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
Clinical governance 4. In order to raise awareness, it is recommended that the specialist multidisciplinary team should provide regular educational days for all primary and secondary care professionals likely to be involved in the care of women with diabetes in the local population, to cover all aspects of preconception, pregnancy and postnatal care. Audit and research 5. Diabetes networks should carry out regular audits of preconception and pregnancy services. References 1. National Service Framework for Diabetes (England) Standards. Department of Health. The Stationery Offi ce: London: 2001. 2. Confi dential Enquiry into Maternal and Child Health. Survey of maternity services for women with type 1 and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. CEMACH: London; 2004. 3. Jardine Brown C, Dawson A, Dodds R, Gamsu H, Gillmer M, Hall M, et al. Report of the Pregnancy and Neonatal Care Group. Diabetic Med 1996;13:S43-S53. 4. Clinical Negligence Scheme for Trusts Maternity Clinical Risk Management Standards. NHS Litigation Authority. April 2006. Commentary John Scarpello Deputy Medical Director, National Patient Safety Agency Consultant Diabetes Physician, University Hospital of North Staffordshire The CEMACH Diabetes Programme has raised important issues for those providing maternity services for women with diabetes. The CEMACH survey of diabetes maternity services showed an encouraging increase in the support available to women and most of the trusts surveyed had established combined multidisciplinary clinics. However, despite these developments, areas of unsatisfactory practice remain. All members of the multidisciplinary team were only involved in 22% of women in the enquiry and, surprisingly, dietitians were often absent. Dietetic support is important for both maternal and fetal nutrition but is also especially valuable in optimising glycaemic control, which is vital to a successful outcome. Women with type 1 and type 2 diabetes require careful pre-pregnancy assessment with excellent glycaemic control and folic acid supplementation before conception. Once pregnancy is confi rmed prompt referral is required to the multidisciplinary diabetes and obstetric team. The present enquiry has shown several areas where management is suboptimal. These include little evidence of pre-pregnancy planning and a lack of antenatal care guidelines. Diabetes management is now more often provided by primary care rather than the secondary care specialist diabetes service. Whilst there may be advantages to this model for many people with diabetes, the management of women with diabetes of childbearing age demands agreed patient pathways and joint 70
working between primary and secondary providers. The enquiry has found evidence of poor documentation in clinical records, and in many cases the design of the maternity notes was described as not fi t for purpose. The enquiry has also highlighted defi ciencies in communication between the multidisciplinary team and other disciplines, for example, general maternity staff, renal physicians, cardiologists and ophthalmologists. Providers of diabetes maternity services should ensure that agreed standards have been documented in the patient care records, including records of diabetes complications, glycaemic control and blood pressure. Postnatal care plans should include contraceptive advice, insulin management while breastfeeding and targets for glycaemic control. Those providing diabetes maternity services will need to demonstrate that their multidisciplinary team is working to agreed patient pathways and evidence-based standards. The multi-professional team must include specialists (diabetes specialist nurses, obstetric and diabetology consultants, midwives and dietitians) trained in the management of diabetes pregnancy. Unfortunately, the outcomes of pregnancy for women with diabetes remain poor compared to outcomes for the general maternity population. This report challenges policy makers and commissioners to improve the services provided to this high risk group of women. 71
- 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
- Page 69 and 70: During labour and delivery, the maj
- 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: Some quotes from the panel discussi
- 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
- Page 120 and 121: 108 Appendix B: Diabetes enquiry pr
- Page 122 and 123: 110 Appendix B: Diabetes enquiry pr
- Page 124 and 125: 112 Appendix B: Diabetes enquiry pr
- Page 126 and 127: 114 Appendix B: Diabetes enquiry pr
- Page 128 and 129: 116 Appendix B: Diabetes enquiry pr
- Page 130 and 131: 118 Appendix B: Diabetes enquiry pr
work<strong>in</strong>g bet<strong>we</strong>en primary and secondary providers. The enquiry has found evidence of poor documentation<br />
<strong>in</strong> cl<strong>in</strong>ical records, and <strong>in</strong> many cases <strong>the</strong> design of <strong>the</strong> maternity notes was described as not fi t for<br />
purpose. The enquiry has also highlighted defi ciencies <strong>in</strong> communication bet<strong>we</strong>en <strong>the</strong> multidiscipl<strong>in</strong>ary<br />
team and o<strong>the</strong>r discipl<strong>in</strong>es, for example, general maternity staff, renal physicians, cardiologists and<br />
ophthalmologists.<br />
Providers of diabetes maternity services should ensure that agreed standards have been documented<br />
<strong>in</strong> <strong>the</strong> patient c<strong>are</strong> records, <strong>in</strong>clud<strong>in</strong>g records of diabetes complications, glycaemic control and blood<br />
pressure. Postnatal c<strong>are</strong> plans should <strong>in</strong>clude contraceptive advice, <strong>in</strong>sul<strong>in</strong> management while<br />
breastfeed<strong>in</strong>g and targets for glycaemic control. Those provid<strong>in</strong>g diabetes maternity services will need to<br />
demonstrate that <strong>the</strong>ir multidiscipl<strong>in</strong>ary team is work<strong>in</strong>g to agreed patient pathways and evidence-based<br />
standards. The multi-professional team must <strong>in</strong>clude specialists (diabetes specialist nurses, obstetric and<br />
diabetology consultants, midwives and dietitians) tra<strong>in</strong>ed <strong>in</strong> <strong>the</strong> management of diabetes <strong>pregnancy</strong>.<br />
Unfortunately, <strong>the</strong> outcomes of <strong>pregnancy</strong> for women with diabetes rema<strong>in</strong> poor comp<strong>are</strong>d to outcomes for<br />
<strong>the</strong> general maternity population. This report challenges policy makers and commissioners to improve <strong>the</strong><br />
services provided to this high risk group of women.<br />
71
Change language