CHHS16/238

Canberra Hospital and Health ServicesClinical ProcedureInsulin Infusion for Labour and BirthContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – General Information...............................................................................................2

Section 2 – Management of Women during Labour.................................................................3

Section 3 – Blood Glucose levels...............................................................................................3

Section 4 – Insulin Infusion for labour & birth..........................................................................4

Section 5 – Post Partum Care....................................................................................................5

Implementation........................................................................................................................ 6

Related Policies, Procedures, Guidelines and Legislation.........................................................7

References................................................................................................................................ 7

Search Terms............................................................................................................................ 7

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Purpose

The purpose of this document is to support staff to identify those women who require an insulin infusion during labour and birth and to provide evidence based, safe and effective treatment.

To maintain normal capillary Blood Glucose Level (cBGL) in women with diabetes by: maintaining cBGL within 4 to 7mmol/L during pregnancy and labour maintaining cBGL within 5 to 10mmol/L in women undergoing caesarean section and all

women post birth.

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Scope

This document applies to the following medical staff working within their scope of practice: medical officers pharmacists midwives and nurses student midwives and nurses under direct supervision.

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Section 1 – General Information

During pregnancy, the endocrine team will document and communicate to the woman and staff, the plan for peripartum insulin infusion management.

If a plan is unavailable at time of labour contact the endocrine registrar (or endocrine consultant after hours) to discuss management of diabetes.

Indications for insulin and glucose infusionCommence an insulin and glucose infusion for: all women with diagnosis of TYPE 1 DIABETES for labour and/or caesarean section some women with diagnosis of TYPE 2 DIABETES for labour and/or caesarean section as

ordered by the endocrine team.

Very few women with Gestational Diabetes Mellitus (GDM) require insulin and glucose infusions. However, if required the decision is made in consultation with the endocrine team.

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Section 2 – Management of Women during Labour

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This Standard Operating Procedure (SOP) describes for staff

CHHS16/238

Management of women requiring an insulin infusion when in spontaneous, established labour Cease any further subcutaneous insulin injections and commence insulin and glucose

infusion as per protocol below in Section 4.

Management of women having an induction of labour (oxytocin and /or Artificial Rupture of Membranes [ARM]) and requiring insulin and glucose infusion administer half of the usual morning subcutaneous insulin dose give a light breakfast commence induction of labour preferably between 0900 and 1000 hours use 0.9% sodium chloride for oxytocin infusion for both mainline and sideline via a second

cannula in the opposite arm to the insulin infusion commence insulin and glucose infusion according to protocol outlined below in Section 4.

Management of women on personal subcutaneous insulin pump therapy Women on personal subcutaneous insulin pumps will usually be required to turn their

pumps off and follow this protocol. If the insulin pump is to be used during labour it must be in consultation with the Endocrine Team and documented in the clinical record.

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Section 3 – Blood Glucose levels

Blood collection during insulin infusion Collect blood for the cBGL from the opposite arm in which IV insulin infusion is infusing.

If cBGL > 15mmol/L check for blood ketones. Calibrate blood analysing machine touse blood ketone strips. If blood ketones >0.6 mmol/L notify registrar immediately.

Alert:If an insulin infusion tissues, replace IV cannula, as a matter of urgency. Rationale: The half-life of intravenous insulin is 5 minutes therefore cessation of insulin infusion makes the women immediately insulin deficient and at risk of ketoacidosis.

Adjustment of infusion to achieve target cBGL Achieve target cBGLs via insulin adjustments rather than glucose adjustments, unless the

woman is hypoglycaemic then glucose rate may need to be increased.

Hypoglycaemia (cBGL <4.0mmol/L) observe and monitor for signs of hypoglycaemia <4.0mmol/L- i.e. shakiness, pallor,

confusion, drowsiness, sweating as outlined in the CHHS Management of Adult Patients Requiring Continuous Intravenous Insulin Therapy standard operating procedure

treat promptly and document as per CHHS Procedure Hypoglycaemia Management of Adult Patients with Diabetes Mellitus.

Note:

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General anaesthetic, narcotic pain relief or using nitrous oxide may make the woman unable to recognise signs and symptoms of hypoglycaemia therefore a wider range of cBGLs are recommended.

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Section 4 – Insulin Infusion for labour & birth

Record hourly cBGLs for women receiving insulin and glucose infusions Maintain the cBGL between 4 to 7mmol/L pre birth and 5 to 10mmol/L in women

undergoing caesarean section and all women post birth. The rate of the insulin infusion depends on the blood glucose level (BGLs). The rate of the side line maintenance 5% glucose or 0.18% sodium chloride and 4%

glucose infusion remains constant - 1 litre over 8 hours, 125mL per hour. It is important that the maintenance infusion of glucose remains stable to achieve a

constant rate of glucose supply. The maternal insulin requirement falls dramatically immediately post birth of placenta.

Convert to post birth insulin infusion adjustments once the placenta is born (refer to table).

