MAT/GUI/0310/DIABET
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MATERNITY SERVICE GUIDELINE
TITLE:
AUTHORS:
Diabetes in Pregnancy
GUIDELINE LEAD:
RATIFIED BY:
ACTIVE DATE:
RATIFICATION DATE:
REVIEW DATE:
APPLIES TO:
Nickey Tomkins
Maternity Guidelines Group
April 2010
March 2010
March 2013
All BLT Maternity Staff, Tower Hamlets
General Practitioner’s
None
Neonatal hypoglycaemia guideline
Induction of labour
Expressed breast milk policy (2009)
Continuous fetal monitoring in labour
Intermittent auscultation of the fetal heart
rate in labour
EXCLUSIONS:
RELATED POLICIES
THIS DOCUMENT
REPLACES
1.
D. Peterson- Consultant Diabetologist,
A.Sanghi – Consultant Obstetrician,
Nickey Tomkins – Diabetic Specialist
Midwife
Diabetes in Pregnancy Guideline –
Version 6.0, September 2007
INTRODUCTION/PURPOSE OF GUIDELINE
This guideline reflects new developments and current evidence (National
Institute for Health and Clinical Excellence (NICE), 2008).
This clinical guideline is for management of diabetes and it’s complications
in pregnancy and the postnatal period.
The purpose of the guideline is also to provide guidance on screening for
gestational diabetes and its management. As well as the management of
pre-existing diabetes in pregnancy and the postnatal period.
The prevalence of type 1 and 2 is increasing. In particular type 2 diabetes
is increasing in certain ethnic minorities including South Asian. Diabetes,
especially pre-existing, is associated with increased risk for both woman
and the fetus. There is increase risk of miscarriage, pre-eclampsia and preterm labour for the woman. Diabetic retinopathy can worse rapidly during
pregnancy also.
For the fetus and newborn, risks include congenital malformation,
macrosomia, birth injury, prenatal mortality and postnatal complications
(including hypoglycaemia).
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Management of diabetes should be included into the routine care provided
in antenatal, intrapartum and the postnatal period.
2.
IMPLEMENTATION
The updated paper copy will be attached to guideline notice board, in each
clinical area for four weeks.
Electronic copies will be distributed to the lead Midwives in each clinical
area.
The guideline will be available via the trust intranet and circulated to
guidelines folders.
3.
ROLES AND RESPONSIBILTIES
Community team (midwife or General Practitioner) will refer women for Oral
Glucose Tolerance Test (OGTT) if she is deemed at risk of developing
gestational diabetes (see risk factors in screening care pathway (Appendix
2)
Community team will refer all women with pre-existing diabetes to the
Diabetes Specialist Midwife (DSMW) urgently for antenatal booking
appointment as soon as pregnancy is diagnosed
The workload with gestational diabetes has being rationalised to separate
lower risk women with impaired glucose tolerance and these women are
followed in the community.
The Gestational Diabetes Mellitus (GDM) low risk clinic at the Royal
London Hospital (RLH) is run by the DSMW with a Specialist Diabetes
Dietician and Health Advocate for Bengali women. There is no Diabetes
Specialist Nurse or Obstetricians in this clinic. This one-stop education
session will offer women advice about diet and glucometer training only (a
meter is supplied).
Joint Diabetic-Obstetric service
The joint diabetic - obstetric service consists of hospital-based, multidisciplinary team, Consultant Obstetrician (Ms Anita Sanghi), Consultant
Diabetologist (Dr David Peterson), DSMW, Diabetes specialist nurse and
dietician.
Ms A. Sanghi is the named Lead Consultant Obstetrician for all women
with diabetes in pregnancy. Ms Sanghi is also the named Obstetric
Consultant for those women who develop gestational diabetes (GDM) High
Risk Pregnancy (for example women taking Insulin and/or Metformin) and
pre-existing diabetes.
There will be a separate service for lower risk women who do not need to
attend the main Friday ANC, which is aimed at women taking insulin and
those with Gestational Diabetes at higher risk and is facilitated by the
DSMW.
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Both these services are provided by the same overall team and are
detailed in the guide below.
Aim Of Joint Diabetic Obstetric Service (Multidisciplinary Team)
o Provide optimal care for women with pre-existing diabetes
o Assess and establish individual management plans for lower risk
women with gestational diabetes, and liaison with community teams for
their follow up.
o Provide clear routes of referral to clinic and care pathways
o Provide high quality care at clinic appointments.
o Education of pregnant women with diabetes including: diet and healthy
eating, lifestyle, insulin injection and dose adjustment, future risks of
diabetes and pre-conception counselling
o Audit and review of clinic process and outcomes to continue improving
the service.
4.
GUIDELINE
Screening For Diabetes In Pregnancy
Refer to screening and care pathway (Appendix 2)
All pregnant women will have a random blood sugar (RBS) taken at
booking.
RBG should be repeated at 28 weeks for all women.
If RBG is ≥7.0mmol/l (≥5.8mmol/l in a true fasting state), arrange
Immediate OGTT. If this OGTT is normal (see interpretation of OGTT)
repeat the test at 16 and 28 weeks gestation.
The following women are considered at risk of GDM
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BMI at or greater than 30 Kgm-2
Diabetes in first degree relative (mother, father, brother, sister of the
woman). (NICE, 2008)
Previous unexplained stillbirth or IUD
Previous baby 4 kg or more
Glycosuria (twice after 20 weeks, once before 20 weeks)
Polyhydramnios
> 40 years of age
Family origin with a high prevalence of diabetes - South Asian, Black
Caribbean and Middle Eastern women
(NICE 2008, Royal College of Obstetricians and Gynaecologists, 2010)
The 75g Oral glucose tolerance test (OGTT) test is the `gold standard`
diagnostic test used for screening for gestational diabetes (NICE, 2008).
Women are asked to fast from midnight and attend RLH at 09:00a.m for
OGTT. A fasting blood glucose specimen is taken. The woman is asked to
drink 394 ml of Lucozade (75g of glucose). Another specimen is taken 2
hours after the Lucozade.
OGTT should not be performed after 36 weeks. If any concerns discuss
with Consultant Diabetologist/ Consultant Obstetrician.
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Interpretation Of OGTT In Pregnancy (According To Timing Of Test)
NORMAL (mmol/L)
FASTING blood glucose
≤ 5.8 (at any stage of pregnancy)
At 120 min
< 7.8 (up to 30 wks)
< 9.0 (after 30 wks)
Note: NICE (2008) recommends that 6.0 fasting is normal, but local
insulin-resistant population has influenced our choice. (not evidencebased)
Random blood glucose testing is not recommended by national guidance
(NICE, 2008), however, as above, the local population has influenced the
choice that this routine test be included in this guidance.
5.
ANTENATAL MANAGEMENT
(Refer to Appendices 2 and 3 for integrated care pathways)
Women can be come under any of these 4 categories, previous GDM,
current GDM, current high risk GDM (on insulin and/or Metformin) or preexisting diabetes
Management Of Women With Previous History Of Gestational
Diabetes (either diet controlled, required metformin or insulin)
o All women should have RBS test at booking appointment and 28 weeks
o If RBS result is normal, arrange an OGTT at 16 weeks and 28 weeks
gestation.
o If RBS result is abnormal, an immediate OGTT. If the immediate OGTT
is a normal result repeat this test at 16 & 28 weeks.
o If the OGTT result is normal at 28 weeks, the woman does not have
gestation diabetes with the current pregnancy
MANAGEMENT OF ABNORMAL OGTT IN CURRENT PREGNANCY
Community team (Midwife and/or GP) to follow up abnormal OGTT results
within 1 week
Refer to Diabetes Specialist Midwife if:
 Less than 16 weeks and abnormal OGTT (fasting > 5.8 mmol/L or 2
hours 7.8 mmol/L or more).

