Lactnet friends, I put this to your collective minds.

Some time back, Pamela gave a reference and some short quotes on Lactnet:

Garite TJ et al, A randomized controlled trial of the effect of increased
intravenous hydration on the course of labor in nulliparous women, Am J.
Obstet Gynecol 2000:183:1544-8.

I remember that in reading the post, I interpreted what I read as a
matter of labor being shortened by an hour when mothers received 250 cc.
of IV fluid rather than I25 cc. I remember thinking "Big deal! That's a
half a glass of water! I sure don't ever remember seeing people getting
just 250 cc. of fluid intravenously!"

And then, I dismissed it from my mind as having no bearing on my quest to
understand more about the relationship of postpartum swelling to IV's in
labor.

This week I came across it again, and looked it up in it's entirety.
Imagine my surprise to find that it meant 250 cc. *per hour* vs. 125 cc.
*per hour*, which of course, now made more sense to me!

This added up to an average of over 2000 -2400 cc. per mother, with the
L&D nurses giving extra boluses when monitors showed non-reassuring FH
beats. The conclusion in the abstract:

"This study presents the novel finding that increasing fluid
administration for nulliparous women in labor above rates commonly used
is associated with a lower frequency of prolonged labor and possibly less
need for oxytocin. Thus inadequate hydration in labor may be a factor
contributing to the dysfunctional labor and possibly cesarean delivery.
Consideration of this factor in clinical management and in future studies
considering variables that affect labor is warranted."

Sounds pretty reasonable when stated like that. However, as I read the
article I found the phrase "prolonged labor (arbitrarily defined as labor
<12 hours)", and much of the interventions such as "need for oxytocin",
and "C. Section for failure to progress" were based on this and other
such arbitrary definitions. It caused me to wonder whether "in the olden
days", many of us women didn't consider this a really long labor, and
perhaps didn't suffer quite so much engorgement.

In another article (admittedly now nearly 20 years old), I found a
partial answer:

Gonik B, Cotton DB. Peripartum colloid osmotic pressure changes:
Influence of intravenous hydration Am J Obstet Gynecol Sept 1984 150:1,
99-100

(COP = colloid osmotic pressure)

I found this interesting info. "Studies of colloid osmotic pressure in
normal and complicated pregnancies have revealed new insights in the
forces which regulate fluid movement across capillary membranes." (Then
they refer to one of their previous studies) :

Cotton DB et al Intrapartum to postpartum changes in colloid osmotic
pressure Am J Obstet Gynecol 1984; 149:174

"That study suggested that the intravenous fluids administered and not
the type of anesthesia were primarily responsible for the decline in
colloid osmotic pressure. In addition, we demonstrated that patients
routinely received large crystalloid fluid loads quite different from
those ordered by the attending physician." (Hm-m-m. Wonderment mine)

They went on to say: "One clinical method to delineate more clearly the
impact of intravenous fluids alone would be to examine patients
undergoing uncomplicated vaginal deliveries with intravenous hydration
compared to birthing room subjects who receive only oral liquid
supplementation during labor and delivery." (LOL-How would you like to be
thought of as "a birthing room subject" if you were the laboring
mother??!!)

Anyway, "The degree of reduction in colloid osmotic pressure that
occurred during the postpartum period was significantly different between
the two study populations . . None of the patients studied were
identified clinically to have any cardiopulmonary complications . . .
.The data presented here do not negate the routine use of intravenous
fluids in the laboring patient. Conversely, they point out the resilience
of the pregnant woman's cardiocascular and renal systems when confronted
with iatrogenic stresses."

This is a very interesting article I would recommend to anyone wondering
about increased engorgement and ways to prevent it. The end focus of the
researchers in this article was pulmonary edema and cardiovascular
complications.

There was, of course, no mention of engorgement, nor even of pleural
effusion, (which one radiological reference states is found in nearly 50%
of a large group of postpartum women studied! I wonder if mothers who
didn't get IV's were included in that retrospective study.)

Even though engorgement in itself is not imminently life-threatening, its
long-term effect on discontinuation of breastfeeding or poor milk
production may significantly impact the life of both the baby and the
mother.

I don't see us being able to impact the management of labor much in the
forseeable future, though it would be nice to bring into our loop the L&D
nurses who do the actual administration of fluids, and who may be able to
modify the total amounts given in the intrapartum period.

Therefore, more account of this factor must be taken, both in clinical
practice and in research that involves engorgement and its sequelae.
Several large and oft-quoted studies on engorgement make no mention of
this as a variable, if my memory serves me correctly.

Can any nutritionists answer this simplistic question? If a mother eats a
high protein diet several days before induced or managed labor, and
continues it during the post partum period, can this have any effect on
the serum proteins to help offset the changes of IV's on colloid osmotic
pressure?

And nurses and physicians who understand a lot more about IV's than I:
Could part of this fluid replacement be done with colloidal fluids rather
than crystalloid fluids? There was one article that compared the
difference in COP between mothers with elective C. Sections, some
receiving 1000 cc. of colloidal solution, and 2 other groups receiving
1000 cc. and 2000 c.c. of crystalloid solution. The COP was significantly
less in mothers receiving the 2000 cc. of crystalloid fluid.

Oh, dear. So much of this is over my head. But so much of it seems
somehow to have been beyond the gaze of those ordering and administering
the IV fluids, and those doing scholarly research on possible variables
impacting engorgement.

Once again, I feel like the child in the fable, when I cry out "The
Emperor has no clothes!"

Jean
********************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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