[CG] Diabetes : women requiring insulin, diabetes management, labour and delivery

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GENERAL MANAGEMENT

All women will be fasted during labour
Avoid Hartmann’s intravenous solution

**DURING LABOUR TARGET CAPILLARY BLOOD GLUCOSE LEVEL IS 4‐7MMOL/L**

SPONTANEOUS LABOUR

  • Routine admission to labour ward
  • Check capillary Blood Glucose (BM)
  • Inform Middle grade doctor who will discuss care with Consultant if obstetric concerns.
  • Site and date two venflons, the first to be used for the insulin infusion & the dextrose infusion via a non‐return valve. The second to ensure secure IV access.
  • Take bloods ‐ Group & Save, FBC & UE’s.
  • Continuous EFM monitoring
  • Inform On Call Paediatrician and Anaesthetist

COMMENCE SLIDING SCALE (TYPE 1 AND GESTATIONAL DIABETES MANAGED WITH INSULIN IN PREGNANCY)

  • Commence infusion of 1000 ml of 5% Dextrose (Glucose) with 20 mmols (0.15%) Potassium Chloride (KCL), at 100 mls/hr.
  • Commence Insulin Infusion using syringe pump
  • 50 units Actrapid Insulin made up to a total volume of 50mls with Sodium Chloride 0.9%
  • The rate of Insulin is titrated against BM (see below and Table 1 or Table 2 if subcutaneous insulin in last 4 hours)
  • Check BM hourly. Aim to maintain levels between 4.0 – 7.0mmol/l
  • Recordings documented on Insulin Sliding Scale Prescription & Recording Chart
  • Test all urine for ketones. If > 2+ change to 500ml  infusion bags  of 10% Dextrose (Glucose) with 10mmol (0.15%) Potassium Chloride at 100mls/hr.

DELIVERY & 3RD STAGE

  • Experienced personnel should be available for the management of the second & third stage of labour in a diabetic pregnancy with suspected macrosomia.

POST DELIVERY

After delivery women with diabetes require greatly reduced insulin doses

  • Immediately after delivery of placenta stop insulin and dextrose infusions. Infusion should stay in place until main meal ready to be taken. Mother may be given tea and snack while infusion in place but not running.
  • Baby assessed by paediatrician

IF WOMAN REQUIRED INSULIN BEFORE PREGNANCY

  • Recommence subcutaneous insulin at a dose of 50% usual pre‐pregnancy dose with the first normal meal (as indicated in postnatal insulin regimen plan in notes).
  • Check BM’s before subsequent meals and continue to give 50% pre‐pregnancy subcutaneous. insulin with each meal for at least the first 24 hours. Half of the evening pre‐pregnancy dose of long acting insulin should also be given.
  • If breast feeding will require increased carbohydrate (with advice from dietician) and potentially less insulin aiming for a pre‐meal BM of 7‐12 mmols/l
  • If BM > 12mmols /L and not eating normally recommence IV Dextrose & Insulin at reduced doses (Table 2)
  • If hypoglycaemia occurs reduce insulin further from pre‐pregnancy dosages.
  • Liaise with Diabetic team.
  • After the first 24 hours insulin requirement may increase towards normal pre‐pregnancy doses.

IF THE WOMAN HAS GESTATIONAL DIABETES

  • Check BM’s before meals for the first 24 hours. If any BMs> 6mmol/L inform diabetes team next working day. ( If any BMs >12 recommence sliding scale at lower doses as above)
  • Arrange OGTT or fasting glucose at 6/52 post partum
  • Consultant will inform patient and GP re OGTT results (usually by letter).

