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 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-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 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 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