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Cardiotocographs may also be considered from 36 weeks gestation to assess fetal well-being in late pregnancy Diabetes National Service Framework: Intervention details and draft service models; March 2002 rlJ b($'Suboptimal antenatal fetal surveillance(()%CIssues underlying suboptimal fetal monitoring for big babies (n=58)DDoLack of timely follow-upPoor interpretation of ultrasound scansIncorrect actions taken as a response to tests*&3Managing maternal complications: antenatal steroids44pIf delivery is indicated before 34 weeks, corticosteroids should be considered to prevent neonatal respiratory distress. As corticosteroids can lead to maternal hyperglycaemia, additional insulin must be given to prevent the development of diabetic ketoacidosis. Diabetes National Service Framework: Intervention details and draft service models; March 2002B g c+'3Managing maternal complications: antenatal steroids44,(Providing information54% of women in the enquiry had glycaemic control target ranges for pregnancy in the medical records or hospital guidelines. 79% had glycaemic control target ranges for labour and delivery. 86% had a documented discussion about the mode and timing of delivery, by 38 weeks gestation. Z-)#Panel assessment of suboptimal care$$.*DIssues underlying suboptimal maternity care in the antenatal periodEESuboptimal fetal surveillancePoor management of maternal risksAbsence of retinal and renal screeningProblems with the multidisciplinary teamIncluding lack of involvement and poor communicationNeed for more senior obstetrician inputInappropriate mode and/or timing of deliveryt@P'P)P5PUP@')5U/+Postnatal care0,4Issues underlying suboptimal postnatal diabetes care55wSuboptimal management of glycaemic controlLack of contact with the diabetes teamInadequate plan of care at discharge1-Are we providing the best care?;Good practice:78% of women monitored for nephropathy68% receiving antenatal steroids had an intravenous insulin regime commenced86% had a documented discussion about mode and timing of delivery81% had a written plan for post-delivery diabetes management65% had optimal maternity care during labour and delivery0Z-Z-2.Are we providing the best care? iSuboptimal glycaemic control in at least half of women from before pregnancy up to delivery Suboptimal fetal surveillance for half of all babies with antenatal evidence of macrosomia Suboptimal antenatal maternity care for half of all women Suboptimal diabetes care for more than half of all women No postnatal contraceptive advice for a quarter of women v\PP PPP\ 3/Recommendations IXAn individualised care plan covering the pregnancy and postnatal period up to 6 weeks should be clearly documented in the notes, ideally using a standard template. As a minimum, the care plan should include:Targets for glycaemic controlRetinal and renal screening schedulesFetal surveillancePlan for deliveryDiabetes care after deliveryBZZZ40Recommendations IIpThe care plan should be implemented from the outset of pregnancy by a multidisciplinary team present at the same time in the same clinic. Pregnancies with ultrasound evidence of macrosomia should have a clear management plan put in place by a consultant obstetrician. This should include timing of follow-up scans, fetal surveillance and mode and timing of delivery.qZq51Recommendations IIIA care plan