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Nov.23.2020

Insulin: Obstetric Patients (Maternal-Newborn) - CE

ALERT

Remember to route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet).undefined#ref7">7

Take steps to eliminate interruptions and distractions during medication preparation.

OVERVIEW

Insulin is the drug of choice for controlling diabetes during pregnancy. A naturally occurring hormone secreted by the pancreas, insulin is used by the body’s cells to remove glucose from the blood. The cells then convert the glucose into energy, allowing them to perform their functions. During the antepartum and intrapartum periods, the choice of insulin therapy to manage elevated blood glucose levels depends on the individual patient’s needs, the type of diabetes, the practitioner’s preference, and the organization’s practice.

Women with type 1 or type 2 diabetes who become pregnant are considered to have pregestational diabetes. Gestational diabetes mellitus (GDM) is diagnosed in the second half of pregnancy between 24 and 28 weeks’ gestation and is characterized by carbohydrate intolerance.1

Blood glucose control is essential during pregnancy because of the potentially negative effects hyperglycemia may have on the fetus and the mother. Pregnant women with diabetes have a greater risk of preeclampsia, gestational hypertension, and cesarean birth. Newborns of mothers with diabetes have a higher risk of malformations, macrosomia, shoulder dystocia, birth injury, respiratory distress syndrome, hypocalcemia, and hypoglycemia.10

Insulin may be administered via a subcutaneous injection or an IV infusion. Insulin may also be administered via continuous subcutaneous insulin infusion (CSII); however, the risk of hyperglycemia and diabetic ketoacidosis (DKA) exists because of the possibility of pump malfunction when CSII is used.11

Many types of insulin with various onsets of action, peaks, and durations are available to provide consistent insulin coverage in pregnancy (Table 1)Table 1. Because the insulin needs of a pregnant patient with diabetes mellitus are constantly changing, blood glucose monitoring is essential (Figure 1)Figure 1. The monitoring regimen that provides the best outcomes during pregnancy involves checking normal fasting and postprandial blood glucose levels.10

For patients with GDM, the American Diabetes Association® recommends preprandial maternal capillary glucose levels of 95 mg/dl or less and either1,3

  • 1-hour postprandial glucose level of 140 mg/dl or less
    Or
  • 2-hour postprandial glucose level of 120 mg/dl or less

For patients with preexisting type 1 or 2 diabetes, optimal blood glucose levels throughout pregnancy, if they can be maintained without excessive hypoglycemia, are:3

  • Preprandial, bedtime, and overnight glucose, 60 to 99 mg/dl
  • Peak postprandial glucose, 100 to 129 mg/dl
  • A1C, less than 6%

Insulin requirements during pregnancy vary by phase (Figure 1)Figure 1.

  • For women with type 1 diabetes or insulin-dependent type 2 diabetes, insulin requirements may decrease in the first trimester, possibly leading to episodes of hypoglycemia.4
  • During the second half of pregnancy, insulin needs increase in women with type 1 or type 2 diabetes, possibly leading to hyperglycemia. Women with type 1 diabetes have a greater risk of an earlier development of DKA during the second half of pregnancy.10
  • Toward the end of the third trimester, insulin requirements may level off.4
  • On the day of birth, maternal insulin requirements decrease dramatically, approaching prepregnancy levels.4
  • Breastfeeding mothers maintain insulin requirements that are as much as 25% below prepregnancy levels; insulin needs of nonbreastfeeding mothers are again at prepregnancy levels in 7 to 10 days.4 Breastfeeding mothers have a risk of hypoglycemia.3

Patients need to be instructed to check blood glucose levels anytime symptoms of hypoglycemia occur. Symptoms include dizziness, blurred or double vision, headache, tingling sensation in mouth or tongue, slurred speech, hunger, nervousness, shakiness, sweating, unexplained weakness, irritability, and troubled sleep or nightmares (Table 2)Table 2. Severe hypoglycemia may lead to confusion, seizures, and loss of consciousness.9

During labor, control of blood glucose levels with insulin IV infusion is typically needed in patients with type 1 diabetes, and it may be needed in women with GDM or type 2 diabetes who used insulin during the pregnancy. Hourly maternal capillary glucose levels should be monitored while the patient is receiving an insulin infusion during labor.10 An IV infusion with 5% dextrose should be used to prevent hypoglycemia and to help maintain blood glucose levels between 90 and 110 mg/dl;4 this target range helps prevent hypoglycemia in the neonate.4

Tubing or catheter should be traced from the patient to the point of origin before connecting or reconnecting any device or infusion.7 Tubing should be labeled at the connection site closest to the patient and at the connection site closest to the source when there are different access sites or several bags.7 Labeling reduces the chance of misconnection, especially in circumstances where multiple IV lines or devices are in use. Connections should not be forced, and equipment should only be used for its intended purpose.7 Forced connections or workarounds could indicate that the connection should not be made.