16 weeks or more and OGTT result of fasting of ≥7.0mmol/L and 2
hours 13.0mmol/L or more.
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These women will be offered diet education and glucometer training in
the MONDAY afternoon clinic first and then a review blood glucose
readings the Friday clinic when a decision on treatment is made, before
discharge to community if controlled.
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All other women should be referred to GDM low risk clinic on Monday
afternoon’s - for Group Education and glucometer training

Referral to Monday appointments, send referral (Appendix 1) to
Antenatal clinic by Thursday midday. Please fax urgent referral to
Antenatal Clinic (ANC) 0207 3777460.
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Women will be discharged after one visit, for the community team will
review Capillary blood glucose (CBG) record in 2 weeks. (See criteria
for CBG control below)
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Women should be encouraged to follow the recommendations of the
clinic, the recommended diet containing: high fibre, low fat, low sugar
and 5 portions of fruit and vegetables a day of adequate portion sizes.
Gentle exercise or increased activity is encouraged, such as walking or
swimming
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Women will be instructed in the use of a CBG monitoring meter, and
advised to: -
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Monitor their CBG twice daily according to the repeating pattern below:Day 1 – before breakfast and 2 hours after
Day 2 – before lunch and 2 hours after
Day 3 – before evening meal and 2 hours after
Note: NICE (2008) recommends CBG testing one hour after meals (which
is not evidence-based) and current local practice will continue for the
present at 2 hours post-meal with a lower cut 2 hr cut off result of
7.0mmol/L.
COMMUNITY REVIEW OF 2 WEEKS AFTER GDM LOW RISK CLINIC
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If CBG’s are within the expected range, continue community team care
Midwife (CMW) and GP. At every antenatal appointment, CBG record
will be reviewed. If no record is produced, measure CBG in clinic.
Reviewing CBG in the community should be every 4 weeks until
delivery.
Aim for fasting blood sugar between 3.5 - 5.8 mmol/L, and 2 hours postmeals ≤7.0 mmol/L. If concerned, community team member to
telephone Diabetes Specialist Midwife for advice. The DSN will
advise if review required (Including review by joint diabetic obstetric
service).
If the CBG levels are ≥7.1 mmol/L on two or more occasions, or >9.0
mmol/L on one occasion, or fasting glucose is 5.8 mmol/L or more, the
woman will be advised to contact the Diabetes Specialist Midwife for
advice.
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No routine growth scans are required unless there are concerns of the
fetal growth
If any obstetric concerns, please make referral for Obstetric Consultant
review.
Blood should be collected and tested for Corrected Fructosamine at
36 weeks; results should be reviewed by community team.
If the Corrected Fructosamine result is <395 and there is no evidence
of macrosomia then continue care following the low risk care pathway.
If either a Corrected Fructosamine result is >395, concern about CBG,
or fetal macrosomia. Refer to Joint Diabetic Obstetric Clinic – Friday
Clinic.
Women in the GDM low risk care pathway will be induced for post dates
according to the induction of labour guideline. If women go into
spontaneous labour, with no concerns of macrosomia or abnormal CBG
can have intermittent auscultation. If there are no other obstetric problems.
When a woman starts Metformin and/or insulin treatment she will be reclassified as a GDM High Risk pregnancy, and be cared under the joint
diabetic obstetric clinic – Friday Clinic.
6.
MANAGEMENT OF GDM HIGH RISK PREGNANCY (TREATED WITH
METFORMIN AND/OR INSULIN)
Women will enter the antenatal care pathway (Appendix 3)
Antenatal visits, corrected fructosamine and ultrasound scan are in
accordance with the table below.
Antenatal Visits
Every
two Weekly from 36 weeks
weeks to 36
weeks
Fructosamine
Corrected Fructosamine
at commencement of insulin
Then Fructosamine every 4 weeks
Ultrasound Scan
Dating
Anomaly Scan at 20 weeks
Growth Scan at 26, 30, 34, 36, 38 weeks
In the absence of any other indication these women do not need a cardiac
scan for the baby, unless pre-existing diabetes is suspected.
Fundoscopy is not indicated in Gestational Diabetes unless Type 2
diabetes is strongly suspected.
Induction of labour, decision for induction should be made by a consultant
obstetrician. Target for induction should be 39 weeks, unless concerns
about macrosomia or CBG control.
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7.
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MANAGEMENT OF PRE-EXISTING DIABETES (TYPE 1 AND 2)
Refer to antenatal care pathway for timetable of antenatal appointments
(Appendix 3)
Community team will refer all women with pre-existing diabetes to the
Diabetes Specialist Midwife (DSMW) urgently for antenatal booking
appointment as soon as pregnancy is diagnosed.
The DSMW will conduct a booking history and arrange an appointment for
the joint diabetic obstetric service – Friday Antenatal clinic.
All subsequent follow up appointments are with the joint diabetic obstetric
service in Friday Antenatal clinic.
Dating scan will be offered, as well as combined screening for
Chromosomal anomalies.
Fetal Ultrasound For Pre-Existing Diabetes
 20 weeks - all women should have four chamber view of the fetal heart
and outflow tracts, uterine artery Doppler’s and anomaly scan.
 The findings of this ultrasound should be printed and securely stored in
the maternal records.
Targets For Glycaemic Control
 All women with pre-existing diabetes will be advised of the optimal
target range for glycaemia control during pregnancy (if safely