for postnatal management should be clearly documented in the notes for all women. As a minimum, this should include:Plan for management of glycaemic controlNeonatal careContraceptionFollow-up care after discharge from hospital<rr62Recommendations IVResearch should be carried out to investigate:the most appropriate management strategy following antenatal evidence of macrosomia in babies of women with diabeteshow best to achieve optimal blood glucose control during pregnancy, labour and delivery. /jObCARING FOR BABIES AFTER BIRTH Neonatal care of babies of mothers with type 1 and type 2 diabetes8c#+#C   kP BackgroundKRoutine admissions of babies of diabetic mother44% in 1994 (Pregnancy& Neonatal care group)One-third in 2003 (CEMACH Diabetes in Pregnancy report)Standards of neonatal care (CEMACH 2003)Low intention to breastfeed at birth Concerns about management of hypoglycaemia & early feeding Neonatal enquiry into care of term babies 0ZeZ)ZbZ*ZZZ0e)b*lQMethodsNExcluding deaths, congenital anomalies, multiple and gestation < 37/40(n=112)OPON mRMethodsIndependent assessment Enquiry panels in 5 regions Care on labour ward, postnatal ward or NNUAnonymised neonatal records (first 3 days)Pro formaAssessed against standards: CEMACH diabetes programmeBaby Friendly InitiativeFZ3Z3  nS#Avoidable admissions to the NNU (1)2Main indications of admission to the NNU (N=42): .22oT#Avoidable admissions to the NNU (1)1Clinical indications for admission (N=18, 43%): 41ZZ1pU#Avoidable admissions to the NNU (2)Decision to admit:SHO in 24 (57%) Panel assessment: 24 (57%) admissions avoidableSubsequent care adversely affected (15/24) Main area affected was feeding (12/24) `r$   rqV#Avoidable admissions to the NNU (3)rW"Admissions to NNU: Recommendations##"]Written policy for management of baby. Should assume babies will remain with their mothers.0'  5 ^sXFBarriers to breastfeeding: early feeding and close contact with motherGG Skin-to-skin documented in 29% (30/102)77% of babies first fed on the labour wardtY0Barriers to breastfeeding: breastfeeding supportOn labour ward:26% (29/112) of mothers had documented supportOne-third of mothers had no documented support (despite intending to breastfeed)In neonatal unit:One-third of mothers had documented support`,,uZ: Barriers to breastfeeding: type of milk at first feed (1);;Formula as first feed for 63% (67/106)All admitted babies received formulaNOT mother s feeding intention for 28%R(%'(%'v[9Barriers to breastfeeding: type of milk at first feed (2)9 TMain reason for formula when remaining with mothers was maternal choice 46% (32/70)T w\0Panel assessment of feeding in the neonatal unitkType of feed inappropriate in 38% (16/42)Management of baby likely to have affected feeding in 36% (15/42)x]Breastfeeding: RecommendationsMothers with diabetes should be informed antenatally of beneficial effects of breastfeeding on metabolic control for both themselves and their babies.Mothers with diabetes should be offered opportunity for skin-skin contact with their babies immediately after delivery. Breastfeeding within 1 h of birth should be encouraged.Midwives should recognise importance of supporting early breastfeeding for women with diabetes, and need to document this aspect of care.Zy^Blood glucose management (1)Timing of first blood glucose testing too early< 2 hrs after birthMedian time of NNU admission 1.2 (95% CI 