If the mother and support person express concern regarding the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Instruct the mother and support person regarding the potential side effects and adverse reactions to the medication.
  • Allow the patient and support person an opportunity to ask questions or to discuss any unresolved concerns about insulin therapy.
  • Ensure that the practitioner reviews with the patient and support person the potential complications of uncontrolled blood glucose levels during pregnancy and the risks to the fetus or newborn caused by macrosomia.10
    • Low blood glucose level
    • Low calcium level
    • Difficulty breathing
    • Increased number of red blood cells
    • Jaundice
    • Birth trauma resulting from difficult delivery of shoulders: Temporary or permanent arm weakness or loss of motion, broken collarbone
    • Decreased blood oxygen for the fetus during pregnancy, which may cause brain damage
    • Developmental deformities
    • Intrauterine fetal death
    • Fetal death at delivery
    • Increased risk of the newborn becoming obese
    • Increased risk of the newborn developing type 2 diabetes as an adult
    • Increased risk of birth canal lacerations (e.g., perineal, vaginal, cervical)
    • Increased risk of cesarean delivery
    • Increased risk of maternal hemorrhage
  • Educate the patient and support person about administering insulin and reducing the risk of adverse effects.
    • Proper dosage if insulin is to be used at home
    • Different types of insulin, including the onset, peak, and duration of action
    • Appropriate diet as prescribed
    • Importance of eating within 30 minutes of administering regular or short-acting insulin to avoid hypoglycemia2
  • Ensure that the patient understands self-administration techniques if insulin is to be used at home.
    • Safety and hygiene
    • Proper storage of insulin
    • Proper technique for mixing different types of insulin in one injection
    • Proper technique for drawing up insulin
    • Importance of using the same type of syringe for each injection
    • Proper technique for administering injection
    • Appropriate sites for injection and rotation: typically, upper thighs, abdomen, and upper arms
  • Verify that the patient and support person understand the symptoms of hypoglycemia and hyperglycemia (Table 2)Table 2.
  • Instruct the patient and support person regarding treatment for hypoglycemia (blood glucose level less than 70 mg/dl).4 Follow the organization’s practice for hypoglycemia treatment.
  • Ensure that the patient understands the treatment of hyperglycemia. Follow the organization’s practice for hyperglycemia treatment.
  • Verify that the patient and support person understand the details of proper blood glucose monitoring.
    • Monitoring regimen
    • Proper use of monitor
    • Need to check blood glucose level when symptoms occur
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact.
  2. Introduce yourself to the mother and support person.
  3. Verify the correct patient using two identifiers.
  4. Assess the patient’s medication history and drug allergies.
  5. Assess the patient for specific contraindications to receiving insulin and advise the practitioner accordingly.
  6. Assess the patient’s blood glucose level.
  7. Determine whether the patient has received insulin previously and when the last dose was administered.

Preparation

  1. Verify the practitioner’s order.
  2. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.6 Stated, estimated, or historical weight should not be used.6
  3. Obtain the medication, check the practitioner’s order, verify the expiration date, and inspect the medication for particulates, discoloration, or other loss of integrity.
    Rationale: Regular insulin should be clear. Characteristics of insulin (e.g., clumping, frosting, precipitation, change in clarity or color) could signal a loss of drug potency.
    Do not use medication that is cloudy or precipitated unless such is indicated by its manufacturer as being safe.
  4. Review medication reference information pertinent to the medication’s action, purpose, onset of action and peak action, normal dose, and common side effects and implications.

Preparing for Subcutaneous Administration

  1. Mix the insulin by gently rotating the insulin vial. Do not shake the vial.
  2. Rationale: Intermediate- and long-acting insulin clump if shaken. Insulin becomes suspended in the diluents and needs to be reintegrated before being drawn up to ensure more accurate dosing.
    If mixing two types of insulin in the same syringe, draw rapid-acting insulin into the syringe before longer-acting insulin.
  3. Cleanse the vial’s stopper with an antiseptic swab.
  4. Pull the plunger back to fill the insulin syringe with air equal to the number of units of insulin to be administered.
  5. Holding the syringe by the barrel, push the needle through the rubber stopper and push the air into the insulin.
  6. Leaving the needle and syringe in place, turn the vial upside down.
  7. Ensure that the tip of the needle remains in the insulin.
  8. Draw the prescribed amount of medication into the syringe, reading the medication label again for a double-check of the correct name and dose against the medication administration record (MAR).
  9. Before removing the syringe from the vial, check the syringe for air bubbles. If bubbles are present:
    1. Instill air from the syringe into the insulin vial.
    2. Slowly pull the plunger back again to the line for the correct dose of insulin.
    3. Repeat this until no large air bubbles are in the syringe.
  10. Ask a second staff member to verify the correct insulin, dose, and patient.
  11. Label the syringe with the drug name, strength, amount, and expiration date.
  12. Label a multidose vial with the date and time it was opened and store it according to the manufacturer’s recommendations.

