glucose and insulin in pregnancy complicated by gestational diabetes mellitus (GDM). METHODS: A one-group repeated measures design was used. Women aged 18-38 with GDM, no other complications, not on insulin, and not exercising regularly were recruited. The women rested or exercised at the two intensities for 30 min and rested for 2 h after each session. Blood was sampled for blood glucose, insulin and hematocrit at baseline and every 15 min. RESULTS: There was no difference at baseline in blood glucose levels. The blood glucose level was significantly lower for each exercise condition compared to rest, and for moderate compared to low-intensity exercise (5.2 vs. 4.3 vs 3.9 mmol/l) at the end of exercise (30 min), and for the two exercise conditions compared to rest at 15 min after exercise (4.9 vs 4.4 vs. 4.0 mmol/l). By 45 min after exercise, the blood glucose values were nearly identical. The area under the curve for blood glucose was significantly lower for low- and moderate-intensity exercise than for rest (p = 0.01). The slope of change in insulin among the three conditions, from baseline to the 30-min session, approached significance (p = 0.065). The power for that analysis was 0.51. A sample of 23 would have been required to increase the power to 0.80. CONCLUSIONS: Significant declines in blood glucose level were observed during low- and moderate-intensity exercise compared to rest. These differences were gone by 45 min after exercise. Continued research should examine those with high body mass index and more pronounced hyperglycemia for further evaluation of the effect of exercise on blood glucose and insulin levels in women with GDM.

The experience of sexuality during breastfeeding among primiparous women.

The purpose of this study was to describe various aspects of sexuality for primiparous breastfeeding women. The conceptual framework used for the study was Bernhard's theory of women's integrated sexuality which describes female sexuality as a multidimensional, biopsychosocial phenomenon. The investigators used a descriptive design, analyzing data from the 576 primiparous breastfeeding women who, as part of a larger study, completed the Breastfeeding and Sexuality Tool at the time of complete weaning. The women were from a large, private hospital in urban Minnesota. Subjects completed initial questionnaires during the postpartum hospitalization. Follow-up data were collected by phone at 1, 3, 6, and 12 months postpartum. Those who had not weaned by 12 months were followed every 3 months until complete weaning was reported. Overall, women perceived that breastfeeding had a slightly negative impact on the physiologic aspects of sexuality, but did not greatly affect the woman's sexual relationship with her partner. In addition, breastfeeding mothers perceived their partners' attitudes towards breastfeeding and sexuality as slightly positive, and did not worry that sexual activity would harm their milk supply or their ability to nurse. Overall, breastfeeding had a slightly negative impact on sexuality. However, a wide range of responses were reported by the women. Health care providers should be familiar with the whole range of possible responses to sexuality while breastfeeding in order to appropriately counsel women about what is normal and what to expect during this time.

Diabetes in pregnancy: the midwifery role in management.

Although the primary focus of midwifery is on uncomplicated pregnancy, all midwives must screen for and, in some cases, comanage the care of women with diabetes mellitus and gestational diabetes. This article will review the types of diabetes, implications for preconceptional and pregnancy care, the changing recommendations relative to diabetes in pregnancy, and the role of the midwife in providing antepartal and intrapartal care for women with diabetes in collaboration with other health care professionals and in accordance with the philosophy and standards of the American College of Nurse-Midwives. A specific case study will highlight the role of the midwife, with an overall focus on medical consultation, collaboration, and referral, as well as client involvement in the planning of care.

The evolution of the core competencies for basic midwifery practice.

The Core Competencies for Basic Midwifery Practice, as promulgated by the American College of Nurse-Midwives (ACNM), was first published in 1978 to provide a standard approach to nurse-midwifery education. Since then, it has been revised three times, most recently in 1997, and now serve as the curricular template for ACNM-accredited education programs. This paper discusses the historic evolution of the core competencies and the document's use in midwifery education and practice.

Outcomes of macrosomic infants in a nurse-midwifery service.

