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