achievable, in the absence of persistent hypoglycaemia), this target will
be documented in their maternal records (Diabetes in Pregnancy
records).
The recommended target ranges (NICE, 2008)
3.5mmol/L
5.9mmol/
- fasting or before meals
3.5mmol/L
7.0mmol/L
– 2hr after meals (NICE, 2008
7.8mmol/L – 1hr after meals)
recommend
Glycated haemoglobin (HbA1c) 6.1% (if safely achievable – in the
absence of severe hypoglycaemia)
7.8
TYPE 1 DIABETES – MANAGEMENT
i.
All women will require 4 x daily insulin (basal/bolus) to achieve required
control.
ii.
Note: NOVORAPID or HUMALOG are the bolus insulin’s used during
pregnancy (both are licensed for use and recommended during
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pregnancy (NICE, 2008). LEVEMIR is the basal insulin used (there is
no evidence available for the use of this insulin during pregnancy and
NPH insulin such as INSULATARD is recommended by NICE as first
choice of longer acting insulin. However, analogue insulin’s such as
DETEMIR and GLARGINE reduce the incidence of hypoglycaemia,
especially nocturnal hypoglycaemia which is common among women
with Type 1 diabetes during pregnancy (Gallen & Jaap, 2006). This
information will be discussed with women at the booking appointment.
iii.
Women with Type 1 diabetes will be advised of the risks of
hypoglycaemia and hypoglycaemia unawareness, especially in early
pregnancy, and this will be documented in the woman’s maternity
records (Diabetes in Pregnancy).
iv.
Glucose hypo kits will be prescribed for all women with Type 1 diabetes.
v.
WHEN WOMEN ARE SUSPECTED OF HAVING DIABETIC
KETOACIDOSIS
 Any woman with Type 1 diabetes suspected of having diabetic
ketoacidosis (DKA) must be immediately admitted to the
obstetric high dependency unit.
 They should be reviewed by both the diabetes and obstetric
team as a matter of urgency.
 An individual management plan should be devised, including
both medical and obstetric plans. This care should be provided
by the multidisciplinary team.
7.9 TYPE 2 DIABETES – MANAGEMENT
i.
Woman will continue taking oral hypoglycaemic agents until seen by the
DWMS or in the joint diabetic obstetric service –antenatal clinic.
ii. METFORMIN will be continued or initiated if appropriate as well as
INSULIN therapy, either or both NOVORAPID and DETEMIR. Diet
treated may also require metformin and/or insulin, and will be carefully
evaluated first.
7.10 DOCUMENTATION OF INDIVIDUAL MANAGEMENT PLAN ALL WOMEN
WITH PRE-EXSISTING DIABETES FOR PREGNANCY AND POSTNATAL
PERIOD
i.
An individual management plan of care for pregnancy and the postnatal
period will be documented in the Diabetes in Pregnancy maternal
records.
ii. This is given to all women with pre-existing diabetes at the initial
booking appointment with the diabetes specialist midwife.
iii. The individual management plan will be reviewed and revised by the
multidisciplinary team at each antenatal appointment if necessary.
iv.
Plans for management of labour and birth and the postnatal period will
be documented in these notes after 34 weeks gestation.
8. IF PRE-EXISTING NEPHROPATHY (Renal Disease)
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i.
ii.
iii.
iv.
v.
8.1.
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U&E, Creatinine, LFTs monthly.
24-hour urine protein /PCR every 2 weeks
Metformin is not used if eGFR is <60ml/min in pregnancy, but should
probably be avoided in any woman with renal disease in pregnancy.
Thromboprophylaxis (Enoxaparin 40 mg S/C daily) if proteinuria is
above 5 gm/day.
Document results in the maternal records (ideally on a Obstetric
/cumulative Investigations Record)
If Pre- Existing Retinopathy
Pre-existing retinopathy often worsens in pregnancy.
Frequency of dilated fundoscopy required depends on findings at start
of pregnancy.
iii.
Minimum in women with known diabetes is at booking and at 28 weeks.
iv.
Use retinal photography screening form to enrol in Mile End Hospital
system. (Appendix 7)
i.
ii.
8.2.
PLANNING INDUCTION OF LABOUR
i.
Each individual case will be discussed with a Consultant Obstetrician
ii.
Timing of induction of labour is usually offered from 37 – 39 weeks
gestation, unless there is any concern about the macrosomia or with the
blood glucose control
8.3. PLANNING FOR BREASTFEEDING
Women who choose to breastfeed will be shown how to hand express and store
colostrum safely (see BLT Expressed Breast Milk (EBM) policy, 2009).
Harvesting can be performed at any time during pregnancy, however, ideally four
weeks prior to birth (for example from 34 weeks gestation).
9.
9.1.
9.2.
9.3.
9.4.
9.5.
9.6.
9.7.
9.8.
ANTENATAL STERIOD THERAPY IN DIABETES
For all women with diabetes (GDM and Pre-existing diabetes)
Refer to pre-term Birth care pathway (appendix 4)
Betamethasone administration 12mg intra-muscular injection (2 doses 12
hours apart) should be considered if delivery anticipated before 36 weeks
gestation.
Steroid therapy can have an adverse effect on glucose tolerance causing
disturbance in blood sugar control. As the effects of steroid therapy on the
diabetic mother can be dramatic.
Careful planning is required with the woman’s named obstetric consultant
or the on-duty consultant
Expect the blood glucose levels to rise 9-15 hours after the first dose of
Betamethasone and it may also rise 9-15 hours after the second dose. It
may take as long as 18-30 hours to achieve normoglycemia.
Women treated using diet and only will have their CBG’s monitored at
usual times before and after meals. If their CBG’s rise persistently over
7.0mmol/L, only then will they need IV supplementary insulin.
Women taking Metformin and or insulin will be admitted to Delivery Suite
for planned supplementary sliding scale of insulin, in addition to continuing
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normal diet and insulin/Metformin. Glucose 5% IV is ONLY given, when a
woman is not eating or drinking.
9.9. Insulin is given by a supplementary intravenous, variable dose sliding scale