Preparing for an IV Infusion

  1. Obtain the basic metabolic profile per the practitioner’s order.
  2. Use a premixed insulin bag with premixed solution.
  3. Ask a second staff member to verify the correct insulin, correct dose, and correct patient.
  4. Only regular insulin may be administered intravenously.
  5. Label the IV bag with the drug name, strength, amount, and expiration date.

PROCEDURE

Subcutaneous Administration

  1. Perform hand hygiene and don gloves.
  2. Verify the correct patient using two identifiers.
    Ensure that the patient is involved in the identification process. Rather than simply reading the patient’s name off the identification band, ask the patient to state it.
  3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
  4. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the MAR to the patient’s identification band.
  5. Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.8
  6. Assist the patient to an appropriate position to expose the selected subcutaneous site.
  7. Cleanse the subcutaneous injection site with an antiseptic swab.
  8. Administer the medication at the selected subcutaneous site.
  9. Remove the needle and discard it in the proper sharps receptacle.
  10. Apply gentle pressure to the site with an alcohol swab or a gauze pad.
  11. Assess the injection site for complications and apply an adhesive bandage if needed.
  12. Discard supplies, remove gloves, and perform hand hygiene.
  13. Document the procedure in the patient’s record.

IV Infusion

  1. Perform hand hygiene and don gloves.
  2. Verify the correct patient using two identifiers.
    Ensure that the patient is involved in the identification process. Rather than simply reading the patient’s name off the identification band, ask the patient to state it.
  3. Explain the procedure to the mother and support person and ensure that the mother agrees to treatment.
  4. Ensure the six rights of medication safety: right medication, right dose, right time, right route, right patient, and right documentation. Use a bar code system or compare the MAR to the patient’s identification band.
  5. Label all medications, medication containers, and other solutions. The only exceptions are medications that are still in their original container or medications that are administered immediately by the person who prepared them.8
  6. Ensure IV access and confirm that a mainline fluid (e.g., 0.9% sodium chloride solution5) is infusing. (This solution may be alternated with a dextrose 5% solution to maintain blood glucose levels according to the practitioner’s order.4)
  7. Prime the tubing with 20 ml of insulin before the infusion (and whenever the tubing is changed).5
    Rationale: Priming the tubing saturates binding sites on the plastic tubing. 5
  8. Trace tubing or catheter from the patient to the point of origin.7
  9. Label the tubing at the connection site closest to the patient and the source.7
  10. Cleanse the IV injection port closest to the IV access point with an antiseptic swab.5
  11. Program the insulin through the pump and piggyback the insulin preparation to the cleansed IV port via the appropriate IV tubing.5
  12. Administer the insulin as a bolus dose and a continuous (basal) insulin infusion via an organization-approved IV infusion pump at a rate determined by the blood glucose level and according to the practitioner’s order.5
    Rationale: The insulin infusion start rate and titration practice are determined by a specific sliding scale or columnar dosing chart and depend on the hourly blood glucose levels. 10
    Preferences regarding the sliding scale may differ among organizations and practitioners. Follow the organization’s practice.
  13. Discard supplies, remove gloves, and perform hand hygiene.
  14. Document the procedure in the patient’s record.

MONITORING AND CARE

  1. Monitor the patient for adverse and allergic reactions to insulin. Recognize and immediately treat respiratory distress and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
  2. Assess, treat, and reassess pain.

Antepartum Period

  1. Monitor the patient’s blood glucose levels.
  2. Assess the patient for signs and symptoms of hypoglycemia and implement a hypoglycemia protocol per the organization’s practice.
  3. Assess the patient for signs and symptoms of hyperglycemia and report abnormal blood glucose levels to the practitioner.
  4. If the patient has severe adverse reactions to the insulin, discontinue it and report them to the practitioner immediately.

Intrapartum Period

  1. Monitor the patient’s vital signs and the fetal heart rate (FHR) pattern.
  2. Assess the patient for signs and symptoms of hypoglycemia.
  3. Ensure that a specialized neonatal team is present to care for the newborn at delivery.

