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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.
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). Because the insulin needs of a pregnant patient with diabetes mellitus are constantly changing, blood glucose monitoring is essential (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
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
Insulin requirements during pregnancy vary by phase (Figure 1).
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). 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.
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.
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.
Ensure that the tip of the needle remains in the insulin.
Only regular insulin may be administered intravenously.
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.
Rationale: Priming the tubing saturates binding sites on the plastic tubing.
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.
Preferences regarding the sliding scale may differ among organizations and practitioners. Follow the organization’s practice.
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.
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