Care of the Obstetric Patient with Diabetes (Maternal-Newborn) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Route tubes and catheters having different purposes in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet).

Take steps to avoid interruptions and distractions when getting medications ready.

Give medication and hydration infusions using a programmable infusion pump with a dose error-reduction software system, when available.^{undefined#ref5">5}

OVERVIEW

The prevalence of diabetes is increasing in patients of reproductive age worldwide in all forms: type 1, type 2, and gestational diabetes.³ Pregestational diabetes includes both type 1 and type 2 diabetes that existed before the pregnancy.⁴ Although often referred to as a generalized term, gestational diabetes may be classified into 2 subgroups:⁴

• Class A1: Patient with gestational diabetes whose fasting and postprandial glucose values are diet controlled.
• Class A2: Patient with gestational diabetes whose fasting and postprandial glucose values require insulin or oral hypoglycemic medication for control.

Blood glucose monitoring, with both fasting and postprandial blood glucose testing, is the key to improved outcomes in obstetric patients with diabetes.^3,9 Average blood glucose levels of 100 mg/dl minimize risks and complications during pregnancy.² Risks during pregnancy are related to the degree of hyperglycemia and the impact on both the fetus and the pregnant patient, in addition to the relationship of diabetes to other comorbidities (Table 1).³ Glycemic goals during pregnancy should be maintained as able without the patient experiencing significant hypoglycemia (Box 1).³ Inpatient management of hyperglycemia may be needed during periods of illness (e.g., dehydration, diabetic ketoacidosis [DKA], preterm labor, preeclampsia).

Insulin is the drug of choice for controlling hyperglycemia during pregnancy.^1,2,3 Many types of insulin with various onsets of action, peaks, and durations are available to provide consistent insulin coverage during pregnancy (Table 2).

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

• Patients with type 1 diabetes or insulin-dependent type 2 diabetes (preexisting):
  • First trimester:
    • Insulin requirements may decrease.⁴
    • Early pregnancy has a risk of hypoglycemia for patients with type 1 diabetes.
  • Second half of pregnancy:
    • Insulin needs increase⁴
    • Toward the end of the third trimester, insulin requirements may level off.⁴
    • Patients with type 1 diabetes have a greater risk of DKA during the second half of pregnancy, especially when illness or infection present.^4,10
    • DKA may occur at lower blood glucose levels than a nonpregnant patient (greater than 180mg/dL during pregnancy compared to greater than 300 in nonpregnant patients)^4,10
  • Postpartum:
    • Day of birth and first few days postpartum: insulin requirements decrease to 50% below prepregnancy levels.³
    • Breastfeeding patients who are taking insulin have an increased risk of hypoglycemia due to additional changes in sleep and eating schedules.³
  • Patients with gestational diabetes mellitus (GDM):
    • Glucose levels may be controlled by diet and exercise.
    • Insulin resistance increases during pregnancy and pharmacologic treatment may be needed. Insulin is the first choice.
    • Postpartum: normally do not need insulin after birth.⁹

During the antepartum and intrapartum periods, the method of insulin therapy used depends on the individual patient’s needs, the type of diabetes, the practitioner’s preference, and the organization’s practice.

It is recommended that laboring patients with diabetes be managed as high risk patients (Box 2).^2,11 However, some patients with diet-controlled GDM may be managed as lower risk pending provider orders. Frequency of blood glucose measurements vary by institution and protocol. Recommendations on the frequency of intrapartum blood glucose testing vary, with the more frequent range of measurements occurring during active labor. Recommendations include:

• GDM diet controlled (with normal blood glucose): every 2-4 hours¹¹
• Any glycemic medication therapy: every 1-2 hours¹¹
• Pregestational (active labor) or with continuous insulin infusion: hourly⁴
• More frequent blood glucose monitoring may be needed based on:
  • Medication administration (e.g., ephedrine, epinephrine, terbutaline, antenatal corticosteroids)
  • Infection

For patients with pregestational diabetes who are in active labor, an IV infusion with 5% dextrose may be used to prevent hypoglycemia and to help maintain blood glucose levels less than 110 mg/dl; this target range helps prevent hypoglycemia in the neonate.⁴ For a patient with Type 1 diabetes, if glucose levels decrease to less than 70 mg/dl or the patient begins active labor, maintenance fluids are generally changed from 0.9% sodium chloride to 5% dextrose and delivered at a rate of 100 to 150 ml per hour to obtain glucose levels around 100mg/dl.²

