nuzhat aziz head, dept of obstetrics fluid management in labour website :
TRANSCRIPT
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Nuzhat AzizHead, Dept of Obstetrics
Fluid Management
in Labour
Website : www.fernandezhospital.com
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Labour and Delivery
Labor and birth: physical endurance (12 METS)
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Percentage of Water in Human Body
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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
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Total Body Water70 ml / kg, 45 L
Intracellular2/330 L
Extracellular1/315 L
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Extracellular Fluid
Intravascular1/35L
Interstitial +III space + Lymph2/310 L
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Crystalloid and Colloid Oncotic Pressures
Non pregnant
28
Pregnancy
22
Pre eclampsia
18 - 20
Post Partum
16 - 18
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Fluid Loss
Dehydration : 1% loss of body fluid Symptoms : – Dry skin, loses elasticity– Dry mucosal membranes– Impaired cognitive function– Sunken eyes– Headaches– Fatigue
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Circulating Volume Decreases
Hypotension, tachycardia Thready pulse Oliguria Organ failure and death
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Fluid Balance
Intake : – Food and drinks
Output: – Mainly urine– Sweat– Respiratory tract
Thirst - ADH - Conservation of fluids
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Assessing Fluid Balance
Clinical assessment
Weight loss
Input and output measurement
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Urine Output
Pale straw coloured
Normal urine output is 1ml/kg/hour
Minimum required is 0.5 ml/kg/hour
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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
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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
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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
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Why are ANAESTHETISTS worried about giving food and fluids in Labour?
General anaesthesia risks– Increase in BMI– Enlarged breast– Edema– Preclampsia
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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
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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
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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.
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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
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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
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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
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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
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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.
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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
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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
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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.
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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.)
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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
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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
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Oxytocin Infusion Protocol
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Special Conditions
Epidural analgesia – Pre loading Pre eclampsia Heart Disease in Pregnancy, Pulm edema Acute Kidney Injury Post partum hemorrhage
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Preloading for Labour Epidural Analgesia (LEA)
1000 ml of Ringer Lactate Prevent hypotension Post LEA variable FHR decelerations Heart disease or preeclampsia – 500 ml
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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
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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
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Oliguria, Acute Kidney InjuryChronic renal disease
Multidisciplinary team
May need invasive monitoring
Prone for fluid overload
Fluid intake = Urine output + 30 ml
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Post Partum Hemorrhage
Resuscitation of lost intravascular volume Fluid ? How much ?
Revision! Basics of fluid distribution across the compartments
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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
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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
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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
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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
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Summary
Not much evidence for restriction of fluid in labour
Supportive Care and Patient’s choice