Week 7 Part 4 - Diabetes in labour, GBS, Shoulder Dystocia, Perineal tears

Diabetes in Pregnancy ​

• ​Type 1 Diabetes Mellitus​

• Type 2 Diabetes Mellitus ​

• Gestational Diabetes Mellitus (GDM)​

• Risks GDM: Family Hx. of diabetes, obesity, prior GDM, HTN, pregnant person age > 40years, PCOS, prior LGA baby, prior unexplained stillbirth, hx.of fetal anomalies ​

Diabetes in Pregnancy​ S/S

• routine screening is done where most pts don’t develop serious symptoms before detection

• Polyurea, polydipsia, weight loss(inadequate gain), fatigue,glucosuria, etc.

  • can overlap w preg symptoms ​

• Obstetrical Specific…​

  • Recurrent infections (vaginitis, UTIs, pyelonephritis)​

  • Increased SFH (symphysis fundal height) for gestational age​

    • Polyhydramnios ​

    • Fetal macrosomia ​

Diabetes in Pregnancy: Complications ​- pregnant person

Hyperemesis gravidarum (severe vomit), gestational HTN, infections, retinopathy (other neuropathies), polyhydramnios, preterm labour, spontaneous abortion, increased AVD and CS

Diabetes in Pregnancy: Complications ​- Fetus

• Early Pregnancy​

  • Congenital defects, IUGR (pre-existing DM), spontaneous abortion ​

• Later Pregnancy ​

  • Macrosomia —> shoulder dystocia (birth trauma, e.g. torticollis, Erb’s palsy, etc.), still birth, newborn hypoglycemia, RDS

Diabetes in Pregnancy: Intrapartum Management ​

• Offered IOL earlier​

  • WHY? —> complications and harder to deliver ​

• Close monitoring of blood sugars ​

  • Nurse assess POC BG —> finger prick glucometer ​

• Encourage infant feeding ASAP after delivery ​

  • Why? —> higher risk of hypoglycemia due to higher levels of insulin prod in utero (response to maternal hyperglycemia)​

• Postpartum F/U ​

  • OGTT @ 6 weeks and 6 months for GDM —> should return to normal (if not may have T2DM) ​

Diabetes Induction, BG, IV, Diet

Induction usually planned at 38–40 weeks​

• Earlier if poor glucose control or other complications​

Blood Glucose Monitoring​

• Check q1h​

• Aim for 4–6 mmol/L (within 4–7 mmol/L guideline range)​

IV Therapy​

• Combined insulin + glucose infusion → maintains stable glucose levels and reduces neonatal hypoglycemia risk​

Diet​

• Intrapartum → clear fluids only​

• Postpartum → discontinue IV (D5W + NS) once client is eating (immediately for GDM; gradual for T1D/T2D)​

  • GDM —> placenta removed, BG normalizes

​

Point of Care Glucose Testing (POC BG)​

• Turn machine on scan everything and confirm ID​

• Test strip in machine ​

• Wash hands, don gloves​

• Clean site ​

• Poke with lancet, put in sharps​

• Blood on strip​

• Interpret BG, give client 2x2​

• Doff gloves, clean everything ​

Equipment: : EtOH swab, lancet,test strips, glucometer &2x2/cotton ball

Intrapartum Management with IV Insulin & D5W ​

• Start IVs & Prime lines ​—> (sometimes sits in line for 30 mins)

• Check drug guide for mixing​

• What solution should this drug be mixed with and how much? For example, Normal Saline 0.9%​

• Check compatibility guide for solutions and drugs ​

• What can I combine when connecting IV lines? ​

IV Insulin​

• ALWAYS: Regular (a.k.a. Toronto, NovoLin ge, HumuLin-R)​

• 100 units in 100 mL of NS = 1 unit per mL​

• This is set as a primary infusion (prime line with insulin solution)​

• Another IV needs to push it through (IV maintenance line)​ —> since it small infusion rate (1 Ul/hr)

IV Glucose (maintenance)​

• Dextrose 5% and 0.9% sodium chloride at 100 ml/hr​

Diabetes in Pregnancy —> S/S of hypoglycemia + hypokalemia

• Monitor for S&S of hypoglycemia​

• Neurogenic (trembling, sweating, anxiety, nausea) & Neuroglycopenic (poor concentration, confusion —> drowsiness —> coma)

• pts describe as similar to post workout fatigue ​

• Monitor for S&S of hypokalemia ​

• Muscle cramps, muscle weakness, abnormal heart rhythms, lethargic, etc. ​

positive relationship between potassium + glucose (both increase/decrease tgt)

GBS+: Preventing Neonatal GBS Disease ​

Group B Streptococcus (GBS) —> gram-positive bacteria ​

• Causes early-onset neonatal sepsis in term neonates ​

• Pregnant people can be colonized in their vagina or rectum ​

  • Can pass to fetus via birth canal, ascending infection from vagina via amniotic fluid, intact membranes (less common)​

• IF the GBS+ pregnant person is not treated with intrapartum antibiotic prophylaxis: ​

  • Large portion of babies will become colonized​

  • Of these, 1-2% GBS Disease (bacteremia, pneumonia, meningitis)​

  • Early Onset GBS Disease = < 7 days ​

  • Late Onset GBS Disease = 7 days to 3 months ​

Intrapartum Antibiotic Prophylaxis (IAP)

• ↓ pregnant person colony counts ​

• Prevent ascending infection in the pregnant person​

• Achieve effective concentrations of antibiotic in the fetus during labour (by crossing placenta)​

Timing Matters! ​

• ≥ 4-hour optimal ​

• What does this mean for your practice? —> start abx early, might give mulitple doses ​

Who gets IAP?

