A midwifery practice dichotomy on oral intake in labour

A multicenter interdisciplinary survey of practices and opinions regarding oral intake during labor

INTRODUCTION

Different society guidelines diverge regarding oral intake in labor. Our goal was to assess practices and opinions in Israeli labor and delivery units, comparing different disciplines.

METHODS

An anonymous Google Forms survey was sent to anesthesiologists, obstetricians and midwives in all Israeli labor and delivery units.

RESULTS

Responses were collected from all 27 labor and delivery units contacted, with a total of 501 respondents comprising 161 anesthesiologists, 102 obstetricians and 238 midwives. Forty-eight per cent stated there were no institutional guidelines for oral intake. The most common oral intake permitted was light food (60%). Midwives were significantly more likely than anesthesiologists and obstetricians to consider that women who are both low risk for cesarean delivery (P <0.00001) and high risk for cesarean delivery (P=0.001) should eat. Epidural analgesia did not impact recommendations regarding oral intake. The most common reasons for restricting oral intake were obstetric. Sixty-two per cent identified aspiration as the main risk associated with eating during labor, but 19% of midwives compared with 4% of anesthesiologists and obstetricians stated there were no risks (P <0.00001). The annual delivery volume of the unit did not impact staff practices.

CONCLUSIONS

There was a discrepancy between opinions and practices across all disciplines. Permissive practices identified in this survey should be addressed to find the safe middle ground between restrictive and permissive policies for low- and high-risk women.

Oral fluid intake during the first stage of labour: A randomised trial

BACKGROUND

Obstetric anaesthesia has been associated with concern for the inhalation of gastric contents for many years, justifying fasting during labour. However, many anaesthesiologists and obstetricians now allow fluid intake during labour.

OBJECTIVE(S)

We hypothesised that allowing oral fluid intake during labour is not associated with increased gastric contents. We used ultrasound assessment of gastric contents to evaluate this hypothesis.

DESIGN

A randomised, single-blind and intention-to-treat noninferiority trial comparing antral area measured by ultrasound in fasting parturients and in those who were allowed to drink fluid for 90 min after randomisation.

SETTING

Tenon University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France.

PATIENTS

Pregnant women, aged from 18 to 40 years and from week 36 of an uncomplicated singleton gestation, were randomised into a fasting group and a fluid intake group after admission to the delivery room. Of the 184 patients screened, data from 125 were analysed: fasting group (62), fluid intake group (63).

INTERVENTION

Women in the fluid intake group were allowed to drink up to 400 ml of apple juice for 90 min after randomisation.

MAIN OUTCOME MEASURE

We compared the percentage of women with an 'empty stomach' between the two groups: empty stomach was defined as an antral cross-sectional area (CSA) less than 300 mm assessed in a semirecumbent position with a 45-degree head-up tilt.

RESULTS

At full cervical dilatation an antral CSA less than 300 mm was measured in 76 and 79% of the parturients in the fasting group and the fluid intake groups respectively (P = 0.633).

CONCLUSION

The current study reveals that the percentage of pregnant women with an 'empty stomach', defined by an antral CSA less than 300 mm in a semirecumbent position with a 45-degree head-up tilt, was comparable at full cervical dilation among those who remained nil by mouth and those allowed to drink up to 400 ml for 90 min after their randomisation.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02362815.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Mother's wellbeing and regional or systemic analgesia for labor]

INTRODUCTION

These guidelines deal with the parturient wellbeing in terms of hydration and regional and systemic pain management during labour.

METHOD

Guidelines were established based on literature analysis and experts consensus.

