Launceston General Hospital Clinical Guidelines SDMS ID: P2010/0504-001 2.

34-07WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: P2010/ 0486-001 Intrapartum Fetal Monitoring P2010/ 0384-001 Postnatal Ward Management of Term Newborns at Risk of Hypoglycaemia Introduction During pregnancy, women with pre-existing diabetes mellitus (type1 DM & type 2 DM) and women who develop diabetes during pregnancy (gestational diabetes GDM) are cared for in the combined Antenatal/Diabetes clinic. A plan for glucose control during birth will have been discussed and documented in the antenatal medical record during an antenatal visit from 36 weeks. The aim for blood glucose levels during labour/birth is 4 to 7 mmol/L i.e. a much tighter range than for patients on the general wards. The reason for this is to reduce the likelihood of neonatal hypoglycaemia. The following guidelines will often need tailoring for individual women. The Diabetes Team expects to be used as a resource. The Diabetes Physician is contactable via switchboard. Women with their own subcutaneous insulin infusion pumps will be individually managed by the diabetes team. Management of Maternal Diabetes in Labour New Guideline Management of maternal diabetes in labour Midwives and medical staff, QVMU IDDM, Gestational Diabetes, Insulin infusion

Summary Protocol A: Women on insulin: type 1 DM, type 2 DM, GDM 1. Management during labour/birth Overview Spontaneous labour Induction of labour Elective Caesarean birth 2. Management post-birth Type 1 DM Type 2 DM GDM Protocol B: Women on diet alone: GDM 1. Management during labour/birth (Spontaneous labour/induction/Caesarean) 2. Management post-birth
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Page 2 3 3 3 4 4 4 5 5
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Insulin and dextrose infusion protocol Protocol A: Women on Insulin: Type 1 DM, Type 2 DM, GDM Obstetric Management 1. Overview

6 7

NOTE: Occasionally women with GDM/type2 DM are on small doses of insulin at term (total daily insulin dose <30 units). For these women, IV insulin and dextrose is not required unless the blood glucose levels are abnormal. Use common sense when starting IV insulin and dextrose infusions: in women in whom birth is imminent and BGL 7.0, there may not be the time or need to set up the infusion.

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Protocol A: Women on Insulin: Type 1 DM, Type 2 DM, GDM 2. Management during labour/birth Spontaneous Labour 1. Start IV insulin + dextrose infusion protocol (page 6). Induction of Labour 1. On the night before, give normal short-acting insulin with evening meal: The Diabetes Team may advise reduction of the intermediate-acting insulin (Protophane) by 30% in tightly controlled patients. 2. On the morning of induction, check blood glucose and give short-acting insulin (Novorapid/Humalog/Actrapid) only before breakfast this dose may need to be reduced: the Diabetes Team will advise. Omit intermediate-acting insulin before breakfast. After breakfast (no later than 10.30 am) start IV insulin + dextrose infusion protocol.

3.

Elective Caesarean Birth Patients are booked first on the list For Morning LSCS: 1. On the night before, give normal short-acting insulin with evening meal: The Diabetes Team may advise reduction of the intermediate-acting insulin by 30% in very tightly controlled patients. 2. 3. Nil by mouth from 2 am. Start IV insulin + Dextrose protocol as soon as possible on arrival at the ward (~7 am), prior to transfer to theatre. However, do not delay transfer to theatre set up infusion in theatre if necessary.

For Afternoon LSCS: 1. These women have an early breakfast with short acting insulin prior. Omit intermediate-acting insulin before breakfast. 2. Nil by mouth from 7 am. 3. Start IV insulin + Dextrose protocol as soon as possible on arrival at the ward, prior to transfer to theatre. However, do not delay transfer to theatre set up infusion in theatre if necessary.

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Protocol A: Women on Insulin: Type 1 DM, Type 2 DM, GDM 3. Management Post-Birth Type 1 DM Vaginal birth

Immediately after birth of baby, reduce insulin infusion rate by 50% and continue 5% dextrose. Measure BGL hourly until eating. Restart sc short-acting insulin with first snack or meal. Often much lower doses than pre-pregnancy will be required: Diabetes physician will advise. Stop IV insulin + dextrose 1 hr after first sc insulin dose i.e. overlap 1 hr. When eating, measure BGL pre-meal and bedtime. Immediately after birth of baby, reduce insulin infusion rate by 50% and continue 5% dextrose. Measure BGL hourly until eating. Restart sc short-acting insulin with first snack or meal. Often much lower doses than pre-pregnancy will be required: Diabetes physician will advise. Stop IV insulin + dextrose 1 hr after first sc insulin dose i.e. overlap 1 hr, providing the patient is tolerating oral intake. When eating, measure BGL pre-meal and bedtime.