infusion, started at the same time the first dose of Betamethasone is given.
The initial dosage regimen is determined from the current total daily dose
of subcutaneous insulin, applying one of the scales in the table below. If
the blood glucose level is >7.0 mmol/L on two consecutive hourly
measurements then a change is made to a stronger scale (e.g. B to C). If
the blood glucose is <4.0 mmol/L then a change is made to a weaker scale
(e.g. to A). The supplementary insulin infusion is stopped 15 hours after
the second steroid dose.
9.10. Should the above range of scales fail to keep CBG in range 4.0 –
9.0mmol/L the majority of the time, contact the DSMW or Diabetes Team
for advice, via Switchboard (Bleep 1257).
9.11. If the woman is put nil by mouth or not eating, then Glucose 5% 1 litre
containing 20mmol KCl will be needed running over 12 hours.
9.12. Stop subcutaneous insulin whilst nil by mouth.
< 40
40 – 80
81 – 120
>120
B
C
D
(or other
Rx)
24h sc insulin
requirements (units/day)
A
Hourly blood glucose
(mmol/L)
Intravenous insulin (units/hour)
<4.0
0
0
0
0
4.1 – 6.0
1.0
2.0
3.0
5.0
6.1 – 8.0
2.0
4.0
6.0
9.0
>8.1
3.0
6.0
8.0
12.0
Note: Beware a combination of tocolytics and steroids in diabetic women, as risk
of developing hyperglycaemia, ketoacidosis and pulmonary oedema. Consultant
Obstetrician on call should be kept informed at all times.
10.
MANAGEMENT IN LABOUR (Refer to intrapartum care pathway
(Appendix 5))
10.1. Place Of Birth
i.
Hospital Birth is recommended for women with diabetes in pregnancy (Preexisting and GDM).
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iii.
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GDM women who manage their diabetes with diet, if there is no evidence
of fetal macrosomia and blood glucose control is within expected ranges
have the option of birthing at the Barkantine Centre.
Homebirth is not advisable for women with pre-existing diabetes and
gestational diabetes (whether diet controlled or insulin controlled) because
of the requirement of blood glucose testing during labour and the initial
postpartum period.
10.2. Water birth is not advisable for women with GDM taking insulin or
women with pre-existing diabetes.
Water birth may be considered an option for women who have GDM (diet
controlled) if blood glucose levels are within the expected ranges and no
macrosomia or other risk factors. All requests should be referred to the
woman’s named Obstetric Consultant.
10.3. Induction Of Labour
i.
Refer to the separate induction of labour guideline.
ii.
All women with diabetes (Pre-existing diabetes, GDM, diet or on treatment)
will be induced on the Induction suite on Talbot Ward, unless any other
contraindication or specifically requested by Consultant.
iii.
Women will continue to take normal diet, metformin and or insulin until
labour is established and then change to control of glycaemia in labour.
iv.
Continue monitoring capillary blood glucose 6 times a day as usual in both
diet controlled and insulin controlled GDM and in women with pre-existing
diabetes
10.4.
i.
ii.
iii.
iv.
v.
Artificial rupture of membranes (ARM)
Admit to Delivery suite as soon as a bed is available.
Check capillary blood glucose initially
Diet treated diabetes: continue normal diet and check blood glucose 4
hourly. If blood glucose >7.0 mmol/L (meter) twice start insulin/glucose
infusion (see appendix 5)
If insulin and or Metformin treated: once admitted to delivery suite start IV
insulin infusion (see appendix 6)
Induction or acceleration of labour using Syntocinon – use 0.9% saline
with Syntocinon, NOT Glucose or Hartmann’s.
10.5. Fetal Heart Monitoring
i.
See intermittent auscultation of the fetal heart rate in labour or/ and
continuous fetal monitoring in labour guidelines.
ii.
GDM on Diet only - If no evidence of fetal macrosomia and blood glucose
control is within expected ranges and when there is no other indication for
continuous monitoring; intermittent auscultation is appropriate. If
macrosomia is suspected or any concerns about blood glucose control in
pregnancy, woman will be continuously monitored during labour.
iii.
GDM on Metformin and/or Insulin or Pre-existing Diabetes - Women will be
continuously monitored, once in established labour.
10.6. Control Of Glycaemia In Labour
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GDM on Diet only - Monitor blood glucose 4 hourly. If blood glucose >7.0
mmol/L on 2 consecutive occasions, start IV insulin/glucose infusion (see
appendix 5)
If for Caesarean section: if blood glucose >7.0 mmol/L start IV insulin/glucose
Diabetes controlled with insulin and or metformin
Glucose infusion - 1000 ml Glucose 5% containing 20 mmol potassium
chloride 12 hourly. (83ml/hour)
Insulin infusion - 50units Actrapid insulin in 50 ml Normal Saline 0.9% via an
infusion pump along with the glucose infusion through a Y connector
Blood glucose levels - Monitor hourly. Aim to maintain blood glucose
between 4 – 7mmol/L.
If blood glucose falls below 4.0 mmol/L – double rate of Glucose 5%
infusion
Blood Glucose (mmol/L)
< 4.0
4.1 – 6.0
6.1 – 8.0
8.1 – 10.0
Insulin infusion rate (units/hr)
0
1
2
4 + call doctor to increase scale by 50% at
each level (except < 4.0)
10.7. The standard variable dose scale will need modification in the face of
insulin resistance, for example if it fails to stabilise blood glucose at an
acceptable level of 4-7 mmol/L. If out of range on two consecutive
readings change will be required. Seek guidance from Diabetes Specialist
Trainee Doctor on adjustments to sliding scale of insulin, as this can be
extremely unpredictable.
10.8. Additional fluids - If additional fluids are required during labour e.g. before
commencing epidural analgesia set up a separate infusion to
glucose/insulin and use Saline 0.9%.
10.9. The fluid balance (input and output) will be documented in the partogram
during labour
11. Elective Caesarean Section - Plan operation for 9.00am.
11.1. Diet and Metformin treated:

