Eating and Drinking during Labor

Deanna K. Sanford MS, CNM, Glenda J. Sanford BSN, RN, & Sheliah C. Jackson BSN, RN.

MW11 Critical Inquiry I,

Abstract

The restriction of eating and drinking during labor was first implemented more than a half-century ago when many women gave birth under general anesthesia. Since vomiting while under general anesthesia can result in aspiration of stomach contents, the medical practice at the time was to reduce that risk by restricting oral intake to ice chips or prohibiting oral intake altogether. Although most women no longer give birth under general anesthesia, the practice of restricting intake in labor persists. For those who require or desire it, the delivery of anesthesia has improved so that aspiration is rarely an issue. A 1989 National Birth Center study showed that 11,814 women who were allowed to eat and drink at will during labor did not have a single case of aspiration, even among the 22% of women in the total group who required a Cesarean.

Labor places a significant demand on a woman’s calorie requirements. Withholding nutrition from a laboring woman has been cited as a factor in accelerated starvation during labor that can produce quantifiable effects on blood glucose and ketone levels. Thus, it is possible that some complications of labor and delivery may ultimately be caused by this state of starvation.

Review of the literature reveals current evidence that eating and drinking during labor is a safe practice for low-risk women. This study will describe and assess the benefits of allowing low-risk women to eat and drink to appetite during labor. Nine hundred laboring women in three different health facilities will follow one of three dietary regimens during their labors. Data will be collected using questionnaires, as well as phone and face-to-face interviews. The medical community must be challenged to initiate and adopt evidence based guidelines regarding eating and drinking of low risk women during labor.

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Introduction to the Problem

The restriction of eating and drinking for laboring women was first implemented more than a half-century ago when women often gave birth under general anesthesia (Parsons, 2004b). Since vomiting while under general anesthesia can result in the aspiration of the stomach contents into the lungs, leading to serious breathing difficulties and even death, the medical practice of the time was to reduce the risk of aspiration by drastically limiting intake during labor (Douglas, 2004), often allowing only ice chips or sucking on a wet wash cloth to relieve oral dryness. However, most women no longer deliver under general anesthesia. For those who do, the administration of anesthesia has improved so that aspiration is rarely an issue. Still, the practice of restricting eating and drinking during labor and delivery remains (O'Sullivan & Scrutton, 2003).

Frequently, whether a woman is encouraged, or even permitted, to eat and drink during labor is at the discretion of her health care team. And it is that provider’s association and knowledge of labor practices that often determines their viewpoint regarding restricting or permitting a laboring woman to eat and drink. There are two predominating schools of thought: 1) that nourishment during labor is essential for the sustained health of the laboring mother, and 2) eating and drinking during labor can lead to surgical complications. Currently, the American Society of Anesthesiologists (ASA) and the American College of Obstetricians and Gynecologists (ACOG) recommend that only clear liquids be given to women during labor. They further recommend that the practice of giving clear liquids during labor be limited to women without risk factors that may increase their chances of Cesarean delivery. Women who are at increased risk for a Cesarean delivery are recommended to have nothing by mouth (NPO) during labor. This restriction of limiting intake to laboring women identified as high risk may explain why they are subject to more aggressive medical interventions. Midwives frequently recommend that laboring mothers be encouraged to eat light snacks and liquids to ensure that they maintain their energy during long labors. The Society of Obstetricians and Gynecologists of Canada contends that a woman should be permitted a light diet during labor, and other respected sources advise that, as long as the foods and liquids consumed during labor are light and are not likely to cause nausea (such as heavy foods and juices) these should be not only permitted, but offered (Parsons, Bidewell and Nagy, 2006).

Permitting a laboring mother to consume light snacks and liquids has been shown to provide several physiological and psychological benefits. Parsons’ (2004b) study reinforces the knowledge that "glucose is the principal source of energy for the fetus and is diffused rapidly across the placenta (p.7)." The metabolism of glucose during pregnancy occurs at nearly twice the normal rate because of the demands of the fetus. Therefore, it makes sense to encourage laboring women to maintain these levels by eating and drinking small amounts nutritious foods and liquids. In addition, ketosis occurs in pregnant women after only short periods of fasting and has been indicated as a factor in prolonged labor. It has also been suggested that women who choose what they eat and drink during labor experience an increased sense of control and improved moral during their labor (Parsons 2004b). In summary, it is possible that encouraging women to eat and drink while in labor may present more benefits than drawbacks.

