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Adapted from the Postpartum Care Policies and Procedure at Good

By Randall Hill,2014-05-08 20:23
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Adapted from the Postpartum Care Policies and Procedure at Good

    Adapted from the Postpartum Care Policies and Procedure at Good Samaritan Hospital,

    1998 and Carol Majors, MD lecture postpartum follow-up and Counseling,1999.

    Stanford Women and Children’s Services

    Diabetic Postpartum Care

    I. Purpose:

    A guideline for physicians and nursing staff to maintain good glycemic control (blood glucose pre-meal 70-110 mg/dl and 1 hour post meal 120-160 mg/dl) in diabetic patients during the postpartum period.

    II. Equipment:

    A. Blood glucose meter

    B. Appropriate testing strips

    C. Finger lancing device and lancets

    D. Patient will come from labor and delivery with:

    i. D5LR mainline on infusion pump

    ii. 25u Human regular insulin in 250cc Normal Saline on

    infusion pump

    E. 50% Dextrose vial available on unit and

    1 mg glucagon vial available on unit

    III. Considerations:

    A. Insulin requirements are reduced by half as soon as the placenta is

    delivered, due to cessation of placental hormones that enhance

    insulin resistance.

    B. Since the fetus is no longer a consideration, parameters for

    glycemic control are expanded to pre-meal 70-110 mg/dl and 1

    hour post meal 120-160 mg/dl.

    C. Glucose monitoring is still recommended until glycemic control can

    be established and then testing frequency can be reduced. D. Poor glycemic control postpartum may negatively effect both

    healing and breast-feeding.

    IV. Procedure:

    A. Obstetric patient with Type 1 diabetes, that are NPO after an

    operative delivery: (Cesarean Birth)

    i. Continue D5LR at 125 ml/min via infusion pump.

    ii. Maintain IV insulin infusion but cut intrapartum insulin dose

    immediately in 1/2 once placenta delivered.

    iii. Do not run pitocin in D5

    iv. Reduce IV insulin algorithm to the following:

    (Insulin is mixed-25u Human regular into 250cc NaCl,

    1u=10cc)

    Blood glucose Insulin Infusion Individualized

    Mg/dl Units/hr Ml/hr dose

    <70 0 0

    71-90 0 0

    91-110 0.25 2.5 ml

    111-130 0.5 5 ml

    131-150 1.0 10 ml

    151-170 1.5 15 ml

    171-190 2.0 20 ml

    >190 Call M.D. and check urine ketones

v. Check blood glucose every 2 hours as long as administering

    IV insulin.

    vi. Give non-CHO containing Clear liquids until able to take

    solids.

    vii. D/C infusion when tolerating food and fluids. viii. Use individualized SQ insulin orders when patient resumes

    taking meals. Give first SQ dose of regular insulin 1/2 hour

    before stopping insulin infusion.

    ix. Monitor blood glucose levels as follows: Fasting AM,

    premeal and 1 hour after meals once taking food and fluids. x. Advise patient regarding follow up at 2 and 6 weeks

    postpartum.

    B. Obstetric Patients that have Type 1 diabetes, and taking meals

    soon after delivery. (Vaginal delivery)

    i. Cut intrapartum insulin infusion dose immediately to 1/2

    once placenta delivered.

    ii. Do not run pitocin in D5.

    iii. Continue D5LR at 100cc/hr. Use LR if still requires IV and

    is eating and drinking CHO containing foods.

    iv. Resume ADA diet. Insulin infusion and LR may be

    discontinued when tolerating food and fluid.

    v. Insulin infusion may be discontinued when tolerating food

    and fluid. Give initial SQ insulin regular insulin 30 minutes

    before stopping insulin infusion.

    vi. Monitor blood glucose levels as follows: Fasting AM,

    premeal and 1 hour after meals.

    vii. Reduce insulin intake to 1/3 of the patient’s pregnant

    subcutaneous doses or 1/2 of the early pregnancy dose as a

    starting point and adjust as needed.

    viii. Advise patient regarding follow up at 2 and 6 weeks

    postpartum.

    C. Obstetric Patients (Type 2) requiring insulin during pregnancy with Cesarean birth.

    i. Maintain insulin infusion but cut intrapartum dose

    immediately by 1/2 once placenta delivered.

    ii. Maintain D5 solution at 100-125cc/hr. Do not run pitocin in

    D5.

    iii. Adjust insulin infusion to keep BG between 80-<150 mg/dl. iv. Discontinue insulin once BG is < 150 x2.

    v. Check blood glucose every 1-2 hours while on insulin

    infusion. Give initial SQ insulin regular insulin 30 minutes

    before stopping insulin infusion.

    vi. Check blood glucose every 6 hours when NPO and without

    insulin infusion.

    vii. Discontinue D5 or resume insulin infusion if blood

    glucoses >150 mg/dl.

    viii. Give non-CHO containing clear liquids until able to take

    solids.

    ix. Monitor blood glucose levels as follows: Fasting AM,

    premeal and 1 hour after meals until stable.

    x. Resume insulin at a reduced level if blood glucose is above

    200 mg/dl.???

    xi. Advise patient regarding follow up at 2 and 6 weeks

    postpartum

    D. Obstetric Patients Type 2 with a vaginal delivery. i. Discontinue insulin infusion immediately once placenta

    delivered.

    ii. Discontinue D5 solution. Do not run pitocin in D5. iii. Target blood glucose is fasting <110 mg/dl and post meal at

    1 hour at < 150 mg/dl.

    iv. Resume ADA diet.

    v. Monitor blood glucose levels as follows: Fasting AM,

    premeal and 1 hour after meals until stable.

    vi. Resume insulin at a reduced level if blood glucose is above

    160 mg/dl.

    vii. Advise patient regarding follow up at 2 and 6 weeks

    postpartum

    E. Insulin using Gestational Diabetic patients after vaginal or cesarean birth.

    i. Continue D5LR 125 cc/hr via IV infusion pump until taking

    PO well.

    ii. Discontinue insulin after delivery of placenta.

    iii. Institute regular (non-ADA) diet when taking food or fluids.

    iv. Check finger stick blood glucose 1 hr after 3 meals and

    obtain one fasting blood glucose on the day of discharge.

    v. If blood glucose is elevated above fasting >110 mg/dl

    or >160 mg/dl post meal notify MD and Sweet Success team.

    Client should maintain a blood glucose log until Sweet

    Success return appointment.

    vi. If blood glucose is normal advise patient regarding need for

    75 gram GTT at 6 weeks postpartum visit.

    E. Gestational Diabetic patients not requiring insulin before the onset

    of labor after vaginal or cesarean birth.

    i. Continue D5LR 125 cc/hr via IV infusion pump when taking

    PO well.

    ii. Institute regular (non-ADA) diet.

    iii. Check finger stick blood glucose 1 hr after 3 meals and

    obtain one fasting blood glucose on the day of discharge.

    iv. Advise patient regarding need for 75 gram GTT at 6 weeks

    postpartum visit.

    V. Documentation:

    A. Use Labor and Delivery Diabetic Flow Record.

    B. Document IV and insulin administration on Labor and Delivery

    Intensive Care Flow Record.

C. Maintain a permanent In and Out record.

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