Caesarean

Type 2 DM (on oral hypoglycaemic drugs before pregnancy) Vaginal birth Stop IV insulin + dextrose at birth. + Caesarean Manage as for routine post-birth: avoid IV dextrose. Measure BGL 2-4 hrly, then when patient eating, fasting and 2 hrs after each meal until discharged. If not breastfeeding, recommence pre-pregnancy oral hypoglycaemic drug once patient is eating. If patient is breastfeeding, sc insulin may need to be continued: Diabetes physician will advise.

GDM Vaginal birth + Caesarean

Stop IV insulin and dextrose at birth. Manage as for routine post-birth: avoid IV dextrose. Measure BGL 2-4 hrly, then when patient eating, fasting and 2 hrs after each meal for 24 hrs. Check if oGTT at 6 weeks and diabetes educator appointment at 8 weeks has been arranged.

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Protocol B: Women on diet alone: GDM 1. Management during labour/birth (spontaneous labour/induction/Caesarean) 1. 2. Check blood glucose before breakfast (if admitted for IOL) or fasting (if admitted for Caesarean section). Then monitor blood glucose 2 hrly. Meals appropriate for women with diabetes must be ordered. However, the woman cannot become hypoglycaemic so there is no need to be concerned if she does not wish to eat. 3. 4. If intravenous fluids are required, avoid dextrose. If blood glucose > 7, recheck in 30 mins. If still > 7, call Diabetes Physician for advice. IV insulin + dextrose protocol may occasionally be required.

2. Management post-birth Vaginal birth + Caesarean Stop IV insulin and dextrose at birth. Manage as for routine post-birth: avoid IV dextrose. Measure BGL 2-4 hrly, or when patient eating, fasting and 2 hrs after each meal for 24 hrs. Check if oGTT at 6 weeks and diabetes educator appointment at 8 weeks has been arranged.

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Insulin + Dextrose Infusion Protocol 1. Run 5% dextrose 100 ml/hr via infusion pump. This rate is unaltered unless ordered by Diabetes physician. 2. Via the same cannula, run insulin infusion via infusion pump: 100 units of actrapid + 100 ml of 0.9% saline i.e. 1 unit/ml. It is essential to prime the line before connecting. 3. Target BGL range is 4-7 i.e. a much tighter range than for insulin infusions on the general wards. 4. Check BGL hourly. BGL monitoring can be reduced to 2 hrly if readings are stable (x3 readings in consecutive hours) and no change in clinical status of the patient. 5. If the insulin + dextrose infusion is run for 24 hours, it is mandatory to check serum K+ and replace as required. 6. This protocol represents an average scale and will need to be altered for individual patients. If BGL 4-7 is not achieved, contact Diabetes physician for advice.

BGL
< 3.5

Insulin (ml/hour)
Stop insulin infusion. Check BGL q 15 mins. When BGL > 3.5, start insulin infusion at 50% previous rate.

Comments
If patient very symptomatic: if able to eat, treat with oral glucose as per Hypo Protocol. If nil by mouth, give 12.5 ml 50% dextrose IV and check BGL in 15 mins Target range Target range

3.5 5 5.1 - 7 7.1 9 9.1 11 11.1 13 13.1 15 > 15

0.5 ml/hr 1.0 ml/hr 2.0 ml/hr 3.0 ml/hr 4.0 ml/hr 5.0 ml/hr 6.0 ml/hr

(=0.5 units/hr) (=1.0 units/hr) (=2.0 units/hr) (=3.0 units/hr) (=4.0 units/hr) (=5.0 units/hr) (=6.0 units/hr)

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Obstetric Management Women with diabetes are considered high risk and will have a detailed obstetric management plan documented by the obstetric registrar or consultant. Continuous electronic fetal monitoring is recommended for all women requiring insulin during pregnancy and/or labour (Intrapartum Fetal Monitoring Guideline WACSClinProc2.3). If fetal macrosomia is suspected staff should be prepared for the possibility of shoulder dystocia. The paediatric registrar or consultant should be informed antenatally of any concerns regarding fetal wellbeing (fetal distress, prematurity, meconium liquor, intrauterine growth restriction, non reassuring fetal heart rate). The paediatric registrar or consultant should be informed if the newborn is unwell, small for gestational age (<10th centile) or large for gestational age (>90th centile). All well term newborns should have skin to skin contact with their mother, their first feed within the first hour of birth and blood glucose level at birth (Postnatal Ward Management of the Newborn at Risk of Hypoglycaemia WACSClinProc4.26).

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Attachments
Attachment 1

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Corbould (Director of Diabetes Centre, Dept of Medicine)

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: August 2007

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