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  6. Diabetes, continuous subcutaneous insulin infusion (CSII) in labour: Protocol for patient self management (521)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Diabetes, continuous subcutaneous insulin infusion (CSII) in labour: Protocol for patient self management (521)

Please report any inaccuracies or issues with this guideline using our online form

General notes

This protocol is for women who choose to continue to use their insulin pump (CSII) in labour.

Women following this guideline must be aware that clinical staff will NOT adjust settings on pump and that they will not advise of setting changes outwith those discussed in this guideline.

Women must be aware that wishes to continue pump will be taken seriously but there is a need to be flexible with clinical recommendations.

IF AT ANY POINT THE WOMAN BECOMES UNABLE TO MANAGE THE DEVICE THEN THEY SHOULD BE SWITCHED TO INTRAVENOUS INSULIN AND THE PUMP STOPPED. IT IS NOT APPROPRIATE FOR MIDWIFERY STAFF OR BIRTH PARTNERS TO ADJUST THE INSULIN PUMP.

Caesarean Section

There is a risk that diathermy will interfere with the insulin pump settings. 

For women undergoing Caesarean section the pump should be disconnected from the infusion set prior to the procedure, and IV insulin infusion as per guideline should be established. The infusion set can be left in situ.

Following delivery the pump can be re-connected to the infusion set. Insulin settings after delivery are 50-75% of the pre-pregnancy doses (see below) 

Equipment

All women should have

  • 2 x Spare set of batteries
  • 2 x reservoirs
  • 5 x infusion sets including lines (and inserter device)
  • Back-up insulin pens (long and short acting insulin)

At onset of labour (0-4cm) – NB: many women will be at home

  • Woman should ensure:
    • New batteries inserted into pump
    • Fill a new reservoir with insulin
    • Put in a complete new infusion set (including line)
    • Locate the infusion site below rib cage and towards back so that it will not interfere with emergency intervention
  • Continue current basal rates and bolus ratios.
  • Pregnant woman or midwife should check capillary blood glucose (CBG) 2 hourly or sooner if symptomatic of hypoglycemia
  • Pregnant woman should treat hypoglycaemia as she would if not in labour
  • If more than 2 hypoglycemic events during the initial stage of labour, then woman should reduce all basal rates by 50%
  • If CBG > 10 mmol/l then check ketones and give a correction dose as per sensitivity (see guidance below)

Active labour (4cm-delivery)

  • IV access should be obtained in case of need for IV insulin therapy or treatment of severe hypoglycemia
  • Basal insulin should continue at current rates
  • Women are not usually advised to eat/drink during this stage but if they do, then bolus insulin ratio should be given at the same ratios as before labour.
  • Blood glucose monitoring should be taken hourly by pregnant woman/clinical team and recorded by clinical team (using the insulin sliding scale in labour chart)

  • If CBG < 4 mmol/l, then treat the hypoglycaemia as normal (may require IV glucose if strictly NBM)
  • If CBG < 4 mmol/l on more than one occasion, then reduce basal rate further by 50%
  • If CBG >10 mmol/l
    • Check for ketones
    • If ketones positive then start IV insulin sliding scale with fluids immediately, with insulin pump continuing in background
    • If ketone negative give correction dose as per below sensitivity and recheck in 1 hour
    • If CBG not falling repeat this step and recheck CBG after 1 hour
    • If CBG rising despite correction dose or not coming down after 2 correction doses then start IV insulin infusion (continue pump in background and perform set change)

Immediately (within 30 minutes) after delivery:

  • Immediately following delivery of placenta, the basal rates on pump should be set to 50-75% of pre-pregnancy rates and bolus ratios should also be administered at 50-75% of prepregnancy doses. These should be prescribed on attached sheet and discussed with the woman.
  • If the pre-pregnancy rates are not known, the diabetes team should advise what basal rates should be set to and bolus ratio should start at 1 unit for 20g carbohydrate.
  • Women on CSII are usually very comfortable managing their diabetes and should not be discouraged from adjusting their own settings Review by diabetes team within 24-48 hours of delivery

IF AT ANY POINT THE WOMAN BECOMES UNABLE TO MANAGE THE DEVICE THEN A SWITCH TO INTRAVENOUS INSULIN SHOULD TAKE PLACE AND THE PUMP STOPPED.

IF AT ANY POINT THE WOMAN BECOMES UNABLE TO MANAGE THE DEVICE THEN A SWITCH TOINTRAVENOUS INSULIN SHOULD TAKE PLACE AND THE PUMP STOPPED.

List not exhaustive but may include:

  • Pregnant woman too distressed or uncomfortable to manage the pump
  • Complications with clinical staff feeling that the more familiar IV insulin therapy be commenced instead – please discuss with woman
  • Erratic blood sugars with multiple adjustments required during labour
  • Requirement for Caesarean Section

Insulin prescription as suggested by Diabetes team

Patient

CHI

Diabetes type

PRE-LABOUR/EARLY LABOUR

basal rates:

bolus ratio:

Correction e.g. 1 unit will correct by 3 mmol/l:

ACTIVE LABOUR (4cm dilatation-delivery)

Basal rates:    

 bolus ratio:

Correction doses e.g. 1 unit will correct by how many mmol/l:

FIRST 24-48 HOURS POST-DELIVERY OF PLACENTA:

Basal rates:       

 bolus ratio:

Correction doses e.g. 1 unit will correct by how many mmol/l:

Back-up Insulin pens- insulin type and dose. 

Diabetes StR/Consultant should review within 24-48 hours of delivery to advise on further dose adjustment.

Editorial Information

Last reviewed: 26/04/2018

Next review date: 01/03/2022

Author(s): David Carty.

Version: 2

Approved By: Obstetrics Clinical Governance Group

Document Id: 521