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

Fast from 12 midnight the night before
OMIT Metformin
Admit to delivery suite at 8.00am
Monitor capillary glucose on admission and then 4 hourly.
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If blood glucose > 7.0 mmol/L (meter) start insulin/glucose infusion (see
appendix 5)
11.2. Insulin treated:

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



Fast from 12 midnight the night before
Continue BASAL (Detemir) insulin for women with Pre-existing diabetes
OMIT normal morning insulin (Novorapid) and Metformin.
Monitor capillary blood glucose.
Start IV glucose and insulin by 8am, at least one hour before operation.
Send blood for glucose and U&Es.
Consult anaesthetist about regimen if timing of operation changed from
morning
12. POSTNATAL MANAGEMENT(Refer to postnatal care pathway (Appendix6))
MOTHER
FOLLOWING VAGINAL BIRTH
i.
ii.
iii.
iv.
v.
i.
ii.
iii.
iv.
v.
i.
ii.
Pre-existing Diabetes
Individual management plan for postnatal period to be documented in the
third trimester by joint diabetic obstetric team
In women treated with diet or tablets (pre-pregnancy) stop IV insulin and
glucose infusion.
Consult Diabetes Specialist Doctor (via switch) or DSMW for advice about
medication.
Continue IV insulin at half the rate of insulin used in labour and continue
same glucose infusion until next meal. Then return to pre-pregnancy
insulin doses documented in the diabetes antenatal notes
Advise woman to monitor CBG as before pregnancy – before and or 2
hours after meals
Gestational diabetes
Stop IV insulin and glucose infusion immediately after delivery.
Stop metformin
Monitor blood glucose 4 hours after third stage complete.
Monitor CBG levels 6 hourly for 24 hours (unless woman is asleep) then
stop, if remain within range.
If CBG persist >7mmol/L contact diabetes team
FOLLOWING CAESAREAN SECTION
Pre-existing diabetes
Continue IV insulin at half the rate used in labour and continue same
glucose infusion until mother able to eat and drink reliably (usually 24
hours)
Measure blood glucose hourly for 4 hours following delivery and then 2
hourly until IV infusion discontinued
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iii.
iv.
i.
ii.
iii.



When able to eat convert back to pre-pregnancy insulin dose and
metformin, as appropriate (and contact diabetes team as above for postvaginal delivery). Overlap pump and first subcutaneous injection of insulin
by at least 30 minutes
Consult a Diabetes Specialist Doctor (via switch board) or the Diabetes
Specialist Midwife if concerned.
Gestational diabetes
Stop IV insulin and glucose infusion. Continue with Saline 0.9% until able
to drink
Stop metformin
Check blood glucose 4 hours after birth and then 6 hourly over next 24
hours. Stop after 24 hours if remains within range
BREAST FEEDING
Refer to Postnatal care pathway (appendix 6)
i.
ii.
iii.
iv.
v.
vi.
Pre-existing Diabetes
The babies of women who have chosen to breastfeed can be given
colostrum that has been harvested during pregnancy immediately following
birth to prevent hypoglycaemia (see BLT EBM policy, 2009)
Women who breast feed can continue to take metformin, and may also
require an insulin mixture twice daily and titration of doses to maintain
glycaemia within the expected range (4-7mmol/L)
Advise women treated with insulin or sulphonylureas to take healthy
snacks and adjust insulin doses when breastfeeding to reduce likelihood of
hypoglycaemia
Metformin and Glibenclamide are safe hypoglycaemic agents for breast
feeding
Women who do not breast feed - convert back to pre-pregnancy oral
hypoglycaemic agents (details in postnatal birth plan in diabetes antenatal
notes)
Refer any concerns to the Diabetes team.
12.1 MANAGEMENT OF NEWBORN
(See Neonatal Hypoglycaemia guideline refer to postnatal care pathway in
Appendix 6)
i.
ii.
iii.
These infants are at risk of developing significant hypoglycaemia as their
normal protective and compensatory mechanisms are impaired and so
babies will need screening for hypoglycaemia according to the regimen
detailed in the guideline on the Management of Neonatal Hypoglycaemia.
They are also at significantly increased risk for congenital malformations,
birth injury including shoulder dystocia; respiratory distress; polycythaemia
and neonatal jaundice.
Inform Neonatal St1-2 when the woman is in labour and ensure monitoring
blood glucose is adhered to postnatal.
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


12. 2 POSTNATAL FOLLOW UP REVIEW
12.2.1 The main purposes of post-natal follow up review is to identify impaired
glucose, offer advice about the risks of Type 2 diabetes and discuss
planning for future pregnancies. This preconception advice includes advice
about effective contraception and the importance of planning for a future
pregnancy to give opportunity to optimise glycaemia control and minimise
fetal risks.
12.2.2 Pre-existing diabetes
 Postnatal women on discharge should have an 8 – 12 weeks appointment
made with Consultant Diabetologist (Dr P. Peterson) Monday afternoon
diabetic clinic. The appointment should be made via his secretary – ext
2267 or switch.
 If pre-existing impaired glucose tolerance, ask General Practitioner (GP’s)
to decide if referral to consultant diabetologist is indicated.
12.2.3 Gestation Diabetes mellitus
 Continue on a healthy diet and increased level of activity.
 Postnatal women on discharge from hospital will have had an appointment
arranged for OGTT (Ext 60346) organised for 6 weeks postnatal at Mile
End Hospital.
 Midwife responsible for discharge is to complete pathology request form to
give to the woman to take to OGTT appointment.
 A 6-7 week postnatal diabetes appointment to see Diabetes Specialist
Midwife at Royal London Hospital on a Wednesday afternoon will also be
arranged.
 Women with normal postnatal GTT will be counselled that they are at an
increased risk of GDM and Type 2 diabetes.
 Women will be advised to attend their GP’s surgery for fasting blood
glucose annually, regarding diet, exercises and healthy lifestyle.
13. BREACH OF GUIDELINES/POLICIES
13.1. Staff members failing to adhere to the above guidelines should justify this
and document the reasons clearly in the notes.
13.2. Breach of guidelines should be reviewed within the risk management
framework and feedback and training given to staff as required.
14.
MONITORING COMPLIANCE (See Appendix 8)
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


REFERENCES
Confidential Enquiry into Maternal and Child Health (CEMACH) (2005) Pregnancy
in women with type 1 and type 2 diabetes: 2002-2003 England, Wales and
Northern Ireland Executive Summary. London: CEMACH
Gallen, IW. & Jaap, AJ. (2006) Insulin glargine use in pregnancy is not associated
with adverse maternal or fetal outcomes. Diabetes, 55 (Suppl 1), ppA417-1804.
Kaushal, K. et al., (2003) A Protocol for improved glycaemic control following
corticosteroid therapy in diabetic pregnancies. Diabetic Medicine, 20(1), pp73-5.
National Institute for Clinical Excellence (NICE) (2008). Diabetes in pregnancy.
Management of diabetes and its complications from preconception to the
postnatal period. London: RCOG Press
Centre for Maternal and Child Enquiries (CMACE) / Royal College of
Obstetricians and Gynaecologists (RCOG) (2010) CMACE/ RCOG Joint Guideline
on Management of Women with Obesity in Pregnancy. London: CMACE/RCOG
APPENDICES LIST
1.
2.
3.
4.
5.
6.
7.
8.
Referral for Glucometer training and Diabetes Education
Diabetes and Pregnancy – Screening and Care Pathway
Diabetes and Pregnancy – Antenatal Care Pathway
Diabetes and Pregnancy – Preterm Birth Care Pathway
Diabetes and Pregnancy – Intrapartum Care Pathway
Diabetes and Pregnancy – Postnatal Care Pathway
Referral for Retinal Screening
Process for monitoring the Management and Implementation of Care
pathways for women with pre-existing diabetes
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


