Advantag of ingestion administration way is its easiness even when applied at home. But with their help necessary treatment concentration in blood cannot be always quickly achieve buy antibiotics online transaction is carried out on anonymity and mutual profit principles, and in addition customers will be positively surprised with quality and speed of service.

Diabetes – labour

DIABETES – LABOUR

PREPARATION
 Discuss with woman
Time and mode of delivery
 Woman diet-controlled with normally grown fetus:
 advise induction of labour at 40 weeks’ gestation  advise induction of labour at 38 weeks’ gestation

Analgesia and anaesthesia
 Offer women with diabetes and co-morbidities (e.g. obesity or autonomic neuropathy)
obstetric anaesthetic assessment in third trimester
Care during and after labour
 Analgesia and anaesthesia
 Prevention of neonatal hypoglycaemia  Care of baby/breastfeeding

PRETERM LABOUR
 Pulmonary maturation delayed in fetuses of diabetic women, particularly where control
 Where premature delivery anticipated, give betamethasone for women with established diabetes – see Preterm labour guideline
 Steroid administration worsens diabetic control and may lead to ketoacidosis in women with pre-existing type 1 diabetes – anticipate an increase in insulin requirement and administer insulin as per local Trust policy for steroids in diabetic pregnancy
INDUCTION OF LABOUR

 See Induction of labour guideline
Diabetic control
 Before labour established, normal metformin/insulin regimen and diet

DURING LABOUR
Risk
 Increased risk of shoulder dystocia particularly if baby macrosomic – ensure obstetric
registrar is available on delivery suite during second stage – see Shoulder dystocia
guideline
 Increased risk of cephalopelvic disproportion – be vigilant for delay and, if occurring, use
Monitoring during labour
Woman
 Record capillary glucose level hourly
 Once sliding scale regimeN commenced, monitor blood glucose hourly  Monitor blood glucose at 30 min intervals after induction of general anaesthesia and birth  Check urine for ketones
Continuous fetal monitoring
 Maternal hyperglycaemia may cause fetal acidosis, check maternal glucose if any EFN
 Fetal blood sampling if indicated as normal labour – see Fetal blood sampling guideline

Metformin and diet controlled
 If blood glucose elevated e.g. persistently above Unit threshold, commence insulin and IV
fluid regimen below

Gestational diabetes mellitus
Insulin controlled – Dependent on amount of insulin required – dosage as per local

Elective caesarean section
 If caesarean section carried out before 39 weeks’ gestation, consider administration of
antenatal steroids. This will require sliding scale  If not on sliding scale for steroids, give usual metformin/insulin day before procedure  Commence insulin and fluid regimen from 0600 hr. See below
Emergency caesarean section
 Check blood glucose level and commence insulin and IV fluid below

INSULIN AND IV FLUID REGIMEN
 500 mL glucose 10% with 10 mmol potassium chloride 8-hrly
 50 units soluble insulin (Actrapid/Humulin S) in 50 mL sodium chloride 0.9% via syringe pump according to blood glucose checked at time of admission and hourly thereafter by glucometer  Determine rate of fluid infusion depending on blood glucose concentration and local policy  Aim to keep woman’s blood glucose concentration between 4–9 mmol/L  Most women will need 2–4 units/hour  Avoid large changes in insulin infusion rate and therefore in glucose concentration  If blood glucose not maintained within normal range, contact diabetes team Always use commercially produced pre-mixed bags of glucose 10% with potassium

POSTNATAL MANAGEMENT
 Diabetes team will write management plan
Inform women with insulin-treated diabetes that they are at increased risk of
hypoglycaemia in postnatal period, especially when breastfeeding. Advise to have a
meal or snack available before or during feeds

Stopping insulin and fluid regimen
 Continue sliding scale regimen until able to eat and drink normally
Type 1 diabetes
 Revert to pre-pregnancy reduced insulin requirements or the regimen advised by diabetes
 Keep sliding scale running for 30–60 min after first subcutaneous insulin dosage  May require less insulin if planning to breastfeed  Review by diabetes team as appropriate
Type 2 diabetes
 Stop insulin and fluid regimen
 Metformin not contraindicated in breastfeeding, but avoid sulphonylureas Gestational diabetes
 Women with gestational diabetes mellitus who have required sliding scale will cease to
 Arrange postnatal OGTT or fasting blood glucose at 6 weeks

Neonatal care
 See Staffordshire, Shropshire & Black Country Newborn Network Hypoglycaemia

Future plans
 While still using contraceptives, mother to discuss future pregnancy with diabetes team
who will provide information on pre-conception care

Source: http://www.networks.nhs.uk/nhs-networks/staffordshire-shropshire-and-black-country/documents/Diabetes%20-%20Labour%202013.pdf

balancing-point.net

Balancing Point Center for Wellness WOMEN’S FERTILITY QUESTIONNAIRE Name: ___________________________________________ Date: _______________________ 1.Basic Information a. Address: ____________________________________________________________________________________________ 2. Menstrual History 3. Gynecologic History a. At what age did you begin your menses? ________a. D

Ijs_july_aug_05.pmd

Safety of early oral feeding aftergastrointestinal anastomosis: a randomizedclinical trialDepartment of Surgery, Baqiyatallah University of Medical Sciences, 1 Azad-Tehran University of Medical Sciences, Tehran, IranFor correspondence:SA Fanaie, Department of Endoscopic Surgery, 13th Floor, Milad Hospital, Hemat Highway, Tehran, IR, Iran. E-mail: [email protected]: Different abdom

Copyright © 2010-2014 Medical Articles