RESULTS

Clear liquids consumption is permitted all along labor and postpartum, without volume limitation, in patients at low risk of general anesthesia (grade B). The consumption of solid foods is not recommended during the active stage of labor (consensus agreement). It is recommended to promote on regional analgesia to prevent inhalation (grade A). Pain relief using regional analgesia is a part of normal childbirth. It is recommended to provide regional analgesia to parturient who wish these technics. Regional analgesia is the safest and most effective analgesic method for the mother (grade A) and the child (grade B). It is recommended to inform women on the analgesic technics, to respect their choice and consider the right for a parturient to change her strategy in obstetrical circumstances or in cases of untractable pain (consensus agreement). It is recommended to perform a "low-dose" regional analgesia that respects the experience of childbirth (grade A) and maintain it with a patient controlled epidural analgesia technics (grade A). There is no minimum cervical dilation to allow epidural analgesia (grade A). In cases of rapid labor or after delivery for revision, spinal or combined spinal epidural can be used (grade C). Epidural has not to be ended before birth (consensus agreement). Blood pressure and fetal heart rate must be monitored every 3minutes after induction and/or each 10mL bolus then hourly (consensus agreement). Systematic and preventive fluid loading is not needed if only due to regional analgesia (grade B). Deambulation or postures are allowed in the absence of motor block and must be traced and do not alter the distribution of the regional analgesia (grade C). The postures of childbirth do not alter regional analgesia spread (NP2). There is no effect low dose regional analgesia on the duration of obstetric labor, nor the rate of instrumental births or caesarean section (NP1). Systematic use of oxytocin due to epidural analgesia is neither useful nor recommended (AE). Regional analgesia has no side effect on the fetus or newborn (NP1). If regional analgesia is contraindicated or during the waiting time, alternatives analgesic drugs (entonox, nalbuphine and tramadol or pudendal block) can be used but their analgesic efficiency remains mediocre to moderate and they are associated with adverse maternal and especially neonatal side effects (NP2). Remifentanil, ketamine and volatile anesthetics are excluded from these recommendations.

CONCLUSION

The present guidelines were established to update wellbeing of normal parturient during normal labor: hydration is recommended and low dose patient-controlled regional (epidural and spinal) analgesia is the most effective and safest analgesic method.

A qualitative study of factors that influence midwives' practice in relation to low-risk women's oral intake in labour in Australia

BACKGROUND

Restriction of food and fluids during labour increases women's discomfort, anxiety and stress which are associated with obstruction of the normal process of labour. Whilst research evidence and clinical guidelines recommend that normal uncomplicated labouring women should not be limited in their oral intake during labour, some midwives continue to restrict or discourage women's oral intake. To promote best practice, it is important to understand the influencing factors which affect midwives' decision-making processes.

OBJECTIVE

This study aimed to investigate the influences that affect midwifery practice regarding oral food and fluid intake for low-risk labouring women.

DESIGN

An interpretive descriptive approach employed 12 semi-structured interviews with registered midwives with current labour and birthing experience in Australia. Data was analysed using thematic analysis.

FINDINGS

Three themes were identified: midwives' knowledge and beliefs; work environment and women's expectations of care. Midwives' practice was affected by their knowledge and values developed from professional and personal experiences of labour, their context of practice and work environment, the clinical guidelines, policies and obstetric control, and women's choice and comfort.

CONCLUSION

This study indicates that midwives' decision-making in relation to women's oral nutrition during labour is multifaceted and influenced by complicated environments, models of care, and power relations between doctors and midwives, more so than clinical guidelines. It is important for midwives to be aware of factors negatively influencing their decision-making processes to enable autonomy and empowerment in the provision of evidence-based care of labouring women.

Oral intake during labor: a review of the evidence

The purpose of this article is to review evidence and practices within and beyond the United States related to the practice of maternal fasting during labor. Fasting in labor became standard policy in the United States after findings of a 1946 study suggested that pulmonary aspiration during general anesthesia was an avoidable risk. Today general anesthesia is rarely used in childbirth and its associated maternal mortality usually results from difficulty in intubation. Healthcare professionals have debated the risks and benefits of restricting oral intake during labor for decades, and practice varies internationally. Research from the United States, Australia, and Europe suggests that oral intake may be beneficial, and adverse events associated with oral intake such as vomiting and prolongation of labor do not seem to be associated with alterations in maternal or infant outcomes. The World Health Organization recommends that healthcare providers should not interfere in women's eating and drinking during labor when no risk factors are evident. Nurses in intrapartum settings are encouraged to work in multidisciplinary teams to revise policies that are unnecessarily restrictive regarding oral intake during labor among low-risk women.

Oral nutrition in labour: 'whose choice is it anyway?' A review of the literature

OBJECTIVE

to identify factors affecting women's oral nutrition in labour.

DESIGN

literature review (1988-2009).

SETTING

Westernised maternity care settings.

PARTICIPANTS

women, midwives, obstetricians, anaesthetists and hospitals.

MEASUREMENTS AND FINDINGS

when addressing labour stages, the risk categorisation of women and maternal/fetal birthing outcomes, there was a lack of consistent evidence identifying adverse outcomes for mothers/infants when oral nutrition in labour had occurred.

KEY CONCLUSIONS

little evidence exists to support the continuance of restrictive practices around oral nutrition in labour for all women. Women's choice is impacted by health practitioners' opinions, experience and practice methods and policy (or lack thereof). Policies are not reflective of current evidence.