• Clients who are GBS+ (antenatal screening)​

• GBS bacteriuria in current pregnancy​

• Prior infant with GBS disease ​

• Preterm labour (GBS unknown)​

• ROM > 18 hours (unknown) ​

• Term PROM ​

• Temperature > 38◦C​

What does this mean for your practice? —> assess risk, give abx, monitor vs/fhr ​

IAP First line treatment

First Line Treatment​

• IV penicillin G 5 million units (first dose) ​

• Then, 2.5 or 3 million units q4h until delivery ​

• OR IV ampicillin 2 g ​

• Then, 1 g q4h until delivery ​

Allergy to Penicillin?​

• Cefazolin 2 g IV​

• Then, 1 g q8h until delivery ​

Allergy to Penicillin & Cefazolin?​

• GBS culture tested —> abx sensitivites

• Clindamycin 900 mg IV, q8h, until delivery (sensitive)​

• Not sensitive? —> Vancomycin 1 g IV, q12hr until delivery​

IAP Allergies

Why does this matter in your practice? ​

• Check Allergies!​

• Type 1 Hypersensitivity: Rash, edema of hands & feet, SOB, etc.​

• ppl w penicillin allergies can also cefazolin reaction

Nursing Response? ​

• Stop the drug​

• Notify the MRP​

• Ensure the client has IV access (What size of IV?)​

• Assess severity and monitor closely for further progression ​

• Administer any ordered medications ​

  • Diphenhydramine AKA Benadryl (IV PUSH IF RN)​

  • New antibiotic? ​

• Update allergy record​

Shoulder Dystocia ​

• One or both shoulders are trapped above the pelvic brim after the head has delivered (vertex —> head down) ​

  • One anterior shoulder is impacted against the symphysis pubis (more common)

    • head will retract —> turtle sign​

  • Both shoulders are stuck above the pelvic brim and posterior shoulder at the sacral promontory (RARE)​

  • Inability of the fetal shoulders to deliver spontaneously with pushing from the pregnant person alone OR gentle downward traction on the fetal head from the healthcare provider during a vaginal cephalic delivery

  • EMERGENCY as cord can be compressed ​

Recall —> what should you do in practice when the anterior shoulder has been delivered? ​

Proceed w 3rd stage of labour —> administration of 10 units oxy IM (unless alr receiving oxy)

• in shoulder dystocia, this pauses as priority shifts to delivering baby

Shoulder dystocia - What are the risks

Obstetrical History (Prior Pregnancy)​	Obstetrical History (Current Pregnancy)​	Intrapartum Factors ​
Prior Shoulder Dystocia​	Suspected fetal macrosomia (>4000g)​	Prolonged second stage​
Prior fetal macrosomia​	Diabetes ​	AVD​
​	Obesity​	​
​	Excessive weight gain ​	​
​	Post dates ​	​

• half pts who have dystocia have no identifiable risks —> can happen at any vaginal delivery be prepared to act quickly

Shoulder Dystocia: Why is this a problem? - fetal

• Neonatal brachial plexus palsy (NBPP) —> injury to C5-T1 nerve roots

  • often temp can be permanent —> weakness/paralysis (shoulder, arm, hand)​

  • head pulled down

• Fractures (clavicle & humerus) —> tend to heal very well ​

• Hypoxic ischemic encephalopathy —> brain injury ​

• Death

Shoulder Dystocia: Why is this a problem? - pregnant person

• Severe perineal tears —> Obstetrical Anal Sphincter Injury (OASI)​

• Uterine atony —> PPH (uterus struggles to contract) ​

• Pelvic complications —> diastasis (seperation of pubic symphysis), neuropathy, etc.

Shoulder Dystocia DOs and DONTS

DO Follow ALARMER​

• Ask for help​

• Lift/hyperflex legs (McRoberts) —> pulled back ​

• Anterior shoulder disimpaction —> pushing into pubic bone ​

• Rotation of posterior shoulder (internally by OB) ​

• Manual removal of posterior arm (internally by OB) ​

• Episiotomy (surgical cut between vag/anus) ​

• Roll over on all fours ​

DO NOT​

• Panic/ Push on the fundus (can cause hemorrhage) ​

• Rotate the head/Pull on the head —> nerve damage ​

Providing Instructions​

• Avoid pushing during manoeuvres and contractions ​

• Push when asked ​

Shoulder Dystocia —> four effective maneuvers

1. Flip into Gaskin’s (hands and knees)

2. Lift leg for running start

3. rotate to oblique —> inside vag, rotates baby (30-45)

4. remove the posterior arm —> inside vag

Perineal Tears​

• Laceration​

• Ranked based on thickness​

• 1st —> perineal skin only near or inside vag opening. heal quite well within a few wks —> require a few stitches. minimal long term issues

• 2nd —> skin + muscles of pelvic floor, dissolvable sutures, couples wks to heal. long term issues rare

• 3rd —> 1-2% extends to muscle that controls anal sphincter

• 4th —> into rectal mucosa

  • pain, incontinence, may require pelvic floor therapy

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Risks​

• First birth, Macrosomia​, AVD​

• no way to prevent —> perineal massage in late preg, time for controlled gentle pushing can help

Perineal repairs: Clinical Pearls​

• Pain management (top priority) —> if no epi have to get pain med, if has epi we typically leave it running during repair and discontinue when complete ​

• Sharp count ​

• Health teaching…​

  • Bowel protocol (stool softeners?) and perineal support with BM (with their fingers)

  • Medication timing (pain)​

  • Sitz bath (soak in warm water epsom salt) and padcicles (frozen perineal pads, some add witch hazel /aloe ) ​

  • Wait for intercourse —> wait at least 6 wks ​

  • Report incontinence ​