fluids in Labour

Report
Fluid
Management
in Labour
Nuzhat Aziz
Head, Dept of Obstetrics
Website : www.fernandezhospital.com
Labour and Delivery
Labor and birth: physical endurance (12 METS)
Percentage of Water in Human Body
Physiology of Pregnancy
 Total body volume increases (6 – 8 litres)
 Plasma volume - 50%
– Increase more in multifetal pregnancy
– Decreased increment
• Fetal growth restriction
• Pre eclampsia
• Oligohydramnios
Total Body Water
70 ml / kg, 45 L
Intracellular
Extracellular
2/3
1/3
30 L
15 L
Extracellular Fluid
Intravascular Interstitial +
III space + Lymph
1/3
5L
2/3
10 L
Crystalloid and Colloid Oncotic
Pressures
Non
pregnant
Pregnancy
Pre
eclampsia
Post
Partum
28
22
18 - 20
16 - 18
Fluid Loss
 Dehydration : 1% loss of body fluid
 Symptoms :
– Dry skin, loses elasticity
– Dry mucosal membranes
– Impaired cognitive function
– Sunken eyes
– Headaches
– Fatigue
Circulating Volume Decreases




Hypotension, tachycardia
Thready pulse
Oliguria
Organ failure and death
Fluid Balance
 Intake :
– Food and drinks
 Output:
– Mainly urine
– Sweat
– Respiratory tract
Thirst - ADH - Conservation of fluids
Assessing Fluid Balance
 Clinical assessment
 Weight loss
 Input and output measurement
Urine Output
 Pale straw coloured
 Normal urine output is 1ml/kg/hour
 Minimum required is 0.5 ml/kg/hour
38 weeks, spontaneous labour,
at 4 cm cervical dilatation
 Hydration in labour
 100 years ago, women delivered at home,
drank water when they were thirsty,
ate when they were hungry
In 1945




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Curtis Mendelson
66 cases of aspiration
1.5 per 1000 incidence
Changed the practices in labour wards
Aspiration related to size of particles
And acidity of contents
Why are we worried about giving
food and fluids in labour?
 Physiological changes
– Gastroesophageal reflux is more
– Decrease in sphincter tone
 Predisposition to aspiration
– Delayed gastric emptying time
– Riflux + narcotics use
Why are ANAESTHETISTS worried
about giving food and fluids in
Labour?
 General anaesthesia risks
– Increase in BMI
– Enlarged breast
– Edema
– Preclampsia
Changes in
Obstetric Anaesthesia
Practice




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GA rates are declining
Most women take epidural
Opiods in EA
Effect on gastric emptying time
Reduction in aspiration related deaths
38 weeks, spontaneous labour,
at 4 cm cervical dilatation
 Hydration in labour
 In 1950s – Labour and delivery units started
restricting food and fluids in labour
What are the
Recommendations today?
 NICE Intrapartum care guidelines
 Women may drink during established labour
and be informed that isotonic drinks may be
more beneficial than water.
Isotonic Fluids


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RCT with isotonic fluids with water only
500 ml first hour – 500 ml every 3-4 hours
47 kcal/hour
Water only group
– Increased free fatty acids
– Decreased glucose
– No difference in gastric aspirate / vomiting
Kubli et al. An evaluation of isotonic sports drink during labour.
Anaesthesia Analg 2002, 94; 404 - 8
Carbohydrate Solutions


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
Studies in first / second stage of labour
12.6 gm carbohydrate / 100 ml Vs plain water
No difference in labour outcomes
Increase in fatty acids in placebo group
Scheepers et al. Carbohydrates solution intake in labour, a double blind RCT on
metabolic efforts. BJOG, 2002 109; 178-81 and BJOG 2004; 11:1382-7
Patient’s Choice
 40% - Hungry
 92% - Thirsty
 What they did in labour
– 68% only drank did not eat – did not feel like
Newton et al. Oral Intake in Labour. Nottinghams policy
formulated and Audited. Br J Midwif 1997; 5: 418 - 22
Cochrane Review
“there is no justification for the
restriction of fluids and food in
labour for women at low risk of
complications”
Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake
during labour. Cochrane Database of Systematic Reviews 2010, Issue 1.
Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub2
Restriction of Food and Drink


