Diabetes – labour

DIABETES – LABOUR

PREPARATION
 Discuss with woman
Time and mode of delivery
 Woman diet-controlled with normally grown fetus:
 advise induction of labour at 40 weeks’ gestation  advise induction of labour at 38 weeks’ gestation

Analgesia and anaesthesia
 Offer women with diabetes and co-morbidities (e.g. obesity or autonomic neuropathy)
obstetric anaesthetic assessment in third trimester
Care during and after labour
 Analgesia and anaesthesia
 Prevention of neonatal hypoglycaemia  Care of baby/breastfeeding

PRETERM LABOUR
 Pulmonary maturation delayed in fetuses of diabetic women, particularly where control
 Where premature delivery anticipated, give betamethasone for women with established diabetes – see Preterm labour guideline
 Steroid administration worsens diabetic control and may lead to ketoacidosis in women with pre-existing type 1 diabetes – anticipate an increase in insulin requirement and administer insulin as per local Trust policy for steroids in diabetic pregnancy
INDUCTION OF LABOUR
 See Induction of labour guideline
Diabetic control
 Before labour established, normal metformin/insulin regimen and diet

DURING LABOUR
Risk
 Increased risk of shoulder dystocia particularly if baby macrosomic – ensure obstetric
registrar is available on delivery suite during second stage – see Shoulder dystocia
guideline
 Increased risk of cephalopelvic disproportion – be vigilant for delay and, if occurring, use
Monitoring during labour
Woman
 Record capillary glucose level hourly
 Once sliding scale regimeN commenced, monitor blood glucose hourly  Monitor blood glucose at 30 min intervals after induction of general anaesthesia and birth  Check urine for ketones
Continuous fetal monitoring
 Maternal hyperglycaemia may cause fetal acidosis, check maternal glucose if any EFN
 Fetal blood sampling if indicated as normal labour – see Fetal blood sampling guideline

Metformin and diet controlled
 If blood glucose elevated e.g. persistently above Unit threshold, commence insulin and IV
fluid regimen below

Gestational diabetes mellitus
 Insulin controlled – Dependent on amount of insulin required – dosage as per local

Elective caesarean section
 If caesarean section carried out before 39 weeks’ gestation, consider administration of
antenatal steroids. This will require sliding scale  If not on sliding scale for steroids, give usual metformin/insulin day before procedure  Commence insulin and fluid regimen from 0600 hr. See below
Emergency caesarean section
 Check blood glucose level and commence insulin and IV fluid below

INSULIN AND IV FLUID REGIMEN
 500 mL glucose 10% with 10 mmol potassium chloride 8-hrly
 50 units soluble insulin (Actrapid/Humulin S) in 50 mL sodium chloride 0.9% via syringe pump according to blood glucose checked at time of admission and hourly thereafter by glucometer  Determine rate of fluid infusion depending on blood glucose concentration and local policy  Aim to keep woman’s blood glucose concentration between 4–9 mmol/L  Most women will need 2–4 units/hour  Avoid large changes in insulin infusion rate and therefore in glucose concentration  If blood glucose not maintained within normal range, contact diabetes team Always use commercially produced pre-mixed bags of glucose 10% with potassium

POSTNATAL MANAGEMENT
 Diabetes team will write management plan
Inform women with insulin-treated diabetes that they are at increased risk of
hypoglycaemia in postnatal period, especially when breastfeeding. Advise to have a
meal or snack available before or during feeds

Stopping insulin and fluid regimen
 Continue sliding scale regimen until able to eat and drink normally
Type 1 diabetes
 Revert to pre-pregnancy reduced insulin requirements or the regimen advised by diabetes
 Keep sliding scale running for 30–60 min after first subcutaneous insulin dosage  May require less insulin if planning to breastfeed  Review by diabetes team as appropriate
Type 2 diabetes
 Stop insulin and fluid regimen
 Metformin not contraindicated in breastfeeding, but avoid sulphonylureas Gestational diabetes
 Women with gestational diabetes mellitus who have required sliding scale will cease to
 Arrange postnatal OGTT or fasting blood glucose at 6 weeks

Neonatal care
 See Staffordshire, Shropshire & Black Country Newborn Network Hypoglycaemia

Future plans
 While still using contraceptives, mother to discuss future pregnancy with diabetes team
who will provide information on pre-conception care

Source: http://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country/documents/Diabetes%20-%20Labour%202013.pdf