0.4-2.0), range 0-7.6 hInappropriate methods usedReagent strip in 75% (53/70)Post-feed testing in 26% L0U70U7z_Blood glucose management (2) .Poor documentation in 69% (77/112)More so in babies remaining with mothers (p<0.001)Main panels comments:Poor recording of methodNo written plan H#ZJZ+Z#J+{`*Blood Glucose Monitoring - RecommendationsBlood glucose testing performed too early should be avoided in healthy babies without signs of hypoglycaemia. Testing should be performed before a feed using a reliable method (ward-based glucose electrode or laboratory analysis).For all blood glucose tests: time, method, result and action taken should be clearly documented in the notes. Further research is needed to define the optimal testing of first blood glucose test in babies of diabetic mothers. Z|a Conclusion 1Many healthy babies of women with diabetes separated from their mothers without obvious medical reason Could basic neonatal care be more often delivered closer to the mother in maternity units in England, Wales and Northern Ireland? Xhh#$  }b Conclusion 26Clinical concerns such as lack of breastfeeding support, inappropriate blood glucose management and overall poor documentation Little evidence of senior staff involvementGuidelines clarification: NICE diabetes in pregnancy specific guidelines are pendingFurther research needed in some aspects of management.ZZ~c(Diabetes neonatal enquiry project group  )' 'Dr Jane Hawdon, Chair Dr Alison Leaf Dr Dominique Acolet Ms Joan Oliver Dr Laura de Rooy Ms Justine Pepperell Ms Caron Gooch Dr Martin Ward Platt Ms Alison Johns Dr Anthony Williams Ms Alree Hunt XPP'PP#P/789:;<=>?@ A  !"#$%&'()   0` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@|?" dd@   " @ ` n?" dd@   @@``PV    @ ` `p>>  N(    6 ,  T Click to edit Master title style! !  0 'g  RClick to edit Master text stylesSecond levelThird levelFourth levelFifth level!   S`  C *APicture1"   0p Y&  TCEMACH Diabetes in Pregnancy National Report Launch, Sheffield, 26th February 2007UU   nAL Y?$dv418111ucPreview_imgMain#" `SH  0޽h ? 3380___PPT10.O2 Default Design  0 kc@(    6 > T Click to edit Master title style! !  0`a  `  W#Click to edit Master subtitle style$ $  nAL Y?$dv418111ucPreview_imgMain#" `S`  C *APicture1"H  0޽h ? 3380___PPT10.OO 0 zr` (    0Ă! P   P*    0|c    R*  d  c $ ?  !  0Pc  0 !RClick to edit Master text stylesSecond levelThird levelFourth levelFifth level!   S  6c _P  !P*    6c _  cR*  H  0޽h ? 3380___PPT10.Q, 0 RJx(  x x 6 % GCare during pregnancy( x 0(CMr Derek Tufnell Panel Chair for EnquiryConsultant Obstetrician 6(21(2DH x 0޽h ? 3380___PPT10.P@v 0 @0(  x  c $D,G:  x  c $,'  H  0޽h ? 33___PPT10i.M`/;+D=' =@B +] 0 tlP(  x  c $ ,      vQ # #"& vQ   <? vUk#% of HbA1c tests with a result < 7%$$ @`  <` ?"`  UZWeeks of gestation @`  <5? R vQa66%(1757/2655)   @`  <=? R  QO 27+ weeks   @`  <G? S vR a70%(1632/2348)   @`   <\O ?"` S  R d18  23+6 weeks @`   <W? TvS `39%(999/2597)   @`   <! ?"` T S O <13 weeks   @`   <0Q? UvT`28%(382/1384)   @`  <dQ ?"` U TSPre-pregnancy @`ZB  s *1 ? TvTZB  s *1 ? S vS ZB  s *1 ? R vR ZB  s *1 ? UvUZB  s *1 ?  Q`B  0o ? v`B  0o ?  Q`B  0o ?vvQ`B  0o ? QvQ  0Q( 2  6ԸQvJ~H*CEMACH: Pregnancy in women with type 1 and type 2 diabetes in 2002-2003IIH  0޽h ? 33___PPT10i.kM08+D=' =@B + 0 UM(  x  c $PX,   ? 'g # #""_2T   <ؿQ ?  gg5.2 [3.3, 8.2] &" @`  <,Q ?~ t 37%(76/209)6"" " @`  <BQ ? ~ v71% (146/205)6" " @`  <KQ ?'  -After 1st trimester up to labour and delivery,. % @`  <`UQ  ?"`  g X3.4 [2.1, 5.7] @`   <gQ  ?"`~  c61%(118/192)$  @`   <4qQ  ?"` ~ c84%(171/204)$  @`   <|Q  ?"`'  nIn 1st trimester,   @`   <Q ?  g g3.9 [2.2, 7.0] &" @`  <Q ?~   c69%(115/167)$  @`  <pQ ?  ~ c88%(165/187)$  @`  <<=Q ?'  XBefore pregnancy @`  <?Q ? g uAdjusted ORa [95% CI].    @`  <Q ?~   V Good outcome @`  <+Q ? ~  V Poor outcome @`  <Q ?'  {1Panel assessment of suboptimal glycaemic control22 @`fB  6o ?'g`B  01 ?' g `B  01 ?' g fB  6o ?'g`B  01 ?  `B  01 ?~ ~ `B  01 ?  `B  01 ?' g fB  6o ?''fB  6o ?gg  B#Q't2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 3380___PPT10.Mnk 0 0(  x  c $9Q,t Q x  c $ -Q]T Q H  0޽h ? 33___PPT10i.M&+D=' =@B + 0 0(  x  c $M,~ M x  c $\M'g M H  0޽h ? 33___PPT10i.M! +D=' =@B + 0 0(  x  c $(M, M x  c $)M  M H  0޽h ? 33___PPT10i.Mq+D=' =@B + 0  (  x  c $,8M,  M   ]]  # #""kJ2]]  M  <BM ?n c55%(142/258)$  @`  <| M ?n o#- Assessment through dilated pupils$$ @`  <XM  ?"`n ] c78%(343/441)$  @`  <RM  ?"`n ] bMonitoring for nephropathy @`  <lM ?c59%(258/441)$  @`   <dfM ?#Retinal assessment in 1st trimester,$   @`   <qM ?]cWomen in enquiry % (n/N) @`   <M ?]K @``B   01 ?`B  01 ?`B  01 ?]] ZB  s *1 ?n n fB  6o ?]]fB  6o ?]] fB  6o ?]] fB  6o ?] ]   0ЍM I 35% of 89 women with retinopathy were not referred to an ophthalmologistJ 2JH  0޽h ? 33___PPT10i.CM+D=' =@B + 0 0(  x  c $̗M,  M x  c $tM] `, M H  0޽h ? 33___PPT10i.*MJ+D=' =@B +' 0 >60(  x  c $HE,   ( G # #"1G   <Hϕ  ?"`B G[5.3 [2.4, 12.0] @`  <  ?"`3B Ga 37%(27/73)$  @`  <(ҕ  ?"` B 3Ga 67%(35/52)$  @`  <z  ?"`B Gt,Babies with antenatal evidence of macrosomia-- @`  <܃ ?WB h2.3 [0.2, 26.3] &" @`   < ?3WB _ 9%(1/11)$  @`   <~ ? W3B ` 25%(6/24)$  @`   <@ ?W B |4Babies with antenatal evidence of growth restriction55 @`   < ?WuAdjusted ORa [95% CI].    @`  < ?3WV Good outcome @`  < ? 3WV Poor outcome @`  < ? Wy#Suboptimal fetal surveillance for:$$# @`fB  6o ?`B  01 ?WW`B  01 ?B B fB  6o ?GG`B  01 ?  G`B  01 ?33G`B  01 ?GfB  6o ?GfB  6o ?G  BfwMt2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 33___PPT10i.,M>R+D=' =@B +0 0 P0(  x  c $|,{  x  c $T'g   H  0޽h ? 3380___PPT10.-M0<0 0 p0(  x  c $,  x  c $g  H  0޽h ? 3380___PPT10.kM`ZKn 0 b(  ~  s *,    'g # #"&'g   <O!? gV J5% @`  <?' V i#Subcutaneous insulin regime changed$$ @`  <h?V gK68% @`  <?'V o)Intravenous insulin and dextrose infusion** @`  <?g J5% @`   <P?' n(Increased checking of blood glucose only)) @`   <(?egK11% @`   <?'e]No change in management @`   <?geNN=56 @`  <?'eEManagement of glycaemic control in women receiving antenatal steroidsFF @``B  0o ?'gZB  s *1 ?'egeZB  s *1 ?'gZB  s *1 ?' g `B  0o ?'g`B  0o ?''ZB  s *1 ?`B  0o ?ggZB  s *1 ?'V gV H  0޽h ? 33___PPT10i.kM@+D=' =@B +  0 0(  x  c $!,   x  c $!!/ `+ ! H  0޽h ? 33___PPT10i.lMp+D=' =@B +! 0 80 (  x  c $, w  " g+ # #"" ;2g+   <(  ?"`  g+v1.7 [1.1, 2.6] 4" @`  <+  ?"`~ +g58%(118/204)(" " @`  <  ?"` ~ +v72% (146/204)6" " @`  <@  ?"`  +q)Suboptimal diabetes care during pregnancy** @`  <0C  ?"`  g X1.3 [0.8, 1.9] @`   <S  ?"`~  b 34%(72/213)$  @`   <N  ?"` ~ b 39%(78/199)$  @`   <g  ?"`  |4Suboptimal maternity care during labour and delivery55 @`   <$q ? "g i1.9 [1.2, 2.8] (" @`  <{ ?~ "  b 44%(95/215)$  @`  < ? "~ c58%(125/215)$  @`  <Xk ?" }5Suboptimal maternity care during the antenatal period66 @`  <L ? g"uAdjusted ORa [95% CI].    @`  < ?