The feasibility and impact of implementing NICE guidance on diabetes control during delivery

Abstract

Aims: The aim of this study was to report on the practicality, feasibility and impact of implementing the National Institute for Health and Care Excellence (NICE) guidelines for the control of diabetes in women during labour and birth. Methods: We analysed case records of pregnant women with diabetes who delivered in the period between July 2014 and June 2015. The data were collected in relation to the availability of a plan in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4-7 mmol/L, maternal hypoglycaemia during labour and neonatal hypoglycaemia. Results: Fifty-one women with diabetes delivered during this period. Only 45% of women were monitored by complete hourly CBGs until delivery. 27.4% of women had CBG ≥7 mmol/L but only 17.6% were started on VRIII. The VRIII group had a 22.2% incidence of minor maternal hypoglycaemia. Neonatal hypoglycaemia occurred in 47% of the babies. Conclusion: A CBG target of 4-7 mmol/L during labour and initiation of VRIII when levels are above this target in pregnant women with diabetes is difficult to achieve and is associated with some maternal hypoglycaemia. Repeat CBG measurements within half an hour and strict adherence to clear guidelines and protocols supported by more education and adequate staffing may improve results.Br J Diabetes 2017;17:ONLINE AHEAD OF PUBLICATION

Pseudoaxioms in the intrapartum management of diabetes

“…Dashora et al [6] found that the incidence of hypoglycaemia was 22% in women on variable-rate i.v. insulin infusion to achieve an intrapartum target of 4-7 mmol/l [6]. Moreover, in that study, only 45% of women had hourly capillary blood glucose monitoring.…”

Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes

“…dextrose continues to be as high as 28% in a recent multicentre randomized controlled trial setting [13]. Based on capillary glucose levels, 47% neonates had a glucose measurement < 2.6 mmol/l in another study [14].…”

National guidelines have contributed to safer care for inpatients with diabetes

“…However, Kline and Edwards [6] also report a neonatal hypoglycaemia rate of 69%, and the majority of maternal episodes were asymptomatic and discovered incidentally because of the monitoring protocol. Thus, maternal hypoglycaemia during variable rate intravenous insulin infusion has never been a major issue in practice because women are under close supervision with hourly monitoring and are easily treated [9]. Thus, maternal hypoglycaemia during variable rate intravenous insulin infusion has never been a major issue in practice because women are under close supervision with hourly monitoring and are easily treated [9].…”

“…Others have reported zero maternal hypoglycaemia [7] and 7 of 23 studies in a recent metaanalysis did not report any maternal hypoglycaemia [8]. Thus, maternal hypoglycaemia during variable rate intravenous insulin infusion has never been a major issue in practice because women are under close supervision with hourly monitoring and are easily treated [9]. A review of 24 published papers of various protocols for glycaemic control in women with diabetes during labour demonstrated that a target capillary blood glucose of 4.0-6.0 mmol/l can be used safely with a low rate of neonatal hypoglycaemia [10].…”