Elective CS Emergency CS

HES E&W 02/03 ■ CEMACH Diabetes cohort

Figure 17.3 Proportion of pregnancies resulting in elective and emergency Caesarean sections (CS) and spontaneous vaginal delivery (SVD) based on Hospital Episode Statistics (HES) for England and Wales (2002/3) and the Confidential Enquiry into Maternal and Child Health (CEMACH) diabetes cohort.

Managing hyperglycaemia during labour

All obstetric units will have a regime for managing hyperglycaemia during labour. An example from the West Midlands Guidelines is given (Figures 17.4 and 17.5). Glucose and insulin are given by IV infusion and the rate of insulin infusion is adjusted to maintain blood glucose levels between 4-7 mmol/l. The IV insulin pump is maintained until the mother can start her normal meals. Many type 2 patients will not require insulin following delivery but doses should be reduced or adjusted according to plasma glucose levels.

The neonate

The most common neonatal complication is hypoglycaemia that still occurs in about one in five babies of mothers with diabetes. Hyperinsulinaemia results from placental transport of maternal insulin (endogenous or administered) that is surplus to the requirements of the infant. This is the cause of neonatal hypogly-caemia (and of foetal macrosomia, due to growth in a hyperin-sulinaemic environment). Feeding should be encouraged as soon as possible (within 30 minutes) after delivery and every 2-3 hours thereafter. Neonatal blood glucose levels should be monitored regularly. If the level remains below 2.0 mmol/l on two occasions

Diabetic Intrapartum Care

Induction of Labour

• Aim to deliver at < 40 weeks gestation - decided on individual basis

• Inform Delivery Suite of admission

• Routine admission and induction procedure

• Continue present Insulin + diet reglme until in labour

• Intermittent FH auscultation/ CTG

• Sliding scale Insulin + Dextrose regime

• Glucagon (Type 1 diabetes)

• Post delivery insulin regime

• Aim to keep glucoses between 4 - 7mmols/L

(Commence Sliding Scale Insulin + Dextrose IV if not able to do so)

• Transfer to Delivery suite when in established labour or SROM

In established labour or for ARM

• Oral fluids for treatment of hypo's

• Commence IV sliding scale insulin + Dextrose as per protocol

• 2 - 4 hourly cervical assessment for early diagnosis of obstructed labour

Syntocinon regime to be given via a separate venflon

• Low threshold for felal blood sampling

• Be aware of shoulder dystocia and risk of fetal macrosomia

• Accurate documentation of partogram of maternal observations, fetal heart rate and progress of labour/ timing of interventions

• Senior obstetric Involvement

• Admit day before

• Routine admission + CTG

• Routine bloods. FBC. Group and Save + pre - op procedure

• Inform Delivery Suite of her admission.

• Sliding scale insulin + Dextrose

• Post delivery insulin regime

• Treat hypoglycaemia with Dextrose Tabs x 3 or Glucogel then transfer to delivery suite for Sliding scale Insulin + Dextrose

Following morning

• Omit morning dose of insulin.

• Listen to the fetal heart.

• Transfer to Delivery suite 07.00 - 08.00 hrs

• Commence IV Sliding scale Insulin + Dextrose as per protocol

When and how to shop a sliding scale insulin post delivery

Pre pregnancy Diabetes

• Ensure patient is eating and drinking normally

• Give insulin when next due. (Regime in notes)

• Stop insulin + Dextrose after 30 mins

N.B. Regime may vary slightly for each person, please check notes

WANDA. guidelines No:2. Version 2. Dated Jan 07. Figure 17.4 Management of blood glucose during delivery (provided by Dr Aresh Anwar, University Hospital, Coventry).

Sliding scale insulin regime

Consider Sliding scale Insulin for:

Any pregnant woman with diabetes who needs insulin injections who is-

• In established labour • For Betamethasone injections

• For ARM • Ketoacidosis needs accurate diagnosis

• For a LSCS and Consultant Obstetrician + Medical

• Nil by m°u1:h Ondufe rom^n^ Team on call must be informed

A combination of Insulin + Dextrose is given via the same venflon using a "Y" connector

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