Labeling IV tubing reduces the chance of misconnection, especially when multiple IV lines or devices are in use.⁶

If the patient or support person expresses worry about the accuracy of a medication, the medication should not be given. The concern should be explored, the practitioner notified, and the order verified.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style and overall neurologic and psychosocial state.
• Instruct the patient and support person regarding the potential side effects and adverse reactions to the medication.
• Teach the patient and support person the potential complications of uncontrolled blood glucose levels during pregnancy and the risks to the fetus or newborn (Table 1).
• Teach the patient and support person about potential side effects and adverse reactions to the medication.
• Verify that the patient and support person understand the symptoms and treatment of hypoglycemia (Table 3).
• Verify that the patient and support person understand the symptoms and treatment of hyperglycemia (Table 3).
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Clean hands and don appropriate personal protective equipment (PPE) based on the risk of exposure to bodily fluids and infection precautions.
2. Introduce yourself to the patient and support person.
3. Verify the correct patient using two identifiers.
4. Determine if the patient has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
5. Review the patient’s previous experience and knowledge about care of diabetes during pregnancy and understanding of the care to be provided.
6. Assess the patient for signs and symptoms of abnormal blood glucose (Table 3).
7. Assess the patient’s blood glucose level (Box 1).

   Episodes of hypoglycemia should be monitored closely with more frequent glucose checks and vital sign measurements, per the organization’s practice.

8. Review the patient’s clinical situation and electronic health record (EHR) for additional inpatient management considerations (Box 2).
9. Assess the patient’s drug allergies and medication history including if the patient has received insulin previously, type of insulin, and when the last dose was administered.
10. Determine if the patient has specific contraindications to receiving the medication and notify the practitioner as needed.

Preparation

1. Verify the practitioner’s order.
2. Verify the patient’s actual admission weight in kilograms. Reweigh the patient if appropriate.⁵ Do not use stated, estimated, or last documented weight.⁵
3. Get the medication, check against the practitioner’s order, verify the expiration date, and check that the medication and container are clean and intact.

   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.
5. Be sure that all appropriate antidotes, reversal agents, and rescue agents are readily available.⁵

PROCEDURE

Subcutaneous Administration

Follow the organization’s practice for obtaining and mixing insulin.

1. Mix the insulin by gently rotating the insulin vial. Do not shake the vial.

   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.

2. Clean the vial’s stopper with an antiseptic swab.
3. 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).
4. Ask a second staff member to verify the correct insulin, dose, and patient.
5. Label all medications and solutions. The only exceptions are medications that are still in their original container or medications that are given immediately by the person who prepared them.⁸
6. Label a multidose vial with the date and time it was opened and store it according to the manufacturer’s recommendations.
7. Clean hands and don appropriate PPE based on the risk of exposure to bodily fluids or infection precautions.
8. Check the rights of medication safety.
9. Explain the procedure to the patient and support person and ensure that the patient agrees to treatment.
10. Help the patient to an appropriate position to expose the selected subcutaneous site.
11. Clean the subcutaneous injection site with an antiseptic swab.
12. Give the medication at the selected subcutaneous site.
13. Withdraw the needle quickly and smoothly, activating the safety device per the manufacturer’s instructions for use.
14. Apply gentle pressure to the site with an alcohol swab or a gauze pad.
15. Assess the injection site for complications and apply an adhesive bandage if needed.
16. Discard supplies, remove PPE, and clean hands.
17. Document the procedure in the patient’s record.

IV Infusion

1. Use a premixed bag of insulin.
2. Ask a second health care team member to verify the correct insulin, correct dose, and correct patient.

   Only regular insulin may be administered intravenously.

3. Label all medications and solutions. The only exceptions are medications that are still in their original container or medications that are given immediately by the person who prepared them.⁸
4. Clean hands and don appropriate PPE based on the risk of exposure to bodily fluids or infection precautions.
5. Check the rights of medication safety.
6. Explain the procedure to the patient and support person and ensure that the patient agrees to treatment.
7. Ensure IV access and confirm that a mainline fluid is infusing, per the practitioner’s order.
8. Confirm insulin infusion compatibility with ordered solutions and obtain additional access as needed, per the organization’s practice.
9. Prime the tubing with a minimum of 20 ml of insulin before the infusion (and whenever the tubing is changed).¹¹

