Guideline for the management of women With type 1 and type 2 diabetes in pregnancy

Transcription

1 Guideline for the management of women With type 1 and type 2 diabetes in pregnancy This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. Introduction The information in this guideline is to aid the pre-conceptual, antenatal, intra-partum and postpartum management of women with type 1 and type 2 diabetes. Women who develop diabetes during pregnancy are defined as having gestational diabetes. (This is covered in a separate guideline : WAHT-OBS-039). Occasionally both type 1 and type 2 diabetes can present for the first time in pregnancy. Lead Clinician(s) Dr David Jenkins Miss Rachel Duckett Miss Lakshmi Thirumalaikumar Consultant Endocrinologist Consultant Obstetrician/ Gynaecologist Consultant Obstetrician Guideline reviewed and approved by Obstetric Directorate meeting on : 16 th May 2014 This guideline should not be used after end of: 16 th May 2016 WHAT-OBS-038 Page 1 of 23 Version 5.3

2 Key amendments to this guideline Date Amendment Approved by: Links updated and new Sliding Scale document added Judi Barratt (appendix 5) Extended to allow further consultation for review. Rachel Duckett New reference values of HbA1c Rachel Duckett Diabetes care should be documented in orange hand held notes Change in blood glucose targets to pre meals and <7.8 one hour post meals Diabetes management: Use of insulin pump/ Consider use of metformin in selected women. Dietary advice: Consider 75mg Aspirin Screening: Routinely offer cardiac outflow tracts as part of 20/40 scan. Sliding scale now known as continuous variable rate insulin infusion (CVRII). Consider giving steroids if planned C/S prior to 38/40. Alteration to timing of admission pre C/S. New II chart. Commence CVRIII if CBG>7.0 either when in labour or when giving steroids Addition of audit criteria R Duckett Minor changes to neonatal management to link with neonatal guidelines Give steroids if C/S planned prior to 38+6 R Duckett L Thirumalaikumar Give steroids 12 hours apart Clarification of flowcharts for use in labour, with Caesarean section and when giving steroids Link to WAHT-CG 447 (Procedure for self management of insulin) Diabetic women (including those with gestational diabetes controlled by diet alone) requiring steroids should ideally be admitted to the antenatal ward for monitoring of sugars and transferred to delivery suite if they require including continuous variable rate insulin infusion (CVRII) (previously known as sliding scale.) R Duckett L Thirumalaikumar R Duckett L Thirumalaikumar 18/10/13 Document approved by Obstetrics guideline group 15/05/2014 Appendix 2 CVR11 replaced by CVR111 document It is important to ensure women reduce their background insulin (Insulatard, Humulin I, Insuman Basal, Lantus, Levemir) to pre-pregnancy dose on the evening prior to LSCS see (Orange notes) new target aim to keep blood sugars between 7 to 11 mmol/l when using cvriii Judi Barratt WHAT-OBS-038 Page 2 of 23 Version 5.3

3 Guideline for the management of women With type 1 and type 2 diabetes Introduction The aim of care is to achieve a pregnancy outcome in the diabetic that approximates to that of the non-diabetic pregnant woman St. Vincent declaration in Care should commence pre-pregnancy and continue into the post partum period. Background Diabetes is the commonest medical disorder complicating pregnancy in the UK. Approximately 1 in 250 pregnant women have pre-existing diabetes (either type 1 or 2). The World Health Organisation has predicted a worldwide increase in prevalence of 35% between 1995 and An additional 1-6% of women will develop gestational diabetes. Of these 20-50% will go on to develop type 2 diabetes in later life. Despite the St Vincent Declaration in 1989 which set a 5 year target to achieve pregnancy outcome in the diabetic that approximates to that of the non-diabetic pregnant woman, patients with diabetes continue to have a fivefold increased risk of stillbirth, a threefold increased risk of perinatal mortality and a twofold increased risk of congenital abnormality. The specific risks associated with pregnancy in diabetic mothers can be classified: Maternal Worsening retinopathy Worsening renal function Worsening or new onset hypertension Pre-eclampsia Increased risk of infection Reduced awareness of hypoglycaemic episodes Ketoacidosis Polyhydramnios Increased rates of induction /obstructed labour/instrumental/operative delivery Fetal Congenital malformation (5-7% which is 3-5 x higher than in the non-diabetic population) Miscarriage Prematurity IUGR Macrosomia Birth trauma Late intrauterine death Foetal distress Neonatal Hypoglycaemia Respiratory distress Jaundice Prematurity Birth injury Polycythaemia Increased risks of obesity and diabetes in later life WHAT-OBS-038 Page 3 of 23 Version 5.3

