COMMENTARY

Eating During Labor

Maria I. Rodriguez, MD

Disclosures

March 10, 2010

Oral intake during labor was identified in the 1940s as a risk factor for gastric aspiration with general anesthesia.[1] Since that time, restrictions have been placed on the diets of women in labor. At one time, all women in labor were restricted to ice chips in order to reduce the risk for pulmonary aspiration in the small proportion of patients who may require general anesthesia.[2] With improvements in obstetric anesthesia over subsequent decades, this approach has come under criticism.[2,3,4] Although the physiology of pregnancy does increase a woman's risk for aspiration as a result of delayed gastric emptying, pulmonary aspiration is rare.[1] Restriction of food and liquid for low-risk women in labor is felt to be potentially harmful by advocates. They cite concern that hunger may exacerbate fatigue and cause psychological stress.[3]

Wide differences exist in the management of caloric intake during labor, varying dramatically by institution and country.[1,4] Approaches range from "ice chips only" to a liberal diet for women at low risk of needing anesthesia. New evidence exists to help guide management, although the outcome of pulmonary aspiration is so rare that it is not possible to include it as a study endpoint.[1]

A Cochrane review of 5 randomized, controlled trials involving 3130 women in active labor was published recently.[4] The investigators sought to determine the potential for harm or benefit of fluid or food intake during labor. Singata and colleagues identified 5 studies of sufficient quality to include in their meta- analysis.[1,2,3,5,6] All studies included women in active labor who were deemed to be at low risk of needing a general anesthetic. One study looked at complete restriction vs giving women the freedom to eat and drink at will.[2] Two studies looked at allowing water only compared with giving women specific fluids and foods.[1,7] An additional 2 studies looked at giving water only vs giving women carbohydrate drinks.[2,5]

Primary outcomes included cesarean delivery, operative vaginal birth, and a 5-minute Apgar score of < 7.[4] Secondary outcomes were duration of labor and maternal nausea or emesis.[2] No statistically significant differences were identified in any primary or secondary outcome.[4] Patient preferences were not considered in this meta-analysis. This level-1 evidence suggests that there is no justification for restriction of access to fluids during labor in low-risk women.

Critical to interpretation of these studies and application of the findings to practice is consideration of what it means to be "low risk." Exclusion criteria for these studies varied but commonly included preterm labor, multiple gestation, breech position, intent to use analgesia during labor, and "any medical or obstetrical condition increasing risk for instrumental delivery or cesarean."[4] These results may be less generalizable to hospitals with a high rate of cesarean delivery or epidural anesthesia.

In 2007, the American Society of Anesthesiologists updated their obstetric anesthesia guidelines with respect to oral intake during labor.[8] Their panel of experts agreed that permitting intake of clear liquids during labor for uncomplicated parturients does not increase risk for maternal harm.[8] The committee, however, highlighted the need for case-by-case consideration for individuals who had additional risk factors for aspiration, such as obesity, diabetes, or a difficult airway.[8] Obstetric considerations that increase the likelihood of intervention must also be taken into account. The American Congress of Obstetricians and Gynecologists concurs with permitting a modest intake of clear liquids during labor for low-risk patients. In addition, they advise against ingestion of solid food during labor because no evidence supports a safe time period for such consumption.[9]

This evidence provides an opportunity for reevaluation of our practices toward oral intake in women during labor, and suggests that patient preference should guide oral intake of fluids in low-risk women. Care should be taken to consider the incidence of cesarean delivery and anesthesia use at a specific hospital when applying these results to one's own practice. This issue also reminds us of the necessity of close communication between obstetricians and anesthesiologists in individualizing patient care.

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