Nuzhat AzizHead, Dept of Obstetrics

Fluid Management

in Labour

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 Water70 ml / kg, 45 L

Intracellular2/330 L

Extracellular1/315 L

Extracellular Fluid

Intravascular1/35L

Interstitial +III space + Lymph2/310 L

Crystalloid and Colloid Oncotic Pressures

Non pregnant

28

Pregnancy

22

Pre eclampsia

18 - 20

Post Partum

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

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

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

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

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

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-SchrockFam Med 2010;42(1):52-6.)

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

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

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

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 InjuryChronic 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

Intracellular Volume

Extracellular Volume

InterstitialVolume

PlasmaVolume

5% Dextrose 660 340 255 85

NS or RL-100 1100 825 275

Albumin0 1000 500 500

Whole blood 0 1000 0 1000

Doesn’t stay in intravascular compartment at all

1000 ml of fluid when given

Intracellular Volume

Extracellular Volume

InterstitialVolume

PlasmaVolume

5% Dextrose 660 340 255 85

NS or RL -100 1100 825 275

Albumin 0 1000 500 500

Whole blood 0 1000 0 100025% remains - intravascular compartment after 30 min

1000 ml of fluid when given

Intracellular Volume

Extracellular Volume

InterstitialVolume

PlasmaVolume

5% Dextrose 660 340 255 85

NS or RL -100 1100 825 275

Albumin 0 1000 500 500

Whole blood 0 1000 0 1000All in ECV but 50 % to interstitial space and

50% remains in intravascular space

1000 ml of fluid when given

Intracellular Volume

Extracellular Volume

InterstitialVolume

PlasmaVolume

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