Scope of the Problem

In 2003, 4,089,950 live births were reported in the United States, of which 27.5 percent were delivered by Cesarean section. Of these, 2,965,213 women gave vaginal birth and were affected by the delivering practitioners’ recommendations on whether to eat or drink during labor. The practice of allowing women to eat and drink during labor is highly-debated. These debates and well-designed research studies may eventually challenge the 1946 study that brought the NPO policy into the medical practice (O'Sullivan, Liu, & Shennan, 2007). In an effort to resolve the issue, there are medical associations which are conducting their own studies. These studies have shown to provide inconsistent results. Yet, studies that present evidence to the contrary must be heeded despite any desire to do otherwise (Polit & Beck, 2004). Review of the literature offers insight into the problem and invites healthy discussion among doctors, anesthetists, midwives, nurses, and other healthcare service providers. Viewpoints and practice regarding offering eating and drinking to laboring mothers vary largely due to profession (Parsons, Bidewell, & Griffiths, 2007). Women are, for the most part, receiving conflicting advice and information and being permitted to eat and drink during labor based on the type of provider and birth environment rather than well-researched and evidence-based medical practice.

With the amount of information available, many women find themselves overwhelmed or confused by conflicting guidelines related to eating and drinking during labor. Even if the laboring women requests food and fluids their health care provider or birth facility protocols may require that she be NPO or given ice chips only. Pregnant and laboring women need straightforward guidelines based on solid research that will guide them and their health care provider. Since the prevailing tradition is to restrict food and fluid during labor, most women follow the policy of the provider or clinical environment. According to Scheepers, Jong, Essed, and Kanhai (2001) although most women are not given any advice regarding eating and drinking in labor, those who are offered advice generally follow it. Women who are told not to eat generally refrain from doing so, and women who are offered light food and drink during labor are often eager to do so. Since the prevailing tradition is to restrict food and drink to laboring women, most women consume nothing other than clear liquids once labor begins or once they have entered the clinical environment. It may be advisable to restrict the intake of certain women who are known to be high-risk deliveries, yet the restriction policy extends to all women regardless of risk.

Since women are likely to follow the advice of their practitioners, it appears that healthcare providers must ensure that the policies concerning eating and drinking during labor are in the best interest of the laboring mother and her unborn child. It should not merely be a pervasive tradition of medical providers (Scheepers et al., 2001).

Significance to Women’s Heath

One goal of the Healthy People 2010 project is to improve the health and well-being of women, infants, children, and families (U.S. Department, 2007). One way to address the issue of health and well-being are for healthcare practitioners to reach consensus about the issue of eating and drinking during labor based upon solid medical evidence. Currently, some obstetrical and midwifery providers are implementing a model of care that emphasizes less medical interventions, unless necessary. These viewpoints insist that such interventions as the restriction of food and liquids, the required use of intravenous lines, continual electronic fetal monitoring, and the artificial rupture of membranes, are largely unnecessary as routine labor and delivery practices and should be reserved only for special situations. In fact, some interventions, such as refusing nourishment during labor, may actually be harmful (Parsons, Bidewell, & Nagy, 2006). Yet, the practice of subjecting women to restrictive, occasionally painful or harmful, labor and delivery practices that were implemented largely due to reasons which are no longer valid today continues.

Women have expressed their desire to eat and/or drink while in labor. Labor and delivery is an intense activity that requires sustaining calories. Supporting a woman’s caloric needs while she gives birth may ensure that she retains the strength needed to proceed without medical intervention, thereby giving her the best chance to complete the birth process in as healthy and positive manner as possible. Some studies also indicate that the restriction of food and drink during labor makes laboring women feel as if there is something unnatural about the birth process and may even increase their perception of pain and reduce their morale (Parsons, 2004b). Twenty percent of Cesarean deliveries are due to dysfunctional labor, defined as abnormal uterine contractions that interfere with normal progress of labor (Quenby, Pierce, Brigham, & Wray, 2004). The study by Quenby et al. (2004) showed that acidification could depress uterine contraction, possibly contributing to dysfunctional labors. Intracellular acidosis due mainly to lactic acid accumulation has been regarded as the most important cause of skeletal muscle fatigue. The research on athletes have indicated that food and hydration are important aspects of keeping muscles working and reducing acidification, thus demonstrating a possible benefit to laboring women. According to Blackburn (2003) potential physiologic effects of fasting during labor include increased ketones and fatty acids with decreased alanine, glucose, and insulin which increase anxiety and stress for the laboring women.

