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Fluid Management in Labour

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. T otal body volume increases (6 – 8 litres )

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Fluid Management in Labour

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  1. Fluid Management in Labour Nuzhat Aziz Head, Dept of Obstetrics Website : www.fernandezhospital.com

  2. Labour and Delivery Labor and birth: physical endurance (12 METS)

  3. Percentage of Water in Human Body

  4. 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

  5. Total Body Water70 ml / kg, 45 L

  6. Extracellular Fluid

  7. Crystalloid and Colloid Oncotic Pressures

  8. Fluid Loss • Dehydration : 1% loss of body fluid • Symptoms : • Dry skin, loses elasticity • Dry mucosal membranes • Impaired cognitive function • Sunken eyes • Headaches • Fatigue

  9. Circulating Volume Decreases • Hypotension, tachycardia • Thready pulse • Oliguria • Organ failure and death

  10. Fluid Balance • Intake : • Food and drinks • Output: • Mainly urine • Sweat • Respiratory tract Thirst - ADH - Conservation of fluids

  11. Assessing Fluid Balance • Clinical assessment • Weight loss • Input and output measurement

  12. Urine Output • Pale straw coloured • Normal urine output is 1ml/kg/hour • Minimum required is 0.5 ml/kg/hour

  13. 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

  14. 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

  15. Why are we worried about giving food and fluids in labour? • Physiological changes • Gastroesophagealreflux is more • Decrease in sphincter tone • Predisposition to aspiration • Delayed gastric emptying time • Riflux + narcotics use

  16. Why are ANAESTHETISTS worried about giving food and fluids in Labour? • General anaesthesia risks • Increase in BMI • Enlarged breast • Edema • Preclampsia

  17. Changes in Obstetric AnaesthesiaPractice • GA rates are declining • Most women take epidural • Opiods in EA • Effect on gastric emptying time • Reduction in aspiration related deaths

  18. 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

  19. 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.

  20. 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. AnaesthesiaAnalg 2002, 94; 404 - 8

  21. 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

  22. 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

  23. 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

  24. 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.

  25. 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

  26. 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

  27. 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 ObstetGynaecol. 1985 May;92(5):473-9.

  28. IV Hydration – Does it Help ? 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.) Increased IV hydration does not decrease labor duration in nulliparous women when access to oral fluid is unrestricted

  29. 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

  30. 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

  31. Oxytocin Infusion Protocol

  32. Special Conditions • Epidural analgesia – Pre loading • Pre eclampsia • Heart Disease in Pregnancy, Pulm edema • Acute Kidney Injury • Post partum hemorrhage

  33. Preloading for Labour Epidural Analgesia (LEA) • 1000 ml of Ringer Lactate • Prevent hypotension • Post LEA variable FHR decelerations • Heart disease or preeclampsia – 500 ml

  34. 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

  35. 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

  36. Oliguria, Acute Kidney InjuryChronic renal disease • Multidisciplinary team • May need invasive monitoring • Prone for fluid overload • Fluid intake = Urine output + 30 ml

  37. Post Partum Hemorrhage • Resuscitation of lost intravascular volume • Fluid ? • How much ? Revision! Basics of fluid distribution across the compartments

  38. 1000 ml of fluid when given Doesn’t stay in intravascular compartment at all

  39. 1000 ml of fluid when given 25% remains - intravascular compartment after 30 min

  40. 1000 ml of fluid when given All in ECV but 50 % to interstitial space and 50% remains in intravascular space

  41. 1000 ml of fluid when given

  42. Summary • Not much evidence for restriction of fluid in labour • Supportive Care and Patient’s choice

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