Diabetes in pregnancy: are we providing the best care ... - HQIP

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Clinical care issues: pregnancy Table 9.5 Management of glycaemic control during antenatal steroid administration in women with diabetes delivering before 34 weeks gestation Management of glycaemic control with antenatal steroid administration No. of women receiving corticosteroids n(%) (N=56) No change from prior management 6 (11) Increased checking of blood glucose only 3 (5) Subcutaneous insulin regime changed* 3 (5) Intravenous insulin and dextrose infusion started* 38 (68) Information not available 6 (11) * Women who had a change in subcutaneous insulin regime or who started intravenous insulin and dextrose infusion, also had increased checking of blood glucose. 9.7 Discussion of mode and timing of delivery Women with pre-existing diabetes have high rates of obstetric intervention, with a 39% induction of labour rate and a 67% caesarean section rate. 5 It is important that women should be involved in the decisionmaking process regarding mode and timing of delivery. 9.7.1 Enquiry fi ndings A discussion about mode and timing of delivery was documented in the medical records for 86% (329/384) of women who delivered after 24+0 weeks gestation. The fi rst discussion occurred at a median of 35 weeks (range 5 - 40 weeks). A lack of discussion of mode and timing of delivery was associated with poor pregnancy outcome (OR 4.0, 95% CI 1.2 - 12.7, adjusted for maternal age and deprivation, see Chapter 6). Additional case-control analysis (see Appendices C, D and E) showed an association with fetal or neonatal death from 20 weeks gestation but not with fetal congenital anomaly. However, women who did not have a documented discussion delivered at an earlier gestation than women who had evidence of a discussion (median gestation at delivery 35 weeks versus 37 weeks), and there may therefore have been other factors contributing to poor outcome. 9.8 Maternity care during pregnancy, labour and delivery Women with pre-existing diabetes have an increased risk of fetal and maternal complications and it is important that there is ongoing fetal and maternal surveillance throughout pregnancy, labour and delivery to identify and manage any risks. Enquiry panels assessed that maternity care during pregnancy was suboptimal for 51% of 430 women (58% of 215 cases and 44% of 215 controls), and these women were more likely to have a poor pregnancy outcome (OR 1.9, 95% CI 1.2 - 2.8, adjusted for maternal age and deprivation, see Chapter 6). Additional case-control analysis (see Appendices C, D and E) showed an association with fetal or neonatal death from 20 weeks gestation but not with fetal congenital anomaly. 56
During labour and delivery, the majority of women were assessed to have optimal maternity care. Care was assessed to be suboptimal for 35% of 382 women , with no association between suboptimal care and pregnancy outcome (see Chapter 6). 9.8.1 Panel comments on suboptimal maternity care during pregnancy Panels made 378 comments for 228 women, with nearly all of these being about clinical care issues. The two largest categories related to suboptimal fetal surveillance (ultrasound monitoring of fetal growth and fetal heart rate monitoring) and management of maternal risks. Problems with the antenatal diabetes multidisciplinary team, communication and the level of seniority of obstetric staff involved in the woman’s care were also noted (table 9.6). Table 9.6 Panel comments on suboptimal maternity care during pregnancy for women with pre-existing diabetes (table contains information following categorisation of free text) Women assessed to have suboptimal maternity care during pregnancy Good pregnancy outcome (N=95) Poor pregnancy outcome (N=125) No. of comments % of women No. of comments % of women Total comments* 147 - 209 - Suboptimal clinical practice 141 - 178 - Fetal surveillance 47 49 58 46 Management of maternal risks 29 31 39 31 Problem with the multidisciplinary team 17 18 28 22 Need for more senior obstetrician input 11 12 24 19 Mode and timing of delivery 20 21 10 8 No plan of care 7 7 15 12 Steroids not given/full course not completed 4 4 2 2 Other 6 6 2 2 Communication 6 6 31 25 * 22 comments were made about social and lifestyle issues; these comments are not included in this table. 9.8.2 Panel comments on suboptimal maternity care during labour and delivery Enquiry panels made 245 comments for 150 women. The most frequent issues noted were poor management of maternal risks, inappropriate decisions relating to delivery and inadequate fetal surveillance during labour or delay in acting on signs of fetal compromise (table 9.7). 57
Page 1 and 2:
Confidential Enquiry into Maternal
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Contents Acknowledgements .........
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• Members of the CEMACH Diabetes
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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 and 18: Suboptimal fetal surveillance of ba
Page 19 and 20: 3. Summary of recommendations This
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: 9.5.1 Panel comments on suboptimal
Page 71 and 72: Just 52% of 383 women (38% of 164 c
Page 73 and 74: • ‘No serial growth scans perfo
Page 75 and 76: The panel enquiries, which are in e
Page 77 and 78: 10.3.1 Enquiry fi ndings Seventy fi
Page 79 and 80: 10.6 Communication Effective commun
Page 81 and 82: Some quotes from the panel discussi
Page 83 and 84: working between primary and seconda
Page 85 and 86: we therefore selected 7.2% of pregn
Page 87 and 88: 11.4 Preconception behaviour The CE
Page 89 and 90: enquiry related to a 12 month prior
Page 91 and 92: Table 11.10 Differences in postnata
Page 93 and 94: Type 1 and type 2 diabetes have tra
Page 95 and 96: Panels were chaired by the panel ch
Page 97 and 98: In 57% (24/42) of cases, a junior d
Page 99 and 100: Infant formula given as fi rst feed
Page 101 and 102: 2.1 hours in babies remaining with
Page 103 and 104: 12.7.1 Panel comments on suboptimal
Page 105 and 106: The concerns described here probabl
Page 107 and 108: External commentary Patricia Hamilt
Page 109 and 110: informed and motivated to manage th
Page 112 and 113: 100 Appendix A: Pre-pregnancy care
Page 114 and 115: 102 Appendix B: Diabetes enquiry pr
Page 116 and 117: 104 Appendix B: Diabetes enquiry pr
Page 118 and 119:
106 Appendix B: Diabetes enquiry pr
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Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Appendix C Association between demo
Page 134 and 135:
Appendix C Association of preconcep
Page 136 and 137:
Appendix C Association of postnatal
Page 138 and 139:
Appendix D Association of social an
Page 140 and 141:
Appendix D Association of diabetes
Page 142 and 143:
Appendix E Association between demo
Page 144 and 145:
Appendix E Association between prec
Page 146 and 147:
Appendix E Association between post
Page 148 and 149:
Appendix F - CEMACH advisory groups
Page 150:
Appendix F - CEMACH advisory groups
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