The purpose of this study was to compare outcomes of term infants of average birth weight with outcomes of large infants in a nurse-midwifery service. A retrospective study design was used. Data were retrieved from a computer data base that contained information from a data form routinely completed for all births. Subjects were women cared for by the nurse-midwives including those for whom the birth was conducted by a physician. The final n study population was 2,228; 322 (14.5%) of the infants weighed 4,000 g or more. Women who delivered large infants had a significantly higher prepregnant body mass index and pregnancy weight gain. Shoulder dystocia occurred more often in large infants; however, newborn intensive care unit admission rates did not differ between the average birth weight and the large infants. Apgar scores at 1 and 5 minutes were significantly lower for infants weighing > or = 4,500 g compared to those with birth weights of 2,500-3,999 g and those 4,000-4,449 g; however, these differences were not clinically significant. A trend for fewer occurrences of shoulder dystocia in the side-lying birth position was observed. Logistic regression predicting poor Apgar scores (< 7) showed parity as a protective factor and increased gestational age and higher maternal body mass index as predictive of low Apgar scores. Large infants had birth outcomes comparable to those reported by others in the medical literature, suggesting that nurse-midwifery management, including consultation with physician colleagues, can be appropriate and safe.

Effects of a partially home-based exercise program for women with gestational diabetes.

OBJECTIVE: To examine the effectiveness of a partially home-based, moderate-intensity aerobic exercise program for women with gestational diabetes. METHODS: This was a randomized experimental design. Thirty-three women with gestational diabetes were randomly assigned to the exercise or the no-exercise group. Subjects underwent hemoglobin A1C assay and submaximal cycle ergometer fitness tests at baseline and at study conclusion. Subjects kept diaries of home fasting and 2-hour postprandial blood glucose determinations. Exercise subjects were asked to exercise for 30 minutes three to four times weekly at 70% of estimated maximal heart rate for the weeks of study participation. Two exercise sessions weekly were supervised by the investigator, and two were unsupervised at home. Control-group subjects were asked to maintain their current activity level. RESULTS: Daily fasting and postprandial blood glucose levels, hemoglobin A1C, incidence of exogenous insulin therapy, and incidence of newborn hypoglycemia were not different between the groups. There was a training effect in the exercise group (P = .005) but not in the control group (P = .25). A significant decline in daily grams of carbohydrate consumed was observed in the control group (P = .03), but not in the exercise group (P = .97). No complications were found in the subjects who exercised. CONCLUSIONS: A partially home-based exercise program did not reduce blood glucose levels, but did result in a modest increase in cardiorespiratory fitness. The intervention appeared safe.

Remembering the nurse in the business advanced practice.

The question about whether advanced practice nurses maintain a nursing perspective in their practice has been asked. This article explores traditional practice differences between medicine and nursing and proposes a Cure-Care continuum as a framework to look at role delineation. The ANA Social Policy Statements and statements from national organizations representing advanced practice nurses are examined in looking further at advanced nursing practice. The statements reviewed and research to date focusing on outcomes of care by advanced practice nurses leads to the conclusion that the care is high quality and is delivered from a strong nursing perspective. Focus on this growing area of nursing should be on providing quality, comprehensive, cost-effective care in meeting health care needs in the future.

Anemia and insufficient milk in first-time mothers.

Insufficient milk is a poorly understood problem that is often identified as a major reason for early discontinuation of breastfeeding. This study explored the relationship between anemia and insufficient milk in 630 first-time mothers. The frequency of anemia (postpartum hemoglobin < 10 g/dL) was 22 percent. Anemic mothers reported a higher level of symptomatology associated with insufficient milk and were more frequently classified as having insufficient milk syndrome. Mothers with the syndrome reported a shorter period of full breastfeeding, and weaned at an earlier age. They identified not having enough milk, baby nursing too often, and baby not gaining enough weight as the main reasons for discontinuing breastfeeding, compared with baby's disinterest and conflicts with school or work as main reasons among mothers not reporting symptoms related to insufficient milk syndrome. The study results suggest that anemia is associated with the development of insufficient milk, which in turn, is related to duration of full breastfeeding and to age at weaning.

Women's experiences with breastfeeding longer than 12 months.

This prospective, longitudinal study was conducted to describe the experiences of 82 primiparas who breastfed longer than 12 months. They were compared with 541 primiparas who weaned their infants within the first year. Greater age, education, and weeks of exclusive breastfeeding were associated with longer duration of breastfeeding. More than two-thirds (68%) of the women who breastfed longer than one year returned to employment before their infant was 1 year old. The most frequently chosen reason for long-term breastfeeding was that breastfeeding was a special time for mother and baby that the mother was not ready to give up. Nearly half of the women reported breastfeeding their babies on demand. At 12 to 15 months, 54 percent of the babies slept in a crib in a separate room, and 37 percent slept in the same bed with their mother all or part of the night. Most mothers (57%) considered their support group to be slightly or moderately important in influencing their decision to breastfeed beyond a year, and 10 percent considered it to be extremely important. The major themes that emerged from women's comments were the importance of being strong in the face of social unacceptability, development of a close mother-child bond, and the naturalness of breastfeeding beyond 12 months. Health caregivers should recognize the emotional and interpersonal aspects of long-term breastfeeding, support the breastfeeding relationship, and avoid contributing to the development of "closet nursers" so that women may feel free to discuss their concerns about their child's health.

