Management of Diabetes in Pregnancy, Childhood, and Adolescence

The timing of the final admission for delivery is dependent on the quality of glycemic control throughout pregnancy, the accuracy of dating information gathered during the prenatal visits, and the confirmation of fetal pulmonary maturity by amniocentesis. Delivery may be prompted by fetal distress. Spontaneous labor after 36 weeks may precipitate delivery. However, if spontaneous labor does not occur, labor is induced at 40 to 42 weeks in patients with normoglycemia.

The night before labor is induced, the usual dose of basal insulin is administered. Before active labor begins (3 contractions per 10 minutes, each lasting 60 seconds), insulin requirements are high.

However, when active labor begins, insulin requirements drop to zero, whereas glucose requirements increase to 2.55 mg per kg per minute. Hourly blood glucose determinations help guide the administration of dextrose and insulin during labor and delivery, as described in Table 8-8.

Induction of Labor40 The protocol for blood glucose stabilization before labor induction is as follows. Give the usual bedtime basal insulin the night before, and induce labor in the morning, if possible. Mix oxytocin in 50% isotonic saline, and do not P.381 P.382 begin dextrose infusion until the patient is in active labor or the blood glucose value is less than 70 mg per dL. Proceed toward target glucose infusion rate as labor progresses, as in spontaneous labor.

If the blood glucose is more than 120 mg per dL, an alternative protocol for reducing the glucose level is to begin a constant infusion of insulin at a rate of 0.05 U per kg per hour and increase the rate of infusion of insulin until the glucose is stabilized at a level near 10 mg per dL. TABLE 8-8 Labor and Delivery: Insulin and Glucose Requirements Note: The following protocol should be maintained and supervised by a nurse familiar with pregnancy and diabetes.

The aim of this protocol is to maintain blood glucose levels in the range of 60â €“100 mg/dL to prevent fetal and maternal hyperglycemia and neonatal hypoglycemia.

Procedure: 1. If induction of labor is planned, the patient should take her routine bedtime dose of insulin. However, she should consume no AM food and take no insulin.

2. Patient may have ice chips and clear liquids during labor (no sugar drinks).

3. A heparin lock may be inserted from which one might obtain frequent glucose values (at least hourly).

4. Obtain baseline glucose value (either via blood glucose monitor).

5. Start 18-gauge angiocath IV line, 1,000 mL NS or LR primary IV tubing with three-way stopcock and T-connector. This will serve as the mainline IV. Have D10NS available ready to hang if blood glucose levels drop <60 mg/dL. 6. If blood glucose is 60–100 mg/dL, piggyback D5W IV at 100 mL/h (see below). The mainline IV rate may continue at any rate chosen by the physician. The rate may be reduced if fluid restriction is needed or increased if the patient becomes hypotensive or requires a more rapid infusion of fluids for any reason.

7. If blood glucose is <60 mg/dL, piggyback D10NS into mainline with IV pump at 100 mL/h. Set limit at 17 mL (amount to be infused in 10 min), and recheck blood glucose; continue checking glucose values after every 17 mL of D10NS is infused (i.e., every 10 min). Once the blood glucose is >60 mg/dL, resume D5NS or D5LR at 100 mL/h (see below).

8. If blood glucose is 90–120 mg/dL, maintain NS or LR infusion at Unfiled Notes Page 16