Oxford Handbook of Midwifery (78 page)

• Platelet count <100×10
  ⁹
  /L
  
• Rising aspartate transaminase (AST) >50IU/L
  
• Increasing uric acid levels.
  

thrombosis:

• Encourage deep breathing and leg movements
  
• Provide anti-embolic stockings
  
• Enoxaparin sodium, for the prophylaxis of thrombo-embolism is usually prescribed
  
• Attend to the woman’s hygiene needs, ensure sheets are kept fresh and crease-free. Monitor pressure points and skin integrity.
  

• If the fetus is 23–35 weeks, the mother is given corticosteroids (e.g. betamethasone 12mg, repeated in 12/24h if possible according to hospital protocol) to help mature the baby’s lungs and reduce respiratory distress.
  
• Alert the paediatrician and special care baby unit (SCBU) team to ensure availability of cot and personnel. It may be possible for the parents to visit SCBU or for the staff to describe and explain neonatal special care to the parents prior to delivery.
  

Delivery

CHAPTER 18
High-risk labour

338‌‌

Care of the diabetic mother and fetus

When diabetes is present during pregnancy, risks of the following compli- cations during intrapartum care are increased:

• Preterm labour
  
• Unstable lie
  

  •
  Cord prolapse
  

• PPH—may occur as a result of polyhydramnios
  
• PIH occurs earlier in the pregnancy than in non-diabetic women and in a more severe form; it may complicate labour
  
• Large baby (macrosomic)—may result in shoulder dystocia
  

  (b see Shoulder dystocia, p. 446) in the second stage of labour
  

• Fetal abnormality (usually excluded by antenatal ultrasound scan)
  
• IUD when diabetes is inadequately controlled.
  

  It is recommended that woman with diabetes and a fetus which is normal size for dates should be offered elective birth at 38 weeks gestation to prevent complications of fetal macrosomia.
  ¹
  This would mean induction of labour or elective caesarean. However, each woman should be treated individually and given information and choice.
  

  Management during the first stage of spontaneous labour
  ¹
  When a woman who has insulin-dependent diabetes is admitted to the delivery suite and found to be establishing in labour:
  

• Inform the obstetric registrar or consultant on call
  
• Treat the woman as high risk and follow the plan of care documented in the notes; offer vigilant and continuous care
  
• Recognize that when the diabetes is well controlled, progress may be normal
  
• Consider the progress of the pregnancy, review the hospital records, and assess the woman’s blood pressure, urinalysis, pulse, and temperature, ensuring general maternal well-being. Any moderate ketonuria should be reported to the obstetrician
  ²
  
• Obtain IV access and send blood samples to the laboratory for FBC— haematocrit and white cell count/U/E, urates, and bicarbonate/G&S
  
• Review the woman’s record of blood glucose readings. Ask the woman to take a capillary sample for immediate assessment. The reading should be in the range 3–7mmol/L
  
• Gain the woman’s consent to assess the fetus and her contractions by abdominal palpation and to monitor the fetus continuously by CTG. Any non-reassuring patterns should be reported to the obstetrician
  
• Begin an IV regimen (when insulin dependence prior to pregnancy (classified as type 1) is present IV sliding scale is always indicated) that aims to keep the blood sugar level stable, for example:
  
  • An IV infusion with 500mL 10% dextrose saline + 10mmol KCl is set to run at 100mL/h
    
  • An insulin pump with soluble insulin 50IU in 49.5mL saline is set to run according to a standard regimen (Table 18.1)
    
  • Assess blood sugar every 30min. The woman or her partner may be happy to do this. Control the sugar level at 4–7.9mmol/L. If this is not achieved, consult with the obstetric registrar to consider use of the augmented regimen (Table 18.1)
    

    CARE OF THE DIABETIC MOTHER AND FETUS
    

    339
    

    

    Table 18.1
    Insulin sliding scale
    

    Blood glucose (mmol/L)
    

    Insulin dose (IU/h); standard regimen
    

    Insulin dose (IU/h); augmented regimen
    

    <4 0 0
    

    4–5 1 2
    

    6–7 2 4
    

    8–12 3 6
    

    13–17 4 8
    

    >17 6 12
    

    • If the blood sugars are >17mmol/L, obtain a maternal IV sample for measurement of U/E and bicarbonate, the results of which should be reviewed by the obstetrician
      
    • Once stable at 7mmol/L, assess blood glucose hourly.
      

Management in the second stage of labour