Gestational diabetes.

Gestational diabetes is a condition that complicates 0.15% to 12.3% of pregnancies, with wide variation in the incidence of gestational diabetes reported among ethnic groups. When gestational diabetes occurs, health implications occur for the mother and infant not only during pregnancy and birth but for the long term as well. This article reviews what is known about gestational diabetes and presents an overview of carbohydrate metabolism in normal pregnancies and those complicated by gestational diabetes. A review of recent research and advances in the field focusing on the screening, diagnosis, and treatment of gestational diabetes is also provided. The most important aspect of gestational diabetes management is client participation. Recommended education and counseling for women with gestational diabetes is discussed for pregnancy, labor and birth, postpartum, and long-term follow-up. Although medical consultation is necessary in these pregnancies, many nurse-midwives continue to provide care for women with gestational diabetes. Appropriate nurse-midwifery management of women with gestational diabetes is emphasized.

Women's experiences with combining breast-feeding and employment.

A group of primiparas who combined breast-feeding and employment are described in terms of how they felt about the experience, the difficulties they encountered, factors that affected their total duration of breast-feeding, and patterns of feeding while separated from their infant. These women are contrasted with primiparas who weaned prior to returning to work and those who remained homemakers. Of the 619 women included in the analyses, 499 (80.6%) of the women returned to work or school by 12 months postpartum and 288 (46.5%) continued to breast-feed after returning to work. Women who combined breast-feeding and employment were older, had more years of education, worked fewer hours per week, and more worked in professional jobs than those who weaned prior to returning to work. A number of women who chose to express breast milk only at home thought they would have had problems with having enough time and finding a place to express and to store expressed milk had they tried to express breast milk at work. The overwhelming majority of women who combined breast-feeding and employment felt that it was worth the trouble, that they would recommend it to others, and that they had done something special for their infants that no one else could do. The findings suggest that nursing interventions and workplace accommodations could assist more women to experience the benefits and rewards of continuing to breast-feed after returning to employment.

High-tech skills in low-tech hands. Issues of advanced practice and collaborative management.

Nurse-midwifery practice has been defined by the American College of Nurse-Midwives (ACNM) as "the independent management of essentially normal newborns and women ... occurring within a health care system which provides for medical consultation, collaborative management or referral .... "As the health care delivery system in the United States becomes increasingly complex and reliant on new forms of technology, it has become necessary to clarify roles and responsibilities for the nurse-midwife. In addition, mechanisms for acquiring new skills and for collaborating with physician colleagues must be well understood. A question frequently asked is where the boundaries of nurse-midwifery practice end and those of medical practice begin. Although practice scenarios vary for individual nurse-midwives and nurse-midwifery services, recent statements approved by the ACNM Board of Directors discuss these issues in an attempt to clarify the potentially confusing areas of collaboration and skill acquisition. This article explores the areas of expanded nurse-midwifery practice and collaborative management. Although individual clinical skills are not necessarily endorsed, a step-by-step approach that nurse-midwives can use for incorporation of new skills is presented. The concepts discussed will be a valuable tool to nurse-midwives in their practice.

Advanced nurse-midwifery practice.

The Clinical Practice Committee of the American College of Nurse-Midwives is frequently confronted with questions related to clinical practice. Many questions relate to specific clinical procedures and the position of the College as to their appropriateness for nurse-midwifery practice. This paper presents a discussion of a document developed to assist nurse-midwives when such questions arise.

An interlaboratory evaluation of the Syrian hamster embryo cell transformation assay using eighteen coded chemicals.