   Rationale: Priming the tubing saturates binding sites on the plastic tubing.¹¹

10. Trace tubing or catheter from the patient to the point of origin.⁷
11. Clean the IV injection port closest to the IV access point with an antiseptic swab.
12. Program the insulin through the pump and connect the insulin preparation to the cleaned IV port closest to the patient.
    1. All glucose and insulin containing solutions should be connected at ports closest to the patient.
    2. Consider add-on devices (e.g., bifuse, trifuse) for availability of additional ports close to the patient.
    3. Consider use of a second IV site for insulin infusion.
13. Administer the insulin as a continuous (basal) insulin infusion via an organization-approved IV infusion pump at the prescribed rate.
14. When there are multiple access sites or multiple solutions connected to a vascular access device (VAD), label the tubing with the route and medication or solutions at the connection sites closest to the patient and at the container.⁶
15. Discard supplies, remove PPE, and clean hands.
16. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Watch the patient for adverse and allergic reactions to insulin. If a reaction occurs, follow the organization’s practice for emergency response.
2. Continue to monitor for signs and symptoms of abnormal blood glucose and treat accordingly.
3. Repeat blood glucose testing per the organization’s practice.
4. Notify the practitioner of abnormal blood glucose levels, per the organization’s practice.
5. Monitor the patient’s vital signs and the fetal heart rate (FHR) pattern according to patient status and clinical situation.
6. Ensure that a neonatal team is present to care for the newborn at delivery.
7. Discontinue the insulin infusion after delivery per the practitioner’s orders.

EXPECTED OUTCOMES

• Medication administered per the rights of medication safety
• No patient or newborn adverse effects
• Blood glucose levels in goal range

UNEXPECTED OUTCOMES

• Medication not administered per the rights of medication safety
• Patient or newborn adverse effects
• Blood glucose levels not in goal range

DOCUMENTATION

• Verification of the rights of medication safety
• Response to the medication, including any adverse reactions
• 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
• Provider communication
• Education

REFERENCES

1. American College of Obstetricians and Gynecologists (ACOG) Committee on Clinical Practice Guidelines—Obstetrics. (2018, reaffirmed 2019). Practice bulletin no. 190: Gestational diabetes mellitus (Interim update). Obstetrics and Gynecology, 131(2), e49-e64. doi:10.1097/AOG.0000000000002501
2. American College of Obstetricians and Gynecologists (ACOG) Committee on Clinical Practice Guidelines—Obstetrics. (2018, reaffirmed 2023). Practice bulletin no. 201: Pregestational diabetes mellitus. Obstetrics and Gynecology, 132(6), e228-e248. doi:10.1097/AOG.0000000000002960
3. American Diabetes Association Professional Practice Committee (ADA). (2024). Management of diabetes in pregnancy: Standards of medical care in diabetes—2024. Diabetes Care, 47(Suppl. 1), S282-S294. doi:10.2337/dc24-S015
4. Drummond, S. (2024). Chapter 29: Endocrine and metabolic disorders. In D.L. Lowdermilk and others (Eds.), Maternity and women’s health care (13th ed., pp. 618-638). St. Louis: Elsevier.
5. Institute for Safe Medication Practices (ISMP). (2024). 2024-2025 Targeted medication safety best practices for hospitals. Retrieved April 18, 2024, from https://www.ismp.org/guidelines/best-practices-hospitals
6. Infusion Nurses Society (INS). (2024). Infusion therapy standards of practice. Standard 40: Administration set management. Journal of Infusion Nursing, 47(Suppl. 1), S136-S139.
7. Infusion Nurses Society (INS). (2024). Infusion therapy standards of practice. Standard 57: Infusion medication and solution administration. Journal of Infusion Nursing, 47(Suppl. 1), S211-S218.
8. Joint Commission, The. (2024). National Patient Safety Goals for the hospital program. Retrieved April 18, 2024, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2024/npsg_chapter_hap_jan2024.pdf
9. Ketcham, N. and others. (2023). Chapter 10: Complications of pregnancy. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (8th ed., pp. 207-268). St. Louis: Elsevier.
10. Roberts, E., McMurtry Baird, S. (2023) Chapter 19: Critical care obstetrics. In S.S. Murray and others (Eds.), Foundations of maternal-newborn and women’s health nursing (8th ed., pp. 526-552). St. Louis: Elsevier.
11. Roth, C.K. (2021). Chapter 8: Diabetes in pregnancy. In K.R. Simpson and others (Eds.), Perinatal nursing (5th ed., pp. 182-199). Philadelphia: Wolters Kluwer.

ADDITIONAL READINGS

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.

Clinical Review: Aimee Hardt, MN, APRN-CNS, ACCNS-N

Published: June 2024