Postpartum Period

  1. Discontinue the insulin infusion after delivery.
  2. Monitor the patient’s vital signs.
  3. Assess the patient for signs and symptoms of hypoglycemia.
  4. For patients with GDM, continue to monitor blood glucose levels. Follow the practitioner’s orders for frequency. Instruct women with type 1 or type 2 diabetes to continue to check their blood glucose levels per their usual practice.
  5. Assess the patient for signs and symptoms of hyperglycemia and notify the practitioner if blood glucose levels exceed the limits on the practitioner’s orders.

EXPECTED OUTCOMES

  • Medication administered per the six rights of medication safety
  • No patient or newborn adverse effects
  • Patient able to self-administer insulin and monitor blood glucose levels
  • Blood glucose levels in target range

UNEXPECTED OUTCOMES

  • Medication not administered per the six rights of medication safety
  • Patient or newborn adverse effects
  • Patient unable to self-administer insulin or monitor blood glucose levels
  • Blood glucose levels not in target range

DOCUMENTATION

  • Verification of the six rights of medication safety (in the patient’s record and on the patient’s MAR)
  • Patient’s response to the medication, including any adverse reactions
  • Patient’s vital signs
  • Patient’s weight in kilograms per the organization’s practice
  • Blood glucose levels
  • FHR pattern, including changes in baseline, variability, accelerations, or decelerations
  • Interventions related to hypoglycemia or hyperglycemia
  • Route and site of insulin administration
  • IV line patency, insulin drip (e.g., rate, type, concentration), and primary fluid
  • Unexpected outcomes and related interventions
  • Education

REFERENCES

  1. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Obstetrics. (2018). ACOG practice bulletin no. 190: Gestational diabetes mellitus (interim update). Obstetrics and Gynecology, 131(2), e49-e64. doi:10.1097/AOG.0000000000002501 (Level VII)
  2. American Diabetes Association® (ADA®). (n.d.). Insulin routines. Retrieved September 14, 2020, from https://www.diabetes.org/diabetes/medication-management/insulin-other-injectables/insulin-routines (Level VII)
  3. American Diabetes Association® (ADA®). (2016). Management of diabetes in pregnancy. Diabetes Care, 39(Suppl. 1), S94-S98. doi:10.2337/dc16-S015 (Level VII)
  4. Bambini, D.R. (2020). Chapter 29: Endocrine and metabolic disorders. In D.L. Lowdermilk and others (Eds.), Maternity and women’s health care (12th ed., pp. 615-635). St. Louis: Elsevier.
  5. Dude, A. and others. (2018). Management of diabetes in the intrapartum and postpartum patient. American Journal of Perinatology, 35(11), 1119-1126. doi:10.1055/s-0038-1629903
  6. Institute for Safe Medication Practices (ISMP). (2020). 2020-2021 Targeted medication safety best practices for hospitals. Retrieved September 13, 2020, from https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf (Level VII)
  7. Joint Commission, The. (2014). Sentinel event alert 53: Managing risk during transition to new ISO tubing connector standards. Retrieved September 13, 2020, from (classic reference)* (Level VII)
  8. Joint Commission, The. (2020). National patient safety goals for the hospital program. Retrieved September 13, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_hap_jul2020.pdf (Level VII)
  9. Novo Nordisk A/S. (2018). GlucaGen® (glucagon) for injection 1 mg/mL. Retrieved September 13, 2020, from
  10. Scheffer, K.L. and others. (2019). Chapter 10: Complications of pregnancy. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (7th ed., pp. 200-270). St. Louis: Elsevier.
  11. Witcher, P.M., Graves, C.R. (2019). Chapter 15: Diabetic ketoacidosis. In N.H. Troiano, P.M. Witcher, S.M. Baird (Eds.), High risk & critical care obstetrics (4th ed., pp. 203-211). Philadelphia: Wolters Kluwer.

ADDITIONAL READINGS

American Academy of Pediatrics (AAP) Section on Breastfeeding. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827-e841. doi:10.1542/peds.2011-3552 (classic reference)*

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Obstetrics. (2018). ACOG practice bulletin no. 201: Pregestational diabetes mellitus. Obstetrics and Gynecology, 132(6), e228-e248. doi:10.1097/AOG.0000000000002960

Farrar, D. and others. (2017). Different strategies for diagnosing gestational diabetes to improve maternal and infant health. Cochrane Database of Systematic Reviews, 8, Art. No.: CD007122. doi:10.1002/14651858.CD007122.pub4

*In these skills, a “classic” reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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