4 Pre-Pregnancy Management All women with either type 1 or 2 diabetes considering pregnancy should be referred to a consultant Obstetrician specialising in the care of diabetes in pregnancy. The aim should be to avoid unplanned pregnancy in these women. All women with diabetes of childbearing age should be provided with appropriate contraceptive and pregnancy advice. The aims of pre-pregnancy care are: 1) Establish good blood glucose control for at least three cycles prior to conception and in the early weeks of pregnancy during organogenesis (first 42 days of pregnancy) to reduce the risk of congenital malformation. Advise to avoid pregnancy if HbA1c is greater than 86mmol/mol (previously an HbA1c of >10%: see table below for new reference values) DCCT- HbA1c IFCC-HbA1c Risk of Congenital malformation % mmol/mol % % >10.0 >86 25% non diabetic 2% Aim for blood glucose 4-6mmol/l pre-meals and 4-8mmol/l post meals. Target HBA1c of 48mmol/mol (HbA1c of 6.5%) or as close to it without significant hypoglycaemia. 2) Optimise lifestyle (smoking, exercise) 3) Review diet (consider weight reduction) 4) Commence folic acid 5mg (ideally 3/12 prior to conception) 5) Check rubella status 6) Screen for medical complications i) hypertension (check blood pressure) ii) retinopathy (Fundi should be checked or retinopathy screening at least once in the preceding 6/12 period) iii) nephropathy (consider checking U+E, uric acid, 24hour urine collection for protein and creatinine clearance) iv) MSU v) TSH, free T3, T4, thyroid antibodies if symptomatic or FHx vi) Review co-existing medical problems vii) Record height and weight. Calculate BMI 7) Review medication i) Convert patients on oral hypoglycaemics to insulin (unless on Metformin which can be continued until pregnancy confirmed) ii) ACE inhibitors should be stopped or replaced, usually with Methyldopa iii) Stop statins WHAT-OBS-038 Page 4 of 23 Version 5.3

5 8) Warn re risks of hypoglycaemic episodes and loss of warning. The patient s partner or relative must be provided with Glucogel and a Glucagon kit and be instructed how to use them. 9) Discuss specific risks associated with pregnancy: See previous page 10) Consider contraception whilst optimizing pre-pregnancy health status. 11) Identification of any possible contraindications to pregnancy should be sought and the patient advised accordingly. (These may include significant ischaemic heart disease, untreated proliferative retinopathy, severe autonomic neuropathy, advanced nephropathy: >3g/24 hours proteinuria. Serum creatinine >200µmol/l. Creatinine clearance <40ml/min) 12) Advise to access medical care as soon as pregnancy has been confirmed. Antenatal Management The risks to both mother and baby are increased in the presence of poor glycaemic control. Management is by a multidisciplinary team approach involving obstetricians, endocrinologists, specialist diabetes nurses, midwives and dieticians in certain cases (see below*) Care should be individualised as per specific patient requirements and documented in maternity records. The patient should be involved in management and decision making during her antenatal care. Diabetic control Diabetic care should be documented in orange hand held notes. Aim for HbA1c of 48mmol/mol (HbA1c of 6.5%) or as close to it without significant hypoglycaemia. This should be tested at pre-conception, booking, and at least once a trimester and then at the postnatal visit. In some circumstances it may be necessary to check the HbA1c monthly. Calibrate blood glucose meter at booking visit. Aim for blood glucose targets of below 5.3mmol/lmmol/l pre meals and <7.8mmol/l one hour post meals. Warn patients that tight diabetic control is likely to increase the frequency of mild hypoglycaemia. (blood glucose of <4.0mmol/l) This may be accompanied by a loss of warning for hypoglycaemia and hence an increased risk of severe hypoglycaemia. If a severe hypoglycaemic attack occurs (severe hypoglycaemia defined as one requiring 3rd party intervention or blood glucose less than 3.0mmol/l) the patient must contact a member of the team to discuss this. (Provide patient with contact details) See trust guidelines on the management of hypoglycaemia (WAHT-END-004) The patient s partner or relative must be provided with Glucogel and a Glucagon kit and be instructed how to use them. Staff and patients should be aware that insulin requirements increase during the course of pregnancy. WHAT-OBS-038 Page 5 of 23 Version 5.3

