Diabetes in Pregnancy: Management in Labour CPG

• Obstetric Management

• Glycaemic control

• Monitoring

• Management of hypoglycaemia

• Elective caesarean section

• Postpartum

• Neonatal management

Obstetric management

• Timing of delivery. Refer to CPG Diabetes Mellitus: Management of Pre-existing Diabetes Mellitus in Pregnancy and refer to 'Delivery: Timing'.
  

• Continuous electronic fetal monitoring is recommended although may not be necessary for women with uncomplicated gestational diabetes (GDM) in spontaneous labour

• Ensure adequate analgesia with a lower threshold for epidural in labour. Refer to CPG Pain Relief in Labour
  

• Labour should not be prolonged

• The paediatric registrar should be notified of impending delivery

• Delivery should be supervised by an experienced accoucheur (Senior midwife or Obstetric registrar)

• Prepare for the possibility of shoulder dystocia. Refer to CPG Shoulder Dystocia
  

• Active management of third stage. Refer to CPG Labour: Third Stage Management
  
  

Glycaemic control

Pre-induction

• Induction booked by Diabetes Clinic. Refer to CPG Induction of Labour (intranet access only)
  

• Usual insulin while having prostaglandin

• Usual insulin dose night prior to planned amniotomy (ARM)

• Morning of ARM - fasting glucose level, light breakfast, adjust usual short-acting insulin according to fasting glucose level and breakfast

Birthing suite

Monitoring

Urine

• Test for ketones. If ketones are present at a moderate or high level, consider hydration and contact Diabetes Nurse Educator (DNE) (or Diabetes Physician if DNE is not available)

• Test for protein

Blood glucose monitoring

• Type 1 and Type 2 and GDM on insulin 2-hourly
  

• GDM not on insulin 4-hourly
  
  

Intravenous therapy

• Not routinely required for diabetes management

• Normal Saline should be used if requires IV therapy, no need for routine IV Dextrose

• Caution with fluid overload in severe pre-eclampsia

Insulin

• For Type 1 diabetes and women with GDM on insulin receiving < 40 units/day antenatally

• For Type 2 diabetes and women with GDM on insulin receiving > or= to 40 Units/day antenatally

• Suitable for patients requiring intensive therapy and/or poor control on a sliding scale, for example severe preeclampsia. Consult with Diabetes Physician.

• Via syringe pump

• Aim to keep blood glucose level 4-7mmol/L

• Consult Endocrinologist on call for all patients with DIABETIC KETOACIDOSIS

Management of hypoglycaemia

• Treat orally if possible

• Management of Hypoglycaemia (clinical algorithim)

Elective caesarean section

• Usual insulin the night before Caesarean section

• Book first on the theatre list in the morning

• Morning of Caesarean section - withold usual insulin

• Measure blood glucose level in theatre prior to anaesthetic

• Avoid IV Dextrose unless hypoglycaemic

• Postoperatively use low-dose sliding scale

Postpartum

• Blood glucose monitoring within 2 hours of birth then

• Sliding Scale insulin (low dose)

• Regular review by Diabetes Clinical Nurse Consultant and Physician until discharge.

• Type 2 will usually not require insulin in the postnatal period unless blood glucose levels are consistently elevated.

• Oral hypoglycaemic agents are not recommended while breastfeeding.

• Blood glucose monitoring B.D. for 48 hours

• Insulin is ceased post delivery

• If blood glucose levels > 7.0 mmol/L, continue to monitor until discharge - fasting and 2 hours after meals

• If blood glucose levels are persistently elevated after 72 hours, contact Diabetes Clinical Nurse Consultant

Neonatal Management

• at four hours of age or before the second feed (whichever comes first)

• immediately if clinical signs of hypoglycaemia present

• before each subsequent feed until 3 consecutive readings ≥ 2.6 mmol/L or as requested by paediatric registrar.

• poor control during pregnancy (most recent HbA1c > 7.5%)
• BSL > 8 mmol/L during labour
• IV glucose during labour

• unwell (e.g. signs of respiratory distress)
• macrosomic (> 90th centile)
• small for gestational age infants (< 10th centile), low birthweight infants (< 2,500gm) or clinically wasted regardless of birthweight
• preterm (< 37 weeks gestation)
• other reason(s) for SCN admission.

References