Appendix 1
Referral letter to Diabetes low risk GDM Education Clinic for
Blood glucose meter and dietary group education
This clinic is only for Bengali and English speaking women.
IF ANOTHER LANGUAGE SPOKEN, SPECIAL NEEDS, OR IN ANY WAY
UNSUITABLE FOR GROUP EDUCATION, PLEASE REFER TO FRIDAY ANC
If your patient needs an interpreter, please telephone the antenatal department clerk on 020
7377 7431 and request an interpreter and specify which language
GP details:
GP name:
Practice:
Tel No:
Fax No:
Woman’s details:
NHS Number:
Hospital number:
Family Name:
Given Name:
Date of Birth
Telephone
Number:
Mobile
Number:
Address:
Preferred language:
English
Bengali
Other
(please
specify):
Current pregnancy:
LMP:
EDD:
Current
gestation:
Consultant:
Team:
Booking
date:
Reason for current referral: (Please complete fully using boxes)
Previous GDM
Diet/Insulin
Previous Pregnancy GTT Result
New GDM
Gestation
Current GTT Result
0 Min
120 Min
0 Min
120 Min
Please allocate an appointment: English Group 1.00 PM on Mon: Date ……………………
Bengali Group 2.00 PM on Mon: Date ……………………
Venue: Antenatal Clinic, 1st floor, Outpatients Department, Royal London Hospital
Signature: .………………….… PRINT NAME .……………………….... Date …………………
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Appendix 2
Pre Existing Diabetes







Diabetes & Pregnancy Screening and Care
Pathway

Screen
annually
with
Fasting
Previou
Blood
s Glucose
Gestatio
 Refer for
Statin & or Fibrate
AT
AT
ACE/A2RB
BOOKINGnal Preconce
BOOKING
DSMW will stop OHA’s
ption
Random Diabete
Random
Continue Metforminblood
blood
counselli
glucose
Increase CBGM – glucose s
Random
ng
1. IMMEDIATE
NORMAL
Blood
more monitor stripsABNORMA
NORMA
OGTT
L RESULT
RESULT
Glucose
Refer for preconception
advice
Stop!

Risk
of
Diabet
es in
Random
Pregn
Blood
glucose
AT BOOKING
ancy
Risk
of
& 26
weeks
Diabetes in
Pregnancy

BMI >30
L
REPEAT

Previous
Random
Random
ABNORMA
RESULT
AT
16
baby
>7.0mmol/L
<7mmol/L
L RESULT
Weeks
>4kg
NORMA
2. OGTT –

1st
L
16 Weeks
degree
GDM
URGENT FAXED
RESULT
relative
REFERRAL TO DIAGNOSED
Random
3. OGTT – 28
with
Fasting
Blooddiabetes
Royal London
Weeks
>5.8mmol/
Glucose
Hospital

Family
NORMAL
L
OGTT
≤5.8mmol/
origin
GDM
RESULT
2hr
with a
NORMAL
Lfasting
diagnosed
NORMAL
high
RESULT
≥7.8mmol/
REFER
to
<7.8mmol/
prevalen
Diabetes
Result
Fasting
L (before 30
MONDAY
Joint
ce (South
L2 hours
Education &
≤5.8mmol/
weeks
CLINIC
Asian,
Antenatal
capillary
BG
gestation
L black
Royal
London
Discharged
to
Blo
Diabetes
meter
training
2hr
2hr Caribbea
Hospital
Community
od
Clinic
>9mmol/L
n, and
<7.8mmol/
Glu
FRIDAYS
Middle
(after 30Follow-Up
weeks
L
(before
30
Eastern)
gestation)Follow LOW RISK
cos
Corrected
Corrected
weeks
CARE PATHWAY

Age
Continue
care
Fructosamin
Fructosamin e
gestation)
>40yrs

GP/CMW after
2
e
e
in Community
resu
2hr
weeks
 <Persisten
>395mmol
<395mmol lts
LOW RISK
t

CBG review every
9mmol/L
/L
/L
CARE
4glycosuri
4 weeks until
(after
30 weeks
PATHWAY
a
delivery & no
7m
gestation)
evidence of

36 wks =

Previous
Macrosomi mol/
FRUCTOSAMINE
unexplain
a
L
TEST
ed IUD

Polyhydr
amnious
Blood glucose results
Fasting>5.8mmo/L
2 hr>7.0mmol/L
Diabetes Specialist
Midwife 07768702618
(and for any queries)
For referral to Joint
Diabetes ANC (Friday)
GP or CMW care
HOSPITAL team
GP pre pregnancy or
at referral
Barts & The London NHS Trust
2010 (NJT)
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


Appendix 3
Diabetes & Pregnancy
Antenatal Care Pathway
Gestational
Diabetes
treated with Insulin &
or Metformin
Pre-Existing
Diabetes
URGENT
FAXED
REFERRAL
Royal London
Hospital
Booked for
Antenatal Care by
Diabetes Specialist
Midwife
MULTIDISCIPLINARY
DIABETES
ANTENATAL CLINIC
REFERRAL BY
Diabetes
Specialist Midwife
FRIDAY MORNINGS
07768702618
DIABETES TEAM
OBSTETRIC TEAM
7-12 weeks BOOKING appointment – women
to see both teams
HbA1c & FRUCTOSAMINE
12-16 weeks – every 2 weeks
Offer – viability
scans &
combined
screening (1113+ 6 days)
Retinal Screening for Pre-existing
diabetes ONLY unless specified
16 weeks – see
Specialist Midwife
20 weeks - Women see both teams - FRUCTOSAMINE
FRUCTOSAMINE
22 weeks – Diabetes
24 weeks – see
Specialist Midwife
Pre existing diabetes
AN USS, Unless specified

Four chamber view &
outflows tracts of fetal
heart

Anomaly scan

Uterine artery& doppler
26 weeks – Women see both teams
FRUCTOSAMINE
Growth Scan
28 Weeks – Women see both teams - FRUCTOSAMINE
Retinal Screening
30 weeks – Women see both teams
Growth Scan
34 weeks – see
Specialist Midwife
BIRTH PLANS inc:
Colostrum Harvesting
Growth Scan
32 weeks – Women see both teams - FRUCTOSAMINE
36 weeks – Women see both teams -FRUCTOSAMINE
Growth Scan
37 weeks – Women see both teams – DISCUSS
METHOD & MODE OF BIRTH document in notes
38 weeks – Women see both teams - OFFER IOL
Barts and The London
NHS Trust 2010
(NJT)
Growth Scan
39 weeks – Women see both teams
P 19 of 25
40 weeks – Women see both teams
MAT/GUI/0310/DIABET
Appendix 4