6 Diabetes treatment and management The Diabetic Team should document pre pregnancy insulin doses clearly at booking. Insulin management for women with Type 1 diabetes: (see appendix 5) Patients are usually managed on one of the following regimens: Basal bolus regimen: Short acting insulin pre meals (Novorapid, Humalog, Humulin S and Insuman Rapid) Intermediate long acting insulin before bed and possibly before breakfast (Insulatard, Humulin I, Insuman Basal, Lantus, Levemir) Twice daily mixture of short and intermediate acting insulin. Insulin pump Management of women with Type 2 diabetes: In individual cases, some women on metformin may continue on this and some will be converted to insulin. Convert patients on other oral hypoglycaemic agents to insulin if not already done so on discussion with the Diabetic team. Dietary advice Referral may be made to the dietician depending upon the individual case. In most cases the patient is given dietary advice by the specialist diabetes nurse, midwife or an obstetrician. Commence folic acid 5mg/day until 12 weeks gestation. (Continue if already commenced.) Consider 75mg aspirin daily Individualise advice to each patient. Aim for a regular intake of low glycaemic index carbohydrates, low in fat and sugar. Reduce saturated fat intake. If BMI is >35 then advise to reduce calorie intake with the aim of reducing weight gain during pregnancy. Women of normal weight with type 2 diabetes should receive the same advice as those with type 1 diabetes. Provide advice as to coping with more frequent hypoglycaemic episodes especially in the presence of nausea and vomiting. Maternal Health Measure blood pressure and perform urinalysis at every visit. If any proteinuria develops send an MSU for M, C and S. Check for the presence of ketones. Check for retinopathy in each trimester. (More frequently if retinopathy is present). Warn patients that this may involve dilating the eyes and will prevent driving. Retinopathy is not a contraindication to vaginal birth. However planned early delivery is recommended in the presence of sight-threatening macular oedema. (NICE guideline) Review other pre-existing health problems such as nephropathy. Consider referral to a nephrologists if serum creatinine is >/=120 micromol/litre or proteinuria of >/= WHAT-OBS-038 Page 6 of 23 Version 5.3

7 2g.day. If proteinuria >5g/day, then involve a nephrologist. If >5g/day then consider thromboprophylaxis (see Clinical Guideline WAHT-OBS-012) or albumin <30. Screen for other associated disorders such as thyroid disease (Approximately 3x higher in diabetics than non-diabetics). Consider anaesthetic referral if there are other co-morbidities. Fetal Health Perform a dating scan in the first trimester. Offer Downs syndrome screening. Offer mid-trimester detailed anomaly scan at approximately 20 weeks including cardiac outflow tracts. If unable to visualise outflow tracts at departmental scan then refer to fetal medicine for review. Serial growth scans should preferably be offered at approximately four weekly interval from 28 weeks to assess fetal growth and liquor volume. The frequency of these may be changed according to individual circumstances and availability of scan appointments. The frequency of CTG monitoring from 34/40 is at the discretion of the Consultant Obstetrician and individualised per patient. Encourage women to report any alteration in fetal movement and provide contact numbers. Aim for delivery between weeks. Mode of delivery to be reviewed at 36 weeks (or sooner if indicated). Warn patients that decreasing insulin requirements can be a sign of decreased placental function and that they should inform diabetic antenatal team urgently. Ongoing management should be individualised and discussed with the consultant obstetrician. Indications for admission Admission to hospital should be considered in the presence of the following: Ketonuria >/= ++ in association with raised blood glucose levels and an unwell patient. (If unsure, contact the diabetic team). Any patient with diabetic ketoacidosis should be admitted to a level 2 critical care bed where there should be joint review by the obstetric and medical teams. Deteriorating renal function Development of severe hypertension or pre-eclampsia Concern re fetal well being Persistent vomiting or hyperemesis Decreasing insulin requirement (discuss with a senior clinician) See trust guidelines on the management of hypoglycaemia (WAHT-END-004) and ketoacidosis (WAHT-END-001). WHAT-OBS-038 Page 7 of 23 Version 5.3

