Preparing parents for the prospect of the neonatal unit: the role of the diabetes specialist nurse

Despite the relative advances in care and management for women with diabetes in pregnancy, a significant number of their babies still require additional care within neonatal units. Recent statistics from the National Pregnancy in Diabetes Audit Report 2020 (NHS Digital, 2021) indicate that neonatal admissions of babies whose mother has diabetes remains unchanged from 2013. Neonatal unit admissions are particularly prevalent between 34 and 37 weeks’ gestation, with babies born to women with type 1 diabetes remaining higher than those with type 2 diabetes.

Once a baby is admitted to the neonatal unit, parental levels of stress and anxiety are often controlled by the experiences that they have with caregivers, alongside the challenges of uncertainty relating to their baby’s well-being (Guillaume et al, 2013). It is suggested that preterm birth interrupts the natural human process of attachment, which can then develop into a deeper emotional detachment when a baby is being cared for within a medicalised environment where parenting can be restricted (Kim et al, 2020).

This article explores the key role that diabetes specialist nurses (DSNs) and midwives have in helping parents to prepare for possible neonatal admission, and why their input in supporting parents whose baby has required additional care is so important.

Babies of mothers with diabetes: reasons for requiring admission to neonatal units

During pregnancy, a fetus whose mother has either pre-existing or gestational diabetes is faced with a series of possible challenges. Hyperglycaemia is thought to contribute to an increased risk of neural tube defects and congenital heart defects which occur during early fetal development in the first trimester. Maintaining normoglycaemia prior to pregnancy is recognised as one of the most successful measures in relation to minimising risk to fetal well-being (ElSayed et al, 2023). This emphasises the key role of pre-conceptual care provision by diabetes healthcare teams to educate and support women to achieve this aim. 

One of the most common complications associated with maternal diabetes is macrosomia, in which the fetal weight estimate is above the 90^th percentile for gestational age (sometimes referred to as “large for gestational age”). Macrosomia is related to fetal hyperinsulinaemia, which develops as a result of high levels of maternal glucose transfer via the placenta (Arshad et al, 2014). Fetal hyperinsulinaemia acts as a growth factor that encourages excess storage of glucose as glycogen and encourages fetal fat accumulation. Risks for the macrosomic newborn infant include hypoglycaemia; respiratory distress syndrome; and shoulder dystocia and associated morbidities, such as clavicle fracture, as a result of difficult birth (Ladfors et al, 2017).

Further complications include the risk of preterm birth, which is often caused by comorbidities in the mother, such as pre-eclampsia that is linked to diabetes (Weissgerber and Mudd, 2015). Conversely, fetal growth restriction is also a risk for babies. This is hypothesised to be associated with women who suffer frequent hypoglycaemic episodes in pregnancy (American Diabetes Association, 2015). 

All of these complexities, particularly preterm birth, macrosomia and fetal growth restriction, are common reasons why babies are admitted to neonatal units for care and monitoring. This emphasises the importance of preparing parents for possible outcomes and supporting them if the baby requires admission.

The importance of building relationships with the baby during pregnancy

The development of a maternal–fetal relationship is now accepted as a fundamental element for influencing future physical, emotional and intellectual development. When a mother develops a positive attachment to the baby during pregnancy, she is more likely to carry out optimal health behaviours, such as making healthier food choices and reducing risky lifestyle issues such as alcohol or smoking (Massey et al, 2015). Stress, anxiety and poor social support have been associated with poor maternal–fetal attachment, and this has been linked with comorbidities such as premature birth and intrauterine growth restriction (Rubertsson et al 2015; Hopkins et al, 2018). High levels of the stress hormone cortisol in the mother during pregnancy have also been linked to future cognitive development (Bergman et al, 2010). Pregnancy itself is considered to be a stressful event and may contribute towards maternal depressive symptoms that, in turn, could create a trajectory towards reduced self-care and management of diabetes (Mills, 2019).