Diabetes & Pregnancy
Antenatal Steroid Therapy
BIRTH and LABOUR
BEFORE 36 WEEKS
STEROID
THERAPY
PRE EXISTING
DIABETES & GDM
MANAGED WITH
METFORMIN & OR
INSULIN THERAPY
BETAMETHASONE
12mg
Given Intramuscular,
2 doses,
12 hours apart
ADMIT DELIVERY SUITE
GDM
MANAGED
WITH DIET
ADMIT
TALBOT
WARD
Monitor CBG
before & after
meals if persist
ADMIT
>7mmol/L
DELIVERY SUITE
SUPPLEMENTARY INSULIN INFUSION – Transfer to Delivery
Suite. Continue for 15hrs after the 2nd dose. ALSO FOLLOW HIGH
RISK CARE PATHWAY FOR PRETERM BIRTH
WOMAN NOT EATING
& DRINKING
WOMAN EATING


CONTINUE usual insulin doses of both
NOVORAPID & DETEMIR. DO NOT
START GLUCOSE
STOP usual insulin doses if NOT
EATING or DRINKING. START
1000ml/s Glucose 5% containing
20mmol/l of potassium chloride running
over 12hours (83mls/hour)
INTRAVENOUS INSULIN AND GLUCOSE SLIDING SCALE

Insulin is given by a supplementary, intravenous, variable dose sliding scale
infusion which is started at the same time as the 1st dose of Betamethasone
12mg

Prepare insulin pump – 50 units ACTRAPID made up to 50mls 0.9% saline

Calculate the current total daily insulin dose (both insulin’s) & start
supplementary insulin according to one of the scales (A-D) below. If taking
METFORMIN start at scale A

Hourly BG monitoring, chart in diabetes record chart

BG’s >7mmol/L on 2 consecutive occasions, move up to the next scale
BG <4mmol/L
move
down
to the next weaker
If CBG’s persist
outside of
range
4.0-9.0mmols
contactscale.
DSM or Diabetes SPR via
switchboard bleep 1257
24 hourly SC Insulin
Requirement (units/day)
>120
METFORMIN – scale A
Intravenous Units per Hr
D
Hourly BG (mmol/L)
<4mmol/L
0
4.1-6.0
=
<40
40-80
81-120
=
A
B
C
0
0
0
1.0
2.0
3.0
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


Appendix 5 Diabetes & Pregnancy - Intrapartum Care Pathway
ELECTIVE
PLANNED INDUCTION OF LABOUR
CAESAREAN
All women with Diabetes managed with INSULIN AND OR METFORMIN &
SECTION
GDM managed with DIET.
(After 38 weeks
Admit TALBOT
unless indicated)
WARD
FIRST ON

Normal
diet
&
or
(Unless specified)
ESTABLISHED LABOUR –
LIST
insulin
&
or
ALL Women with Diabetes
INSULI
METFORMIN
managed with INSULIN &
N FAST FROM
12 &
DIET

Usual CBG
OR METFORMIN
midnight METFO
Treated
monitoring, before
Omit
RMIN
& after meals (6
morning
Treated
times
daily)
bolus
Established Labour
Omit
or cervix
Prostaglandins
insulin
favourable
Metform
Continue
 ARM
IOL guidelines
07:30
– ADMITinto
for
basal
ESTABLISHED
DELIVERY
SUITE
insulin if
LABOUR
Type
1
Monitor
Monitor
GDM DIET
diabetes
ADMIT TO
CBG’s
on
CBG’s
MANAGED
DELIVERY SUITE

Monitor BG 4
admission
on
hourly
Take Blood
admissi
CBG> 7mmol/L
on 2
Intermittent
- U& E’s &
on & 4
consecutive
occasions
auscultation
glucose
hourly
START
INSULIN
 IV
Normal
diet &
50 units fluids
INFUSION
08:00
If BG
ACTRAPID made

START IV INSULIN INFUSION
Start
>7mmol
up to 50mls with
IV
/L Start

High-risk labour guidelines
0.9% Saline via
INSULI
IV

Check BG hourly
insulin pump
N
INSULI
INFUSI
N
ON
INFUSI
ON
BG’s >8.1
consecutive
readings
1000mls Glucose 5% containing
CONTACT
20mmol/L potassium chloride, 12

Diabetes SPR
hourly (83mls/hour)
bleep 1257 for
advice
Monitor CBG’s hourly & adjust insulin using scale below:


Pre-existing diabetes - CONTINUE basal Insulin
(DETEMIR/GLARGINE)
STOP bolus insulin (NOVORAPID)
Blood Glucose (mmol/L)
Insulin infusion rate (units/hr)
<4.0mmol/L
0
4.1-6.0
1
6.1-8.0
2
8.1-10.
4 + call doctor to increase scale by
50%
at each level (except <4mmol/L)
INDUCTION OR ACCELERATION OF LABOUR - ALL WOMEN
WITH DIABETES
USE 0.9% SALINE AS IV FLUID WITH SYNTOCINON – follow
high risk labour guidelines for IOL procedure
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
Appendix 6


Diabetes and Pregnancy
Postnatal Care Pathway
GESTATIONAL DIABETES
Following Birth
PRE EXISTING DIABETES
Following Birth
Refer to Post Birth Plan in notes
WOMEN ADVISED TO STAY 24HRS
Refer to Post Birth Plan in notes
WOMEN ADVISED TO STAY 24HRS

STOP!





