Diabetes in pregnancy: are we providing the best care ... - HQIP
Diabetes in pregnancy: are we providing the best care ... - HQIP Diabetes in pregnancy: are we providing the best care ... - HQIP
Key fi ndings of the CEMACH Diabetes Programme Two thirds of babies in the neonatal enquiry had suboptimal care on the labour ward and this frequently impacted on subsequent care. 2.9 Postnatal care Half of women in the enquiry had suboptimal postnatal diabetes care. The main underlying issues were poor management of glycaemic control after delivery, lack of contact with the diabetes team, inadequate plans of care at discharge from hospital, and no contraceptive advice given to women. Women who had a poor pregnancy outcome were more likely not to receive postnatal contraceptive advice and were more likely to have had suboptimal postnatal diabetes care. In the enquiry, women with type 2 diabetes were less likely to receive postnatal contraceptive advice. References 1. Confi dential Enquiry into Maternal and Child Health. Pregnancy in women with type 1 and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. CEMACH: London; 2005. 2. The National Sentinel Caesarean Section Audit Report. Royal College of Obstetricians and Gynaecologists, Clinical Effectiveness Support Unit. RCOG Press: London; 2001. 3. Nesbitt TS, Gilbert WM, Herrhen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol; Aug 1998; 179:476-80. 4. Evans-Jones G, Kay SP, Weindling AM, Cranny G, Ward A, Bradshaw A, et al. Congenital brachial palsy: incidence, causes, and outcomes in the United Kingdom and Republic of Ireland. Arch Dis Child Fetal Neonatal Ed; 2003; 88:F185-9. 5. Confi dential Enquiry into Maternal and Child Health. Maternity services in 2002 for women with type 1 and type 2 diabetes, England, Wales and Northern Ireland. CEMACH: London; 2004. 6. National Service Framework for Diabetes (England) Standards. Department of Health. The Stationery Offi ce: London; 2001. 6
3. Summary of recommendations This chapter includes the recommendations that have been made arising from the fi ndings of this report. Details of the process followed to derive the recommendations can be found in Chapter 5. The recommendations below apply to all women with type 1 and type 2 diabetes. Social and lifestyle issues Clinical 1. Preconception and maternity services related to pregnancy should be easily accessible and responsive to all women with diabetes, and provide appropriate care and information. 2. There should be mechanisms in place to identify vulnerable communities and individuals, so that additional services can be provided as appropriate to women of childbearing age with diabetes, thereby ensuring optimal preconception care. 3. Providers of diabetes care should develop educational strategies that will enable all women of childbearing age with diabetes to prepare adequately for pregnancy. Audit and research 4. Research should be carried out to: • identify the barriers to accessing preconception care • identify possible strategies to support self-care and pregnancy planning by women with diabetes. Clinical issues: preconception Clinical 1. Commissioners of services must ensure that all women with diabetes are provided with specialist preconception services, with access to all members of the specialist multidisciplinary team. As a minimum, these services should include: • Clear signposting to different aspects of care • Diet and lifestyle advice • Provision of appropriate contraception • Higher dose folic acid supplementation • Smoking cessation support • Assessment and management of diabetes complications • Setting of glycaemic control targets and regular discussion of results of self-monitoring, to enable the woman to achieve control that is as near to normal as possible before conception • Discussion of diabetes pregnancy risks and expected management strategies • Clear documentation of care and counselling, ideally using a standard template. 7
- Page 1 and 2: Confidential Enquiry into Maternal
- Page 3 and 4: Contents Acknowledgements .........