For a woman with diabetes, the ability to develop a close bond with her baby is particularly important. The increased risks of poor pregnancy outcomes, such as stillbirth, preterm birth and more complex labour and birth issues, create significantly increased anxiety and stress for this group of women alongside the expectation to closely monitor and maintain high levels of compliance in lifestyle to manage normoglycaemia. Evidence suggests that women with diabetes carry exaggerated feelings of responsibility with guilt, worry and self-blame burdening during what should be one of the most positive experiences of their lives (Rasmussen et al, 2008; Rasmussen et al, 2013). This is further compounded if the baby is subsequently admitted to a neonatal unit, as evidence suggests that the natural process of maternal–infant attachment is influenced significantly not only owing to worry and anxiety about the baby’s well-being, but also the alteration in parenting role (Kim et al, 2020).

Continuity of care for women with diabetes in pregnancy

Diabetes specialist nurses are in an ideal position to provide continuity of care and support to women with diabetes in pregnancy. Continuity of care has been recognised as a foundation to improving perinatal outcomes and sits at the core of contemporary maternity healthcare (Sandall, 2017). Building a trusting relationship with a healthcare professional embodies an opportunity for women to become confident and feel valued in their unique experience. Partnership working with women helps them to feel better prepared for their pregnancy and birth experience, and can motivate the healthcare professional to provide a much more holistic approach to care and a better sense of personal growth and satisfaction (Dahlberg and Aun, 2013). Often, DSNs are working closely with women for a number of years before pregnancy occurs through outpatient clinic appointments, so relationship building has often naturally developed.

DSNs can aim to harness and develop opportunities to support women proactively at such a vulnerable time by encouraging them to develop relationships with their unborn baby. This can occur through a range of very simple methods (adapted from: Royal College of Midwives, 2012; Solihull Approach, 2017):

• Encourage women to visualise their baby during pregnancy.
• Encourage women to tune in to their baby’s behaviour during pregnancy (e.g. sleep phases or activity phases).
• Encourage talking, singing or reading to the baby.

Whilst these may sound like basic concepts, often, in a medicalised pregnancy journey, fundamental elements such as this can be lost. Educating women in the antenatal period on issues relating to attachment and bonding is identified as a mechanism for improving maternal and infant outcomes, and is now considered a foundation for both social and emotional development. The Solihull Approach is an example of an educational approach developed in the 1990s that has helped to transform antenatal education by focusing much more closely on increasing parental emotional health and well-being through supportive early intervention strategies during pregnancy. These strategies include encouraging parents to discuss anxieties they are having during pregnancy, how to relationship-build with their unborn baby and understanding the behaviours of their newborn (Solihull Approach, 2017).

Supporting parents whose baby is in the neonatal unit

Parents whose baby is admitted to the neonatal unit face a range of emotions that can include stress, anxiety and depression (Kim and Kim, 2022). Parents can feel helpless and guilty about their baby’s situation and can often struggle to comprehend their parental role within the neonatal unit (Guillaume et al, 2013). A recent report by Bliss (2021) surveyed parents whose baby had been in a neonatal unit during the COVID-19 pandemic. It found that 41% of parents felt that admission to a neonatal unit had impacted on their ability to bond with their baby and 69% felt that their mental health had been impacted by their experience if the baby had had a prolonged hospital stay. The report highlights the essential need for parents to be active agents in their baby’s care and to be more involved in decision-making in care. A key component to care includes parental education and dynamic support that focuses on individualised needs (Kim and Kim, 2022). Clear and consistent communication provided in a compassionate manner are considered essential to parents (Guillaume et al, 2013; De Bernardo et al, 2017). Promoting the concept of family-centred care through acknowledgement of the parent’s key role in caring for their baby is indispensable (Guillaume et al, 2013).

Conclusion

Unfortunately, the statistics remain high for babies of mothers with diabetes being admitted to the neonatal unit for care. DSNs are ideally placed to help and support parents who face this challenging situation. DSNs can promote parental relationship-building with the baby during pregnancy through education on simple methods, such as encouraging talking or singing to the baby and visualising the baby in the womb. Acknowledging the essential role of continuity of care in a woman’s journey throughout pregnancy, and its identified benefits in lowering stress and anxiety, should help the DSN to recognise their influence on well-being outcomes. It is important for DSNs to recognise that they can continue to have an influential role with parents if their baby is admitted to the neonatal unit. Simply acknowledging the difficulties of their experience and utilising listening skills are supportive mechanisms that can make a difference. Clear and honest communication with parents and close liaison with the multiprofessional team can have an impact on longer-term outcomes in relationship-building between parents and their baby.