Eighteen coded chemicals were evaluated in the Syrian hamster embryo (SHE) cell transformation assay in three different laboratories using the same basic experimental protocol with minor modifications. In addition, individual cell and serum sources were selected. Major factors influencing intra-and interlaboratory reproducibility were the source of cells and serum, the toxicity of the chemicals, and the dose-range selected for transformation evaluation. Two or three assays from each laboratory were required to determine the transformation-inducing potential of a chemical because of the low number of transformants scored in any single assay and the difficulty of interpreting morphological variations. Rodent carcinogenicity data were available for 16 of the 18 chemicals tested and the transformation response of 14 of those chemicals was in agreement with the rodent carcinogenicity data (if the positive results are adopted for the four chemicals that produced contradictory results). Four rodent carcinogens, di-(2-ethylhexyl) phthalate, diphenylhydantoin, methapyrilene hydrochloride and o-toluidine hydrochloride, that were negative in the Salmonella/microsome assay, induced morphological transformation in the SHE assay. Although the labour, cost and lack of reproducibility might preclude application of this transformation assay for routine screening, it might, nevertheless, prove valuable for distinguishing between non-mutagenic carcinogens and non-carcinogens.

An interlaboratory comparison of transformation in Syrian hamster embryo cells with model and coded chemicals.

Three independent laboratories tested eight "model" and five coded chemicals in the Syrian hamster embryo clonal transformation assay system to establish the intra- and interlaboratory reproducibility of the system and to identify sources of variability. When a common cell pool and the same lot of fetal calf serum were used, the three laboratories obtained consensus on the activity of eight model chemicals: five chemicals (benzo(a)pyrene, 7,12-dimethylbenz(a)anthracene, N-methyl-N'-nitro-N-nitrosoguanidine, nitroquinoline-N-oxide, and lead chromate) induced morphological transformation without exogenous metabolic activation and three (N-2-fluorenylacetamide, pyrene, and anthracene) produced no transformation response. Five coded chemicals (2,6-dichloro p-phenylenediamine, 4,4'-oxydianiline, cinnamyl anthranilate, dichlorvos, and reserpine), representative of environmental chemical classes, but not necessarily strong carcinogens, produced more equivocal responses in this interlaboratory study. Thus, while the assay can be used to distinguish between transforming and nontransforming chemicals in some cases, the intrinsic limitations in low transformation frequency and in achieving any dose-response results are major constraints to the use of this system in a routine testing program at the present time. Efforts to increase the transformation frequency or to amplify the expression of the transformed phenotype constitute some of the approaches which should be explored in order to overcome these limitations.

Effects of varied cardioplegic perfusion pressure on myocardial preservation with critical coronary stenosis.

Inadequate delivery of cardioplegic solution distal to coronary artery stenosis may result in increased injury during ischemic arrest. This study was performed to determine the effects of cardioplegic perfusion pressure on cardioplegia delivery and myocardial preservation in hearts with critical coronary artery stenosis. Twenty dogs underwent 90 minutes of cold potassium cardioplegic arrest with partial occlusion of the circumflex coronary artery. Group 1 received cardioplegia at 50 mm Hg pressure, Group 2 at 90 mm Hg pressure, and Group 3 at 130 mm Hg pressure. It was found that cooling rates were 5.4 degrees, 9.1 degrees, and 18.2 degrees C per minute in the nonischemic area (p = 0.004) and 2.0 degrees, 4.5 degrees, and 7.9 degrees C in the ischemic area (p = 0.008) in Groups 1, 2, and 3, respectively. Total of cardioplegic solution flows were 86, 188, and 262 ml per minute per 100 gm in Groups 1, 2, and 3, respectively (p = 0.001). However, flow did not differ significantly between groups in the ischemic area. Rate of rise of left ventricular (LV) pressure decreased significantly in Groups 1 and 2 but not in Group 3 (p = 0.002). Other measured variables did not differ significantly between groups, although LV function curves showed less deterioration in the high-pressure groups. It is concluded that higher cardioplegic perfusion pressure resulted in more rapid cooling in normal and ischemic areas and slightly better preservation of ventricular function as measured by some indexes. However, preservation was generally good for each of the pressures for up to 90 minutes of ischemia when the septum was consistently cooled to 10 degrees C.

An early postpartum hospital discharge program: implementation and evaluation.

The philosophy of the FBC strengthens the concept of childbirth as a normal physiologic process. Couples are guaranteed a high level of quality nursing and medical care. Simultaneously, provisions are made to enhance the family's assertiveness in obtaining a satisfying experience in the hospital that extends to the home environment. With careful planning and decision making throughout the pregnancy, early discharge becomes a satisfying and safe alternative for families and provides a means to decrease the ever rising cost of health care.