INSULIN & METFORMIN
Normal Diet
Check BG 4hrs after birth
Check BG 6hrly for 24hrs
If BG >7mmol/L contact DSM

plan in notes






Arrange GTT test 6-7 weeks postnatal (Tel
internal 60346)
GIVE REQUEST FORM Before discharge from
hospital
Postnatal follow-up with Diabetes Midwife in
ANC 6-7wks postnatal
Continue IV insulin at half the total dose
of insulin used in labour until eating &
drinking. Check BG 2hrly
Return to pre-pregnancy doses of
INSULIN, METFORMIN & or
GLIBENCLAMIDE – refer to post natal birth


Other hypoglycaemic agents if NOT
breastfeeding
Bolus insulin (NOVORAPID) with first meal.
STOP IV insulin
Check BG 4hrly
Contact DSM/Diabetes SPR if concerned
Diabetes Midwife to review diabetes medication if
persists outside of expected range 4-7mmol/L
Arrange diabetes follow-up appointment after 8-12
weeks postnatal with Diabetologist – call RLH
internal ext: 2267 to arrange
Infant Feeding – Refer to Neonatal Hypoglycaemia guideline for AT
RISK babies
Hypoglycaemia guideline for AT RISK baby
BREASTFEEDING

Identify “at risk” baby


Breastfeed ASAP after birth, Feed 2-3 hourly

Do NOT TEST “at risk” babies at birth

1st test not before 4 hours, test before a feed



If 2.5mmol/L - test before 2nd feed, 3 x test 1st
24hrs, 2 x test 2nd 24 hrs


If 2-2.4mmol/L – test before every feed until
>2.5mmol/L, give breastfeeding support; hand
express & give colostrum

If >2.5mmol/L – give supplement of EBM or
formula if necessary; BF before supplement

Decrease amount of formula as BF
established

GIVE IV DEXTROSE if baby has signs of
clinical hypoglycaemia


If BG <2.ommol/L on 2 consecutive occasions
despite maximum feeding support, & has
abnormal clinical signs or will not feed orally
effectively, GIVE IV DEXTROSE

INSULIN OR GLICLAZIDE/GLIBENCLAMIDE
-healthy snacks available for when baby
feeds – risk of HYPOGLYCAEMIA
Insulin therapy if other hypoglycaemic agents
– contact DSM
Adjust insulin doses according to BG results
Contact GP or diabetes nurse in community
for advice
DO NOT transfer mother & baby to the home
until after 24hrs old, maintaining their BG
levels & feeding well
Admission to Neonatal Unit
Admit a baby to neonatal unit if he or she:






Is hypoglycaemic with abnormal signs
Has respiratory distress or jaundice that
requires monitoring or treatment
Has signs of cardiac decomposition, neonatal
encephalopathy or polycythaemia
Needs intravenous fluids
Needs tube feeding (unless support is
available on the postnatal ward
Is born before 34 weeks (or between 34 and
36 weeks if dictated clinically by initial
assessment
Refer to Management of Neonatal
Hypoglycaemia guideline
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


Appendix 8 Monitoring Compliance - The Management and implementation of care pathways for women with
pre-existing diabetes
Element to be
monitored
Lead
Audit and
monitoring
Tool
Frequency
Committee to review
the report
Acting on
recommendations
Implementation of practice
changes and lessons learned.
The involvement of the
multidisciplinary team
including the obstetrician,
midwife, diabetes
physician, the diabetes
specialist nurse and
dietician in the provision of
care when appropriate
Consultant
Obstetrician with
a special interest
in diabetes
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Records
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
provision presented.
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Board will monitor
progress against action
plans and targets for all
the audit
Reports will be circulated to all relevant
clinical areas
Emailed to all relevant staff groups
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
Lessons will be shared with the relevant
staff groups
The timetable of antenatal
appointments
Consultant
Obstetrician with a
special interest in
diabetes
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Board will monitor
progress against action
plans and targets for all
the audit
Reports will be circulated to all relevant
clinical areas
Diabetes
Specialist Midwife
An annual sample should
be used
Diabetes
Specialist Midwife
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Records
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
provision presented.
An annual sample should
be used
Emailed to all relevant staff groups
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
Lessons will be shared with the relevant
staff groups
An individual management
plan has been
documented in the records
that covers pregnancy and
the postnatal period up to
Consultant
Obstetrician with a
Specialist interest
in Diabetes
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Reports will be circulated to all relevant
clinical areas
Emailed to all relevant staff groups
P 23 of 25
MAT/GUI/0310/DIABET
six weeks

Diabetes
Specialist Midwife

Records

provision presented.
Board will monitor
progress against action
plans and targets for all
the audit
An annual sample should
be used
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
Lessons will be shared with the relevant
staff groups
Documented targets for
glycaemic control in the
maternal records
(Targets for both pre and
post prandial blood
glucose levels)
Consultant
Obstetrician with a
Specialist interest
in Diabetes
Diabetes
Specialist Midwife
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Records
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
provision presented.
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
An annual sample should
be used
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Board will monitor
progress against action
plans and targets for all
the audit
Reports will be circulated to all relevant
clinical areas
Emailed to all relevant staff groups
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
Lessons will be shared with the relevant
staff groups
Women with Type 1
diabetes are advised of
the risks of hypoglycaemia
and hypoglycaemia
unawareness in
pregnancy and all Type 1
Diabetes have glucagons
kit provided
Consultant
Obstetrician with a
Specialist interest
in Diabetes
Diabetes
Specialist Midwife
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Records
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
provision presented.
An annual sample should
be used
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Board will monitor
progress against action
plans and targets for all
the audit
Reports will be circulated to all relevant
clinical areas
Emailed to all relevant staff groups
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
P 24 of 25
MAT/GUI/0310/DIABET
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

Lessons will be shared with the relevant
staff groups
Women with pre-existing
diabetes are offered
antenatal ultrasound
examination of the four
chamber view of the fetal
heart and outflow tracts at
20 weeks gestation
Consultant
Obstetrician with a
Specialist interest
in Diabetes
Diabetes
Specialist Midwife
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Records
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
provision presented.
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
An annual sample should
be used
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Board will monitor
progress against action
plans and targets for all
the audit
Reports will be circulated to all relevant
clinical areas
Emailed to all relevant staff groups
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
Lessons will be shared with the relevant
staff groups
Women who are
suspected of having
diabetic ketoacidosis
(DKA) are admitted
immediately to a high
dependency unit where
they can receive both
medical and obstetric care
Consultant
Obstetrician with a
Specialist interest
in Diabetes
Diabetes
Specialist Midwife
Audit proforma,
reviewing
Diabetes in
Pregnancy
Maternal
Records
Annual Audit
of 1% of all women who
have a diagnosis of preexisting diabetes.
Rolling audit of service
provision presented.
An annual sample should
be used
The Audit should be
presented to the Maternity
Audit committee, and
report presented to the
labour ward forum.
Labour ward forum will
undertake
recommendations
Maternity and
Gynaecology Governance
Board will monitor
progress against action
plans and targets for all
the audit
Reports will be circulated to all relevant
clinical areas
Emailed to all relevant staff groups
Required changes to practice will be
identified and actioned within a specific
time frame, at the Labour ward forum.
A member of LW Forum or Audit Meeting
will be identified to take each change
forward.
Lessons will be shared with the relevant
staff groups
P 25 of 25