8 Management of Labour and Delivery If a woman on insulin requires admission please refer to WAHT-CG-447(Procedure for self-management of insulin) if she is planning to continue self-testing and administration of insulin. The plans for delivery should be individualised for each woman and documented carefully in hand held and hospital notes. Ideally delivery will occur between 38 and 39 weeks gestation. If a woman chooses to continue her pregnancy beyond 39/40 then she should be offered weekly tests of fetal wellbeing. Earlier delivery may be indicated in the presence of complications such as fetal growth restriction, sudden acceleration in fetal growth, polyhydramnios, hypertension, pre-eclampsia, worsening diabetic complications (e.g. nephropathy), or a progressive unexplained reduction in insulin requirements. Aim for vaginal delivery with continuous monitoring in labour in an uncomplicated pregnancy. Fetal blood sampling should be utilised if indicated. In the presence of complications such as macrosomia (abdominal circumference >95 th centile)mode of delivery should be reviewed carefully by a senior obstetrician.. (Note higher risk of shoulder dystocia in diabetic patients). Betamethasone (or dexamethasone if there are supply problems with betamethasone) should be given to aid fetal lung maturation if delivery is likely to occur prior to 36 weeks gestation. (If a caesarean section is planned prior to 38+6 weeks steroids should be given). See Appendix 1. o Betamethasone (12 mg, 2 doses 12 hrs apart) is a steroid of choice, Dexamethasone base (9.9mg, 2 doses 12 hours apart) can be used as an alternative if Betamethasone is not available (WAHT-OBS-009) Diabetic women (including those with gestational diabetes controlled by diet alone) requiring steroids should ideally be admitted to the antenatal ward for monitoring of sugars and transferred to delivery suite if they require including continuous variable rate insulin infusion (CVRIII) (previously known as sliding scale.) Liaise with the neonatal unit regarding plans for delivery of any diabetic patient regardless of gestation. It is important to ensure women reduce their background insulin (Insulatard, Humulin I, Insuman Basal, Lantus, Levemir) to pre-pregnancy dose on the evening prior to LSCS see (Orange notes) Spontaneous labour All women should have a clearly documented plan for the management of their diabetes whilst in labour, including sliding scale. When a woman on insulin (Type 1, Type 2 or gestational diabetes on insulin) is admitted in labour the following procedures should be performed: Review antenatal notes carefully. Inform the labour ward coordinator. Inform the obstetric registrar. Inform the diabetes team if any additional concerns. Inform the neonatal unit if any additional concerns. Commence continuous CTG monitoring. Once labour is established commence CBG monitoring as per appendix 2. WHAT-OBS-038 Page 8 of 23 Version 5.3

