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

• 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)

• 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 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 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