Significance to Midwifery

Midwives have traditionally attempted to maintain current medical standards and provide their clients with the safest and most satisfying birth outcomes in the most natural environment possible. According to the American College of Nurse-Midwives(2007) the hallmarks of care include recognizing birth as a normal physiologic process, empowerment of women, advocacy for informed choice, shared decision-making, and the right to self-determination. As such, midwives are interested in giving laboring women sound advice based on well-designed and implemented research studies regarding their options of eating and drinking while in labor. Encouraging a woman to eat or drink what she chooses during labor helps the mother maintain a sufficient energy level, increase her sense of control, and keep a positive attitude during the process.

References

American College of Nurse-Midwives. (2007). Core Competencies for Basic Midwifery Practice. Retrieved September 1, 2007 from http://www.acnm.org/siteFiles/descriptive/Core_Competencies__6_07.pdf

Blackburn, S.T. (2003). Gastrointestinal and Hepatic Systems and Perinatal Nutrition. Maternal, Fetal, & Neonatal Physiology: A Clinical Perspective (pp 426-427). St.Louis, MO: Saunders.

Chervenak, F. A., McCullough, L.B., & Birnbach, D.J. (2003). Ethics: An Essential Dimension of Clinical Obstetric Anesthesia. Anesth Analg, 96, 1480-5.

Douglas, J. (2004). General anesthesia for obstetrics: a deadly or a winning combination. Canadian Journal of Anesthesiologists, 51(6) R1-R4.

LaValley, M. (2003). Intent-to-Treat Analysis of Randomized Clinical Trials. ACR/ARHP Annual Meeting, Orlando Florida. Retrieved October 1, 2007 from http://people.bu.edu/mlava/

O’Sullivan, G., Liu, B., & Shennan, A. (2007). Oral Intake During Labor. Int Anesthesiol Clin, 45(1):133-147.

O’Sullivan, G. & Scrutton, M. (2003). NPO during labor. Is there any scientific validation? Anesthesiol Clin North America, 21:87-98.

Parsons, M. (2004a). Midwifery Dilemma: to fast or feed the labouring woman. Part 1: The Case for Restricting Oral Intake during Labour. Australian Journal of Midwifery, 16(4)7-13.

Parsons, M. (2004b). Midwifery Dilemma: to fast or feed the labouring woman. Part 2: The Case Supporting Oral Intake during Labour. Australian Journal of Midwifery, 17(1)5-9.

Parsons, M., Bidewell, J., & Nagy, S. (2006). Natural Eating Behavior in Latent Labor and Its Effect on Outcomes in Active Labor. J Midwifery & Women's Health, 51, e1- e6.

Parsons, M., Bidewell, J., & Griffiths, R. (2007). A comparative study of the effect of food consumption on labour and birth outcomes in Australia. Midwifery, 23, 131-138.

Polit, D. F., Beck, C. T. (2004). Nursing Research: Principles and methods (7th ed.). Philadelphia: Lippincott Williams & Wilkins.

Quenby, S., Pierce, S., Brigham, S. & Wray, S. (2004). Dysfunctional Labor and Myometrial Lactic Acidosis. Obstetric and Gynecology, 103(4), 718-23.

Scheepers, H., Thans, M., Pieter A., Gerard G.M., LeCessie, Saskia, & Kanhai, H. (2001). Eating and Drinking in Labor: The Influence of Caregiver Advice on Women’s Behavior. BIRTH, 28:2.

U.S. Department of Health and Human Services (2000). Healthy People 2010. Retrieved July 8, 2007 from http://www.healthypeople.gov/

Weber, R. (2006). Comprehensive Reliability. CSE Magazine, 5, 52.