9 If CBG 7.0 commence continuous variable rate insulin infusion (CVRIII) (previously known as sliding scale) aiming to keep maternal blood glucose between 7-11 mmol/l. Using 50 units of Actrapid insulin drawn up in an insulin syringe made up to 50mls with 0.9% sodium chloride, to be administered via a syringe driver. (See Appendix 2) Continue CVRIII until patient is able to eat. Recommence diet and normal insulin regime as per Appendix 2 Progress in labour should be reviewed regularly by the obstetric registrar, the risk of shoulder dystocia should be anticipated and the staff should be aware of the shoulder dystocia drills. Commence IV oxytocin infusion (40 units oxytocin in 40mls sodium chloride 0.9% over 4 hours via infusion pump/driver) after the delivery of a macrosomic baby or in the presence of polyhydramnios. Induction of labour Continue normal diet and insulin until in established labour. Once labour is established or ARM has been performed, commence close blood sugar monitoring aiming to keep maternal blood glucose between 7-11mmol/l. Appendix 2 Manage as per routine induction of labour. Watch progress carefully (re increased risk of shoulder dystocia). Caesarean section Any patient requiring insulin antenatally should be admitted the night prior to operation to ensure appropriate treatment in the event of hypoglycaemia during the period of pre-operative fasting. The timing of admission can be arranged on an individual basis (i.e. After dinner if this is the patients choice). Consider reducing background insulin (Insulatard, Humulin I, Insuman Basal, Lantus, Levemir) to pre-pregnancy dose on the evening prior to LSCS see (Orange notes) Normal diet and fluids including bedtime snack should be given on the evening prior to surgery. (Review notes to see whether Diabetologist has given specific instructions about insulin dosage). Nil by mouth as directed by the Anaesthetist. (No food from midnight and no fluids 4 hours pre-op.) Start continuous variable rate insulin infusion (CVRIII) (previously known as sliding scale) on the ward at 6am. (Appendix 2) Women with diabetes should be first on the theatre list. If a general anaesthetic is required blood glucose should be measured every 30 minutes until patient is fully conscious. Commence IV oxytocin infusion (40 units oxytocin in 40mls 0.9% sodium chloride over 4 hours via infusion pump/driver) after the delivery of a macrosomic baby or in the presence of polyhydramnios. Continue CVRIII until patient is able to eat. Recommence diet and normal insulin regime as per Appendix 2. Note: Insulin doses should be prescribed on the Trust CVRIII or subcutaneous insulin prescription chart as appropriate. WHAT-OBS-038 Page 9 of 23 Version 5.3

10 Postpartum Management Mother: Type 1 diabetics: Post delivery insulin requirements should be reduced to the prepregnancy levels (documented in the hospital and orange handheld notes) as soon as eating and drinking normally and the CVRIII has been discontinued. Type 2 diabetics: There should be a post natal plan of management documented in the notes. (Management is tailored to the individual and depends on several factors including maternal choice, breastfeeding and natural history of diabetes.) Note: Women who are breastfeeding may need extra carbohydrate intake. They should be aware that breastfeeding can cause a sudden drop in blood sugar, especially during a feed. Alternatively they may choose to reduce their insulin dose. Discuss contraception before discharge home. Baby: (Refer to guideline WAHT-NEO-017) At delivery the baby should be kept warm and fed as soon as possible. If mother wishes to breast feed, the baby should encouraged to feed within one hour of birth and fed at least every 3 hours. The baby should be kept warm and the temperature checked and recorded 3 hourly The baby s blood sugar should be evaluated by haemacue 3-4 hours after birth before second feed unless the baby shows signs of hypoglycaemia before this time. Feeds should be observed by staff to ensure they are effective. If any blood sugar recordings are below 1.5mmol an urgent referral should be made to the paediatrician. Further blood sugars should be taken 3 hours apart before a feed for 24 hours. Blood sugar monitoring can be discontinued after 4 consecutive readings are greater than 2.0mmols or when the baby is 24 hours old and asymptomatic. Babies in the at risk category who are formula feeding should also be fed within 1 hour of birth and fed at least every 3 hours. Their blood sugar should be estimated as for breast feeding babies. Any baby showing clinical signs of hypoglycaemia should be screened and referred to a paediatrician for assessment. Most neonates can be cared for by their mothers on the post natal ward. Advise any women requiring insulin during her pregnancy that the baby should be observed for at least 24 hours before discharge. Follow up: Inform Diabetes Specialist Nurse of delivery and arrange inpatient review and post partum follow up. Discuss contraception and where appropriate, sterilisation or Mirena. Offer pre-conception counselling. WHAT-OBS-038 Page 10 of 23 Version 5.3