- Page 5 and 6: • Members of the CEMACH Diabetes
- Page 7 and 8: Erb’s palsy Injury to the nerve r
- Page 9 and 10: Neonatal unit A unit which provides
- Page 11 and 12: Foreword This third and fi nal repo
- Page 13 and 14: 1. Introduction This is the fi nal
- Page 15 and 16: 2. Key fi ndings of the CEMACH Diab
- Page 17: Suboptimal fetal surveillance of ba
- Page 21 and 22: 2. Patient pathways of care includi
- Page 23 and 24: the pregnancies meeting this defi n
- Page 25 and 26: in order to remove any identifi abl
- Page 27 and 28: When deriving odds ratios for any p
- Page 29 and 30: Associations are reported in Chapte
- Page 31 and 32: Table 5.1 Characteristics of women
- Page 33 and 34: Table 5.4 Characteristics of women
- Page 35 and 36: was no information available to pan
- Page 37 and 38: 6. Factors associated with poor pre
- Page 39 and 40: Table 6.2 Association of clinical c
- Page 41 and 42: Table 6.5 Association of specifi c
- Page 43 and 44: Table 6.8 Association of postnatal
- Page 45 and 46: folic acid before pregnancy (19% of
- Page 47 and 48: Table 7.2 Panel comments on social
- Page 49 and 50: 7.5 Conclusions One of the key fi n
- Page 51 and 52: 11.Dex S, Heather J (eds). Millenni
- Page 53 and 54: 8. Clinical care issues: preconcept
- Page 55 and 56: chance of induction of labour was r
- Page 57 and 58: 8.6.1 Enquiry fi ndings Just over h
- Page 59 and 60: Some quotes from the panel discussi
- Page 61 and 62: Apart from the explanation of pregn
- Page 63 and 64: was associated with poor pregnancy
- Page 65 and 66: of women after the fi rst trimester
- Page 67 and 68: 9.5.1 Panel comments on suboptimal
3. Summary of recommendations<br />
This chapter <strong>in</strong>cludes <strong>the</strong> recommendations that have been made aris<strong>in</strong>g from <strong>the</strong> fi nd<strong>in</strong>gs of this report.<br />
Details of <strong>the</strong> process follo<strong>we</strong>d to derive <strong>the</strong> recommendations can be found <strong>in</strong> Chapter 5.<br />
The recommendations below apply to all women with type 1 and type 2 diabetes.<br />
Social and lifestyle issues<br />
Cl<strong>in</strong>ical<br />
1. Preconception and maternity services related to <strong>pregnancy</strong> should be easily accessible and<br />
responsive to all women with diabetes, and provide appropriate c<strong>are</strong> and <strong>in</strong>formation.<br />
2. There should be mechanisms <strong>in</strong> place to identify vulnerable communities and <strong>in</strong>dividuals,<br />
so that additional services can be provided as appropriate to women of childbear<strong>in</strong>g age<br />
with diabetes, <strong>the</strong>reby ensur<strong>in</strong>g optimal preconception c<strong>are</strong>.<br />
3. Providers of diabetes c<strong>are</strong> should develop educational strategies that will enable all women<br />
of childbear<strong>in</strong>g age with diabetes to prep<strong>are</strong> adequately for <strong>pregnancy</strong>.<br />
Audit and research<br />
4. Research should be carried out to:<br />
• identify <strong>the</strong> barriers to access<strong>in</strong>g preconception c<strong>are</strong><br />
• identify possible strategies to support self-c<strong>are</strong> and <strong>pregnancy</strong> plann<strong>in</strong>g by women with diabetes.<br />
Cl<strong>in</strong>ical issues: preconception<br />
Cl<strong>in</strong>ical<br />
1. Commissioners of services must ensure that all women with diabetes <strong>are</strong> provided with specialist<br />
preconception services, with access to all members of <strong>the</strong> specialist multidiscipl<strong>in</strong>ary team.<br />
As a m<strong>in</strong>imum, <strong>the</strong>se services should <strong>in</strong>clude:<br />
• Clear signpost<strong>in</strong>g to different aspects of c<strong>are</strong><br />
• Diet and lifestyle advice<br />
• Provision of appropriate contraception<br />
• Higher dose folic acid supplementation<br />
• Smok<strong>in</strong>g cessation support<br />
• Assessment and management of diabetes complications<br />
• Sett<strong>in</strong>g of glycaemic control targets and regular discussion of results of self-monitor<strong>in</strong>g,<br />
to enable <strong>the</strong> woman to achieve control that is as near to normal as possible before conception<br />
• Discussion of diabetes <strong>pregnancy</strong> risks and expected management strategies<br />
• Clear documentation of c<strong>are</strong> and counsell<strong>in</strong>g, ideally us<strong>in</strong>g a standard template.<br />
7
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