~  "V Good outcome @`  <| ? ~ "V Poor outcome @`  < ? "B @`fB  6o ?g`B  01 ?"g"`B  01 ? g `B  0o ?+g+`B  01 ?  +`B  01 ?~ ~ +`B  01 ?  +`B  01 ? g `B  0o ?"+fB  6o ?"`B  0o ?g"g+fB  6o ?gg"  BI0t2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 33___PPT10i.CM@Xd+D=' =@B + 0 0(  x  c $T,  x  c $,'gf  H  0޽h ? 33___PPT10i.NMЅWW+D=' =@B +  0 N(  x  c $d,    'gX  # #"v'gX    <  ?"`!% gX Z 1.8 [1.2, 2.7] @`  <   ?"` % !X c50%(106/211)$  @`  <$  ?"`M % X c66%(133/203)$  @`  <8  ?"`'% M X j"Suboptimal postnatal diabetes care## @`  < ?!g% i 4.2 [2.4, 7.4](" @`   <h ? !% b 16%(26/163)$  @`   <xh ?M  % b 44%(63/143)$  @`   <Xh ?'M % j"No postnatal contraceptive advice ## @`   <`h ?!guAdjusted ORa [95% CI].    @`  <h ? !V Good outcome @`  <h ?M  V Poor outcome @`  <h ?'M B @`fB  6o ?'g`B  01 ?'g`B  01 ?'% g% `B  0o ?'X gX `B  01 ?M M X `B  01 ?  X `B  01 ?!!X `B  0o ?''X fB  6o ?''`B  0o ?ggX fB  6o ?gg  B\hs 'Z t2a Adjusted for maternal age and social deprivation&3 2 2H  0޽h ? 33___PPT10i.OMq+D=' =@B +0 0 0(  x  c $,  x  c $ih'g   H  0޽h ? 3380___PPT10.XMPKt 0 (  x  c $`h'gY h   s 8h0e0e #" 0e,{ h H  0޽h ? 33___PPT10i.hM`=+D=' =@B + 0  0(  x  c $8h,~ h x  c $h `Y h H  0޽h ? 33___PPT10i.RMG$+D=' =@B + 0 0 0(   x   c $|h,  h x   c $h'gY h H   0޽h ? 33___PPT10i.OM@">c+D=' =@B + 0 @0(  x  c $ h,  h x  c $h'g h H  0޽h ? 33___PPT10i.OMf+D=' =@B + 0 P0(  x  c $dc,  c x  c $(c/'gI c H  0޽h ? 33___PPT10i.UMvB+D=' =@B +0 0 `0(  x  c $!,  ! x  c $!'g  ! H  0޽h ? 3380___PPT10.VM j 0 j(  ~  s *M'  M   0pM Jc2 LDr Martin Ward-Platt(2H  0޽h ? 33___PPT10i.P@v+D=' =@B + 0 0(  x  c $M* M x  c $M'g M H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B + 0  x(  x  c $PM* M   <M@)24Random sampling from diabetes cohort study (n=3808)554 RB  s *D2     $M0e0e #" 0e)6  M RB @ s *D6  RB  s *D6  &   <M  mRemained with mothers (n=70)    <M gAdmitted to NNU (n=42) H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B + 0 00(  x  c $M* M x  c $pM  M H  0޽h ? 33___PPT10i.8Ԭ+D=' =@B +  0 PP(  ~  s *M@t M ~  s *M/vm M  0 # lA ? ?"`pG  M>  0(M w |___PPTMAC11  ,namd$ Wingdings    ,namd$ Wingdings  4___PPT10 B___PPT9$R  2  H  0޽h ? 33___PPT10i.8+D=' =@B +  0 pQ(  ~  s * Kt K ~  s *KJ K     # #"&FFFFF` K  BK?k|Q14(&33  B<K?|kp"Other medical condition (cardiac) 2# "&33  BK?k |Q54(&33  B4!K? k|gRespiratory difficulties 2 &33   B%K?kJ  Q34(&33   B*K?J k n Macrosomia (otherwise well baby)2!  &33   B.K?k J Q34(&33   B2K? kJ o!Poor feeding (with hypoglycaemia)2" !&33  B(7K?k  Q64(&33  B;K? k n Hypothermia (with hypoglycaemia)2!  &33`B  0331 ?  `B  0331 ?`B  0331 ? `B  0331 ? `B  0331 ?k k`B  0331 ?  `B  0331 ?J J `B  0331 ?  `B  0331 ?||H  0޽h ? 33___PPT10i.8+D=' =@B + 0 (  x  c $>K Y K   s /K0e0e #" 0edpt K H  0޽h ? 33___PPT10i.h9 5+D=' =@B +G 0 ^V!!(  x  c $8SKwpG K q '" # #"*y"' K  BUK?" 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Are we providing the best care?Recommendations IRecommendations IIRecommendations IIIRecommendations IV  Fonts UsedDesign TemplateSlide Titleswith type 1 and type 2 diabetes BackgroundMethodsMethods$Avoidable admissions to the NNU (1)$Avoidable admissions to the NNU (1)$Avoidable admissions to the NNU (2)$Avoidable admissions to the NNU (3)#Admissions to NNU: RecommendationsGBarriers to breastfeeding: early feeding and close contact with mother1Barriers to breastfeeding: breastfeeding support; Barriers to breastfeeding: type of milk at first feed (1):Barriers to breastfeeding: type of milk at first feed (2)1Panel assessment of feeding in the neonatal unitBreastfeeding: RecommendationsBlood glucose management (1)Blood glucose management (2)+Blood Glucose Monitoring - RecommendationsConclusion 1Conclusion 2)Diabetes neonatal enquiry project group  Fonts UsedDesign TemplateEmbedded OLE ServersSlide Titles-%_|0rosie.houstonrosie.houston  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghiklmnopqrstuvwxyz{|}~     !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)Г(1\PicturesCurrent UserGSummaryInformation(WTPowerPoint Document(jDocumentSummaryInformation8snTTܖx: 0ܖ@ .  @n?" dd@  @@`` ph&  $%&'()*+,-./0123456789:;<!=>?@ABCDEF 3 "7%&#/Xb$&)2N +; R$`jǪ<"D@G 0AA@8wR ʚ; f8ʚ;g4BdBdtx: 0(ppp@ <4dddd  0Td<4!d!d  0Td 80___PPT10pp-    Aspects of care during pregnancy!!Optimising glycaemic controlMaternal and fetal surveillanceManaging maternal and fetal complicationsProviding information !'Previous findings on glycaemic control*(("Enquiry findings#;Issues underlying suboptimal glycaemic control in pregnancy<<178 comments on clinical care: Failure to change insulin regimes to improve glycaemic controlNon-responsive local strategy of antenatal careLack of supportFailure of follow upPoor integration of careProblems within multidisciplinary teamz ZoZ>Z'ZZ o>'  $ 7Optimising glycaemic control during labour and delivery8850% of 354 women with ongoing pregnancies at 24 weeks were assessed to have suboptimal glycaemic control during labour and delivery No association with pregnancy outcome Z%!IIssues underlying suboptimal glycaemic control during labour and deliveryJJInadequate or inappropriate insulin regimes to achieve good controlDelays in commencing intravenous regimesPoor subsequent management &"Maternal surveillance'#Antenatal fetal surveillanceNWomen with diabetes should be offered serial ultrasound scans during the 3rd trimester to monitor fetal growth. Cardiotocographs may also be considered from 36 weeks gestation to assess fetal well-being in late pregnancy Diabetes National Service Framework: Intervention details and draft service models; March 2002 rlJ b($'Suboptimal antenatal fetal surveillance(()%CIssues underlying suboptimal fetal monitoring for big babies (n=58)DDoLack of timely follow-upPoor interpretation of ultrasound scansIncorrect actions taken as a response to tests*&3Managing maternal complications: antenatal steroids44pIf delivery is indicated before 34 weeks, corticosteroids should be considered to prevent neonatal respiratory distress. As corticosteroids can lead to maternal hyperglycaemia, additional insulin must be given to prevent the development of diabetic ketoacidosis. Diabetes National Service Framework: Intervention details and draft service models; March 2002B g c+'3Managing maternal complications: antenatal steroids44,(Providing information54% of women in the enquiry had glycaemic control target ranges for pregnancy in the medical records or hospital guidelines. 79% had glycaemic control target ranges for labour and delivery. 86% had a documented discussion about the mode and timing of delivery, by 38 weeks gestation. Z-)#Panel assessment of suboptimal care$$.