The insulin must be in the mainline and is adjusted as belowThe standard insulin infusion preparation is sodium chloride 0.9% 100 mL with 100 units actrapid insulin therefore 1 unit =1mL. This is made by pharmacy in business hours or on the ward.

The rate of the side line maintenance 5% glucose or 0.18% sodium chloride and 4% glucose infusion remains constant - 1 litre over 8 hours, 125mL per hour.

All lines and infusions must be labelled according to National Standard for User-applied Labelling of Injectable Medicines, Fluids and Lines.

Insulin ScalePre birth Post birth of placenta

capillary BGL(mmol/L)

mL per hour unit per hour mL per hour unit per hour

<3.5 0.0 0.0 0.0 0.0

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3.5 – 5 0.5 0.5 0.0 0.05.1 – 7 1 1 0.5 0.57.1 – 9 2 2 1 19.1 – 11 3 3 1.5 1.511.1 – 13 4 4 2 213.1 – 15 5 5 2.5 2.5Alert:If the cBGL >15mmol/L and is not progressively decreasing, despite an insulin infusion rate of 5 units/hour or greater for more than 2 hours, notify the endocrine registrar for authorisation to increase the insulin doses on the scale.

15.1 – 20 5.5 5.5 3 320 – 25 6 6 4 4>25 6.5 6.5 5 5

In cases of severe insulin resistance, the scale for the insulin infusion rate may need to be increased to deliver more insulin per mmol/L of cBGL.

Re-check any cBGL that is markedly different from a previous level (check the IV cannula site, check that the specimen has not been taken from the insulin infusion arm and check that the infusion bag is not >24 hours old).

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Section 5 – Post Partum Care

The primary treatment goal in the postpartum period is to avoid hypoglycaemia insulin requirements usually dramatically reduce immediately following birth of the

placenta, increasing the risk of hypoglycaemia insulin requirements may be substantially less than the pre gravid insulin requirements

in the first 48 hours postpartum initial subcutaneous doses of insulin postpartum should usually be less than the pre

gravid insulin dosage.

Management of insulin infusion after birth of placenta, as specified by the endocrinologist in the woman’s clinical record, or as follows:

Type 1 Diabetes halve the insulin infusion rate following birth of placenta and follow the post birth

protocol as above in Section 4 the glucose sideline infusion should be continued until the woman is tolerating an

adequate carbohydrate intake attend cBGLs 1/2 hourly for 2 hours, then hourly until routine pre gravid subcutaneous

insulin is commenced as prescribed by the medical officer

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for women who have a vaginal birth introduce subcutaneous insulin at the time of the first meal post birth

for women who have had a caesarean section, continue the insulin infusion protocol until the woman is able to eat

cease insulin infusion protocol 2 hours after the first subcutaneous insulin injection as per medication order

observe the woman closely for signs of hypoglycaemia; treat promptly and document leave cannula in situ for at least 6 hours after cessation of infusion, when BGLs are

stabilised, urine is ketone free and diet is tolerated, remove cannula women should be reassured that a short-term relaxation of tight control is justified to

reduce the risk of hypoglycaemia inform women that breastfeeding may accentuate hypoglycaemia.

Type 2 Diabetes and the few women with Gestational Diabetes Mellitus who have required insulin during birth cease IV insulin infusion after birth of placenta cease IV glucose sideline infusion when diet is tolerated perform cBGL before breakfast and 2 hour post meal until reviewed by the Endocrine

Team notify the endocrinologist if fasting BGLs are >7mmol/L or postprandial cBGLs > 7.8

mmol/L.

Note: Women with Type 2 Diabetes may need to recommence subcutaneous insulin therapy after birth. Insulin therapy is preferable to oral agents if the woman is breastfeeding.

For postpartum care of the baby refer to the Procedure Hypoglycemia in the Newborn

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Implementation

Education provided at interdisciplinary education and in-service training. All staff will receive notification of this Clinical Procedure via email. The document will be placed at ward desks.

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Related Policies, Procedures, Guidelines and Legislation

Policies Health Directorate Nursing and Midwifery Continuing Competence Policy, DGD12-050

Procedures CHHS Hypoglycaemia of the Newborn SOP CHHS Hypoglycaemia Management of Adult Patients with Diabetes Mellitus SOP,

CHHS13/571 CHHS Insulin – Management of Adult Patients Requiring Continuous Intravenous Insulin

Therapy SOP, TCH08:003Back to Table of Contents

References

1. King Edward Memorial Hospital (2015) Clinical Guideline. Intrapartum management of type 1 diabetes mellitus.

2. National Institute for Health and Care Excellence (NICE) (2015) Clinical Guidance. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period.

3. Royal Hobart Hospital (2015) Protocol. Insulin infusion protocol for labour.

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Search Terms

Diabetes, diabetes in labour and birth, diabetes in labour, insulin infusion, insulin infusion in labour, gestational diabetes, GDM, IRGDM.

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Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair

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