IMPLICATIONS FOR PRACTICE

women's choices and desires regarding oral nutrition in labour need to be addressed. Clear guidelines/policies need to be established based on current evidence. Midwives need greater exposure to research, as well as involvement in policy development and implementation.

Effect of food intake during labour on obstetric outcome: randomised controlled trial

OBJECTIVE

To investigate the effect of feeding during labour on obstetric and neonatal outcomes.

DESIGN

Prospective randomised controlled trial.

SETTING

Birth centre in London teaching hospital.

PARTICIPANTS

2426 nulliparous, non-diabetic women at term, with a singleton cephalic presenting fetus and in labour with a cervical dilatation of less than 6 cm.

INTERVENTION

Consumption of a light diet or water during labour.

MAIN OUTCOME MEASURES

The primary outcome measure was spontaneous vaginal delivery rate. Other outcomes measured included duration of labour, need for augmentation of labour, instrumental and caesarean delivery rates, incidence of vomiting, and neonatal outcome.

RESULTS

The spontaneous vaginal delivery rate was the same in both groups (44%; relative risk 0.99, 95% confidence interval 0.90 to 1.08). No clinically important differences were found in the duration of labour (geometric mean: eating, 597 min v water, 612 min; ratio of geometric means 0.98, 95% confidence interval 0.93 to 1.03), the caesarean delivery rate (30% v 30%; relative risk 0.99, 0.87 to 1.12), or the incidence of vomiting (35% v 34%; relative risk 1.05, 0.9 to 1.2). Neonatal outcomes were also similar.

CONCLUSIONS

Consumption of a light diet during labour did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting. Women who are allowed to eat in labour have similar lengths of labour and operative delivery rates to those allowed water only.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN33298015.

The effect of professional socialisation on midwives’ practice

This article discusses the influence that professional socialisation can have on midwifery practice. Differences in beliefs and practices regarding the oral intake of labouring women were the basis for this paper's discussion. Midwives should be aware of the problems that may be caused by the socialisation processes experienced during the training and subsequent working life of a midwife which aim to procure obedience and unquestioning conformity. These attributes diminish the ability of midwives to challenge traditional practices and to make decisions based on the available research evidence and the preferences of women in their care. Basing practice on tradition or practice conventions rather than a formal guideline or an evidence-based policy may expose a midwife to potential litigation should there be an adverse event.

A comparative study of the effect of food consumption on labour and birth outcomes in Australia

OBJECTIVE

to explore the effect of volitional food consumption by women during labour on labour and birth outcomes.

DESIGN

a comparative design using concurrent controls.

SETTING

four public hospitals in Sydney, Australia.

PARTICIPANTS

217 English-speaking, nulliparous women with low-risk pregnancies. The sample was divided into four sub-groups identified post hoc from reported behaviour: (1) 82 women who chose to eat food during early labour only; (2) 10 who ate during established labour only; (3) 31 who ate during early and established labour and (4) 94 who chose to consume clear fluids only during early and established labour.

INTERVENTIONS

voluntarily eating food during labour compared with voluntarily consuming clear fluids only.

MEASUREMENTS

differences between the four eating groups were examined for labour progress using one-way analysis of variance (ANOVA). A hierarchical multiple regression tested the association between eating during labour and labour duration. The relationship between food intake and the incidence of medical interventions was tested using chi(2) tests.

FINDINGS

eating during the early phase of the first stage of labour was associated with M=2.16 hrs longer labour (p<0.01). When women ate food during both their early and established phases of labour, M=3.5 hrs was added to their labour (p<0.01). The incidence of vomiting, medical interventions during labour or adverse birth outcomes were unaffected by food intake.

CONCLUSION

the findings suggest that women should be informed that labour may take longer when they eat food. However, eating does not seem to affect other labour or birth outcomes.

IMPLICATION FOR PRACTICE

the findings challenge the belief among many midwives that food intake is beneficial to labour progress. However, women should not be denied food for fear of vomiting or because it may make labour longer. Women with low-risk labours should be informed of the risk, although rare, of aspiration if general anaesthesia is required, and be allowed to respond to their natural desires for oral intake during labour.

Apports alimentaires per os durant le travail obstétrical : éléments objectifs et subjectifs

Fasting during labour is questioned in France despite the historical recommendations by Curtis Mendelson. Solid food diet increases maternal nausea and vomiting of non digested food associated with a theoretical risk of severe aspiration syndrome. Clear fluids may improve the comfort of some parturients but it remains uncertain whether or not the obstetric consequences (i.e. duration of labour, Caesarean section rate) of carbohydrate supplementation are beneficial.