*DIssues underlying suboptimal maternity care in the antenatal periodEESuboptimal fetal surveillancePoor management of maternal risksAbsence of retinal and renal screeningProblems with the multidisciplinary teamIncluding lack of involvement and poor communicationNeed for more senior obstetrician inputInappropriate mode and/or timing of deliveryt@P'P)P5PUP@')5U/+Postnatal care0,4Issues underlying suboptimal postnatal diabetes care55wSuboptimal management of glycaemic controlLack of contact with the diabetes teamInadequate plan of care at discharge1-Are we providing the best care?;Good practice:78% of women monitored for nephropathy68% receiving antenatal steroids had an intravenous insulin regime commenced86% had a documented discussion about mode and timing of delivery81% had a written plan for post-delivery diabetes management65% had optimal maternity care during labour and delivery0Z-Z-2.Are we providing the best care? iSuboptimal glycaemic control in at least half of women from before pregnancy up to delivery Suboptimal fetal surveillance for half of all babies with antenatal evidence of macrosomia Suboptimal antenatal maternity care for half of all women Suboptimal diabetes care for more than half of all women No postnatal contraceptive advice for a quarter of women v\PP PPP\ 3/Recommendations IXAn individualised care plan covering the pregnancy and postnatal period up to 6 weeks should be clearly documented in the notes, ideally using a standard template. As a minimum, the care plan should include:Targets for glycaemic controlRetinal and renal screening schedulesFetal surveillancePlan for deliveryDiabetes care after deliveryBZZZ40Recommendations IIpThe care plan should be implemented from the outset of pregnancy by a multidisciplinary team present at the same time in the same clinic. Pregnancies with ultrasound evidence of macrosomia should have a clear management plan put in place by a consultant obstetrician. This should include timing of follow-up scans, fetal surveillance and mode and timing of delivery.qZq51Recommendations IIIA care plan for postnatal management should be clearly documented in the notes for all women. As a minimum, this should include:Plan for management of glycaemic controlNeonatal careContraceptionFollow-up care after discharge from hospital<rr62Recommendations IVResearch should be carried out to investigate:the most appropriate management strategy following antenatal evidence of macrosomia in babies of women with diabeteshow best to achieve optimal blood glucose control during pregnancy, labour and delivery. //4789:;<=>?@ A r2|1 ՜.+,0   ?On-screen ShowCEMACH  ArialTimes New RomanZapf Dingbats WingdingsDefault DesignSlide 1!Aspects of care during pregnancy(Previous findings on glycaemic control*Enquiry findings<Issues underlying suboptimal glycaemic control in pregnancy8Optimising glycaemic control during labour and deliveryJIssues underlying suboptimal glycaemic control during labour and deliveryMaternal surveillanceAntenatal fetal surveillance(Suboptimal antenatal fetal surveillanceDIssues underlying suboptimal fetal monitoring for big babies (n=58)4Managing maternal complications: antenatal steroids4Managing maternal complications: antenatal steroidsProviding information$Panel assessment of suboptimal careEIssues underlying suboptimal maternity care in the antenatal periodPostnatal care5Issues underlying suboptimal postnatal diabetes care Are we providing the best care? Are we providing the best care?Recommendations IRecommendations IIRecommendations IIIRecommendations IV  Fonts UsedDesign TemplateSlide Titles