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Accelerated Starvation
Ketosis
Reduction in plasma glucose levels
Reduced insulin levels
History!
In 1960s the use of dextrose infusions in labour
was advocated, but then adverse effects on the
fetus were reported.
Glucose Infusions in Labour
 Decrease in fetal pH
 Hypoglycemia in neonates
 Hypotonic solution- electrolyte imbalance
Dextrose infusions should
not be used.
If DNS is used – not more than 120 ml / hour
In High Risk Mothers
(for Cesarean Section)
 When oral intake is not given
 IV infusion rate should be 2 ml / kg / hour
 60 kg mother
 120 ml per hour of RL / NS
Which Fluid to Use?
 5% or 10% Dextrose or Normal Saline or
Ringer Lactate
 Preference for NS or Ringer Lactate
A comparison of the effects of four intravenous solutions for the treatment of
ketonuria during labour. Morton KE, Jackson MC, Gillmer MD. Br J Obstet Gynaecol.
1985 May;92(5):473-9.
IV Hydration – Does it Help ?
 Increased IV hydration does not decrease
labor duration in nulliparous women when
access to oral fluid is unrestricted
A Randomized Trial of Increased Intravenous Hydration in Labor
when Oral Fluid is unrestricted.
Andrew Coco, Andrew Derksen-Schrock
Fam Med 2010;42(1):52-6.)
Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal
Intrapartum Fluid Balance
Caroline J. Chantry, Laurie A. Nommsen-Rivers, Janet M. Peerson, Roberta J. Cohen
and Kathryn G. Dewey
Pediatrics 2011;127;e171 ; originally published online December 20, 2010;
DOI: 10.1542/peds.2009-2663
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/127/1/e171.full.html
Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal
Intrapartum Fluid Balance
Caroline J. Chantry, Laurie A. Nommsen-Rivers, Janet M. Peerson, Roberta J. Cohen
and Kathryn G. Dewey
Pediatrics 2011;127;e171 ; originally published online December 20, 2010;
DOI: 10.1542/peds.2009-2663
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Oxytocin and Fluid Retention
 Polypeptide, similar to Arginine Vasopressin
 Antidiuretic effect depends on
– Rate
• 45 mU/min rate : same and 20 mU/min : half the effect
– Duration : 6 hours
– High Concentration
– Hypotonic solutions : Use RL or NS only
Oxytocin and Fluid Retention


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Hyponateremia and water intoxication
Nausea, vomiting
Headache
Disorientation
Coma, death
Simple Precaution to avoid this:
Use Normal Saline or Ringers Lactate
for Oxytocin Infusion
Oxytocin Infusion Protocol
Special Conditions
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Epidural analgesia – Pre loading
Pre eclampsia
Heart Disease in Pregnancy, Pulm edema
Acute Kidney Injury
Post partum hemorrhage
Preloading for
Labour Epidural Analgesia (LEA)
 1000 ml of Ringer Lactate
 Prevent hypotension
 Post LEA variable FHR decelerations
 Heart disease or preeclampsia – 500 ml
Pre eclampsia


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Fluid restricted to 80 ml / kg / hour
Contracted intravascular compartment
Decreased colloid pressure
Damaged endothelial surface
PULMONARY EDEMA
Remember!
Oxytocin and Magnesium sulphate infusions
Fluid management in pre-eclampsia, T. Engelhardt, F. M. MacLennan.
International Journal of Obstetric Anesthesia (1999) 8. 253-259
Heart Disease
Complicating Pregnancy
 IV fluid therapy : with caution
– With CVP monitoring : safer
– 0.5 – 1 ml / kg / hour
 Multidisciplinary teamwork
 Oxytocin : syringe pump is better
– 5 units in 50 cc syringe and the rates calculated
– Infusion: Concentrated drip 10 U in 500 ml
Oliguria, Acute Kidney Injury
Chronic renal disease
 Multidisciplinary team
 May need invasive monitoring
 Prone for fluid overload
 Fluid intake = Urine output + 30 ml
Post Partum Hemorrhage
 Resuscitation of lost intravascular volume
 Fluid ?
 How much ?
Revision!
Basics of fluid distribution across the
compartments
1000 ml of fluid when given
5%
Dextrose
NS or RL
Intracellular
Volume
Extracellular
Volume
Interstitial
Volume
Plasma
Volume
660
340
255
85
-100
1100
825
275
Albumin
1000 compartment
500
Doesn’t stay0in intravascular
at500
all
Whole
blood
0
1000
0
1000
1000 ml of fluid when given
Intracellular
Volume
Extracellular
Volume
Interstitial
Volume
Plasma
Volume
5%
Dextrose
660
340
255
85
NS or RL
-100
1100
825
275
0
1000
500
500
25% remains - intravascular compartment after 30 min
Albumin
Whole
blood
0
1000
0
1000
1000 ml of fluid when given
Intracellular
Volume
Extracellular
Volume
Interstitial
Volume
Plasma
Volume
5%
Dextrose
660
340
255
85
NS or RL
-100
1100
825
275
Albumin
0
1000
500
500
Whole
blood
All in ECV but 50 % to interstitial space and
0
1000
0
1000
50% remains in intravascular space
1000 ml of fluid when given
Intracellular
Volume
Extracellular
Volume
Interstitial
Volume
Plasma
Volume
5%
Dextrose
660
340
255
85
NS or RL
-100
1100
825
275
Albumin
0
1000
500
500
Whole
blood
0
1000
0
1000
Summary
 Not much evidence
for restriction of fluid in labour
 Supportive Care and Patient’s choice

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