11 Monitoring Tool STANDARDS % CLINICAL EXCEPTIONS Documented plan of antenatal care 100% Late booker Postnatal plans of treatment and insulin doses 100% Unplanned pre-term documented pre delivery. deliveries Involvement of multidisciplinary team including Obstetrician, Midwife, Diabetic physician, Specialist nurse and Dietician in the provision of care Antenatal ultrasound examination of the four chamber view of the fetal heart and outflow tracts at 20/40 100% Declined by patient, late booker, scan availability MONITORING Item Who will monitor compliance with the guideline? Obstetric Governance Group References 1) Diabetes in pregnancy: are we providing the best care? Findings of a national enquiry. CEMACH ) National Service Framework. Department of Health ) Summary of the recommendations of the St. Vincent Task Force for the management of diabetes in pregnancy ) Ang C, Howe D, Lumsden M. Diabetes. In: High Risk Pregnancy Management Options. Eds James D.K, Steer P.J, Weiner C.P, Gonik B. WB Saunders p ) Boulvain M, Stan C, Irion O. Elective delivery in diabetic pregnant women (Cochrane Review). In: The Cochrane Library, Issue 3, Oxford: Update software. 6) NICE guideline: Diabetes in pregnancy: Management of diabetes and its complications from pre-conception to the post-natal period. March 2008 WHAT-OBS-038 Page 11 of 23 Version 5.3

12 Appendix 1: Management of Women Requiring Steroids Who Have Diabetes Type 1/ Type 2 and Insulin treated GDM requiring steroids will need admission to hospital and two steroid injections given 12 hours apart. Continue long acting insulin (Insulatard, Humulin I, Detemir, Insuman Basal, Lantus, Levemir). This should be prescribed on the insulin chart and given at the usual time. Do not give any other types of the patients own subcutaneous insulin. Take Baseline Capillary Blood Glucose (CBG) prior to administering Betamethasone, and commence 2hrly CBG If CBG 7.0 mmol/l commence continuous variable rate insulin infusion (CVRIII) on regimen 1 Continue to allow normal diet and fluids - (if NBM or vomiting commence IV fluids If CBG < 14 then commence 5% Dextrose. If CBG > 14 then commence sodium chloride 0.9%) Monitor CBG hrly If > 7.0 mmols after 4 hours move to CVRIII regimen 2 Continue with 1 hourly CBG- if after 4 hours CBG still >7mmol/l move to CVRIII regimen 3 Providing the woman is eating and drinking normally the aim is to recommence subcutaneous insulin hours following the second dose of steroid. The subcutaneous insulin should be recommenced at the dose the woman was taking immediately prior to steroids (documented in the notes), to be prescribed according to WAHT-END-011, and ideally at her usual time(s). If commencing quick acting subcutaneous insulin (e.g. Novo Rapid, Humalog, Apidra) give the insulin with food and stop the CVRIIII 30mins after the first dose. If commencing a twice daily biphasic insulin (e.g. Novomix 30, Humalog Mix 25) give the insulin with food and stop the CVRIII 30mins after the first dose. If any concerns please contact the DSN for advice. WHAT-OBS-038 Page 12 of 23 Version 5.3

13 Appendix 2: Adult prescription and monitoring chart for continuous variable rate intravenous insulin infusion (CVRIII) WHAT-OBS-038 Page 13 of 23 Version 5.3

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19 Appendix 3: Schedule of care for women with diabetes during pregnancy First appointment (joint diabetes and antenatal clinic) Booking appointment (ideally by 10 weeks) Offer information, advice and support in relation to optimising glycaemic control. Take a clinical history to establish the extent of diabetes-related complications. Review medications for diabetes and its complications. Offer retinal and/or renal assessment if these have not been undertaken in the previous 12 months. Confirm viability and gestational age. Discuss information, education and advice about how diabetes will affect the pregnancy, birth and early parenting (such as breastfeeding and initial care of the baby). 16 weeks Offer retinal assessment at weeks to women with pre-existing diabetes who showed signs of diabetic retinopathy at the first antenatal appointment. 20 weeks Offer anomaly scan including four-chamber view of the fetal heart and outflow tracts.. 28 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume. Offer retinal assessment to women with pre-existing diabetes who showed no diabetic retinopathy at their first antenatal clinic visit. 32 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume. 36 weeks Offer ultrasound monitoring of fetal growth and amniotic fluid volume. Offer information and advice about: timing, mode and management of birth analgesia and anaesthesia changes to hypoglycaemic therapy during and after birth management of the baby after birth initiation of breastfeeding and the effect of breastfeeding on glycaemic control contraception and follow-up. 38 weeks Offer induction of labour, or caesarean section if indicated, and start regular tests of fetal well-being for women with diabetes who are awaiting spontaneous labour. (Consider reducing background insulin on the eve of LSCS) Beyond 39 weeks Offer tests of fetal well-being individualised to each patient. Women with diabetes should also receive routine care according to the schedule of appointments in Antenatal care: routine care for the healthy pregnant woman. WHAT-OBS-038 Page 19 of 23 Version 5.3