INDUCTION OF LABOUR

  • Admit to ward evening prior to induction
  • Each woman should have individualised plan of care regarding insulin and prostin doses
  • Take bloods Group & Save, FBC & UE’s.
  • Give evening prostin if prescribed
  • Give usual evening dose of long acting insulin if Insulatard/Humulin I,* but only give 70% usual insulin if Lantus/Levemir*
  • Reassess cervix at 0600‐ 07.00

  • If cervix favourable for ARM Transfer labour ward circa 0730
  • Site and date 2 Venflons (16g)
  • No morning insulin to be given
  • Check BM and commence sliding scale at 0800 (labour ward)

  • If morning prostin required may have tea & toast/breakfast.
  • Follow insulin prescription sheet for insulin dose with breakfast or sliding scale as indicated
  • If no breakfast insulin plan available commence sliding scale
  • Adjust sliding scale as needed to cover insulin requirements.
  • Care in labour as detailed for spontaneous labour (above)
  • Post delivery: follow same regimen as outlined for spontaneous labour (above)

ELECTIVE CAESAREAN SECTION

  • Admit to ward the previous evening
  • Each woman should have individualised plan of care regarding insulin doses
  • Take bloods Group & Save, FBC & UE’s.
  • Give usual evening dose of long acting insulin if Insulatard/Humulin I,* but only give 70% usual insulin if Lantus/Levemir*
  • Fast from 12 midnight
  • Transfer to labour ward 0730
  • Site 2 Venflons (16g)
  • No morning insulin to be given
  • Check BM and commence sliding scale at 0800 (labour ward)
  • Post delivery: follow same regimen as outlined for spontaneous labour (above)

SLIDING SCALE‐

  • Commence infusion of 1000 ml 5% Dextrose (Glucose) with 20 mmols
    (0.15%) Potassium Chloride (KCL), at 100 mls/hr.
  • Check BM hourly and adjust Insulin infusion rate according to BM

Table 1: Sliding scale for diabetes in labour

Table 1: Sliding scale for diabetes in labour

Capillary Blood glucose

Insulin
(Units per hour=ml per hour)

Revision of sliding scale if required

Revision of sliding scale if required

0.0‐4.0

STOP INSULIN This is a hypo: assess patient and treat

 

 

4.1‐7.0

1

 

 

7.1‐10.0

2

 

 

10.1‐14.0

3

 

 

> 14.0

6

 

 

 

 

 

Target

Action/revision

SIGNED

SIGNED

SIGNED

Date/ Time

Date/ Time

Date/ Time

Target Capillary Blood glucose is 4‐7 in labour

If Capillary Blood glucose > 7 mmol/l for 2 consecutive hours despite sliding scale contact medical staff for revision of sliding scale.

Table 2: Sliding scale for diabetes in labour if subcutaneous insulin has been taken less than 4 hours previously OR postpartum

Table 2 : Sliding scale for Diabetes in Labour if subcutaneous insulin has been taken less than 4 hours previously OR postpartum (NB need for sliding scale post partum is unusual)

Capillary Blood glucose

Insulin
(Units per hour=ml per hour)

Revision of sliding scale if required

Revision of sliding scale if required

0.0‐4.0

STOP INSULIN This is a hypo: assess patient and treat

 

 

4.1‐7.0

0

 

 

7.1‐10.0

1

 

 

10.1‐14.0

2

 

 

> 14.0

3

 

 

 

 

 

 

Target

Action/revision

SIGNED

SIGNED

SIGNED

Date/ Time

Date/ Time

Date/ Time

Target Capillary Blood glucose is 4‐7 in labour, 7‐10 post partum

During labour:  If Capillary Blood glucose > 7 mmol/l for 2 consecutive hours despite sliding scale contact medical staff for revision of sliding scale.

Postpartum: If Capillary Blood glucose > 14 mmol/l for 2 consecutive hours despite sliding scale contact medical staff for revision of sliding scale.

Last reviewed: 13 December 2016

Next review: 12 December 2021

Author(s): Dr R Lindsay, Consultant Diabetologist PRM; GG&C Diabetes Pregnancy Group

Version: 4

Approved By: Obstetrics Governance Group