20 Appendix 4 WHAT-OBS-038 Page 20 of 23 Version 5.3

21 Contribution List Key individuals involved in developing the document Name Designation Miss R Duckett Consultant Obstetrician/Gynaecologist Dr D Jenkins Consultant Diabetologist Mrs E Innes Diabetes Specialist Nurse Circulated to the following individuals for comments Name Designation Mrs A Blackwell Consultant Obstetrician/Gynaecologist Mrs S Ghosh Consultant Obstetrician/Gynaecologist Mrs R Imtiaz Consultant Obstetrician Mr J Labib Consultant Obstetrician/Gynaecologist Miss J Meggy Consultant Obstetrician/Gynaecologist Mr P A Moran Consultant Obstetrician/Gynaecologist Mr M D Pickrell Consultant Obstetrician/Gynaecologist Mr B A Ruparelia Consultant Obstetrician/Gynaecologist Mrs J Shahid Consultant Obstetrician/Gynaecologist Mr A Thomson Consultant Obstetrician/Gynaecologist Mr J Uhiara Consultant Obstetrician/Gynaecologist Mr J F Watts Clinical Director - Consultant Obstetrician/Gynaecologist Dr P Newrick Consultant Diabetologist Dr I Babar Consultant Diabetologist Dr K Tait Consultant Diabetologist L Gilbert Diabetes Specialist Nurse B Jeans Diabetes Specialist Nurse S Lisseman Diabetes Specialist Nurse S Rogers Diabetes Specialist Nurse S Savin Diabetes Specialist Nurse R Leese Lead Pharmacist Diabetes N Wilcox Midwife ANC, WRH R Carter Matron IP WRH A Talbot Matron IP Alexandra Hospital M Stewart Matron IP/Community P Paine Head of Midwifery K Kokoska Maternity Risk Manager R Fletcher Clinical Pharmacist Circulated to members of Guideline Group (for consultation with peers) Name Designation M Byrne Midwife, Alexandra Hospital H Doherty/J McGivney Community Midwife, Bromsgrove-Redditch Team J S Farmer Midwife, Antenatal Clinic, WRH C Parry Community Midwife, Evesham Team J Martin Midwife, Alexandra Hospital T Meredy Midwife, Antenatal Clinic, Alexandra Hospital R Rees Audit & Training Midwife/WRH representative G Robinson Community Midwife, Worcester Team H Walker Community Midwife, Kidderminster V Tristram Midwife, Kidderminster Hospital/Supervisor of Midwives J Voyce Community Midwife, Malvern Team B Wilkes Midwife, Alexandra Hospital R Williams Midwife, WRH Circulated to the chair of the following committee s / groups for comments Name Committee / group Alison Smith Medicines Safety Committee WHAT-OBS-038 Page 21 of 23 Version 5.3

22 Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Yes/No Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender Yes Pregnant women only Culture No Religion or belief No Sexual orientation including lesbian, gay and bisexual people No Age No 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? N/A No No No 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A If you have identified a potential discriminatory impact of this key document, please refer it to Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Human Resources. WHAT-OBS-038 Page 22 of 23 Version 5.3

23 Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue Yes/No No No 3. Does the implementation of this document require additional manpower No 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff No No Other comments: None If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WHAT-OBS-038 Page 23 of 23 Version 5.3