Maternal outcomes in women supplemented with a high-protein drink in labour

Gastric emptying in pregnancy and its clinical implications: a narrative review

Delayed gastric emptying increases the risk of pulmonary aspiration during anaesthesia for Caesarean delivery. Our aim in conducting this narrative review was to consider the effect of pregnancy on gastric emptying. The indices of gastric emptying after liquids, solids, or both and when fasted in the various trimesters of pregnancy, at the time of Caesarean delivery, in labour, and the postpartum period were assessed. We considered 32 observational studies, one nonrandomised controlled study, and 22 randomised controlled trials. The evidence indicates that, compared with the nonpregnant state, gastric emptying is decreased in the first but not the second and third trimesters. Before elective Caesarean delivery, carbohydrate drink or tea with milk leads to no difference in gastric cross-sectional area at 2 h relative to fasting or water. Following a standard fast for elective Caesarean delivery, patients may still have high-risk gastric contents. Compared with the nonpregnant state and third trimester, gastric emptying is delayed in labour, although the choice of analgesia has modifying effects. Systemic opioids delay gastric emptying. Epidural analgesia increases gastric emptying, but not back to baseline. Intrathecal analgesia delays gastric emptying relative to epidural analgesia. Women in labour who have eaten solids in the last 8 h still have high-risk gastric contents present in the stomach. The evidence with respect to the postpartum period is conflicting. In conclusion, inconsistencies in the literature reflect the unpredictability of gastric emptying in pregnancy and underline the potential value of gastric ultrasound in women who are pregnant.

Ultrasound evaluation of gastric emptying of high-energy semifluid solid beverage in parturients during labor at term: a randomized controlled trial

PURPOSE

What to intake during labor is controversial. The purpose of this study was to compare the gastric emptying of high-energy semifluid solid beverage (HESSB) versus that of carbohydrate (CHO) solution of equal calories and volume by evaluating the gastric antral cross-sectional area (CSA) using ultrasonography in parturients during labor at term.

METHODS

The study was conducted at a maternity and infant hospital between June and October 2020. Forty parturients scheduled for epidural labor analgesia during labor at term were randomly assigned to receive HESSB (300 mL, n = 20) or CHO (300 mL, n = 20). Gastric antral CSA was measured at baseline and 5, 30, 60, 90, and 120 min after consumption of the drink. The primary outcome was gastric antral CSA at 120 min in the HESSB group and CHO group.

RESULTS

The gastric antral CSA between the HESSB group and CHO group at 120 min was not statistically significant (2.73 cm2 ± 0.55 vs. 2.55 cm2 ± 0.72, P = 0.061). All patients returned to baseline at 120 min after intake of 300 mL isocaloric HESSB and CHO, confirmed by evaluation of gastric antral CSA. The visual analog scale score for satiety was higher in the HESSB group (P < 0.001), with better taste satisfaction (7[5-8] vs. 5[4-6], P < 0.001).

CONCLUSION

The change of gastric antral cross-sectional area after HESSB is similar to the corresponding calories and volume of CHO and the gastric emptying of HESSB can be emptied within 2 h with better taste satisfaction and satiety in pregnant women under labor analgesia.

Vaginal Birth at Term - Part 1. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. This first part presents recommendations and statements about patient information and counselling, general patient care, monitoring of patients, pain management and quality control measures for vaginal birth. Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG 190 guideline "Intrapartum care for healthy women and babies". Other international guidelines were also consulted in specific cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions, if this was considered necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of the additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline and the evidence reports of the IQWiG were used to evaluate the quality of the evidence. Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

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.

Drinking during low-risk labor: monocentric randomized clinical trial on patients' satisfaction, and maternal and neonatal outcomes

INTRODUCTION

This study aimed to assess satisfaction of patients affected by various fluid regimes during uncomplicated labor; to identify factors possibly associated with the level of satisfaction; to compare obstetrical and neonatal outcomes between the intervention groups.

METHODS

Between October and December 2014, 40 women were included in the study set at the Poitiers University Hospital, France. Women were randomly allocated to two study arms: 20 to strict and 20 to liberal fluid regime group. Women's satisfaction was assessed using visual analog scale. Categorical obstetrical and neonatal outcomes were analyzed using Chi-squared test and Fischer's exact test. The between-group difference was assessed with Mann-Whitney U-test.

RESULTS

Overall satisfaction was higher among women from the liberal fluid regime than from the strict fluid regime group (median score: 88, interquartile range [IQR]: 21 vs. 72, IQR: 21; p = 0.03). The active phase of the second stage of labor was shorter in the liberal fluid regime than in the strict fluid regime group (median 9 min, IQR: 7 vs. 17 min, IQR: 12; p = 0.02). The length of stay in the delivery room was significantly shorter in liberal fluid regime than in strict fluid regime group (median 190 min, IQR: 128 vs. 340 min, IQR: 195, p = 0.04). There were no significant differences in other obstetrical and neonatal outcomes.

CONCLUSION

Liberal fluid regime during labor was associated with significantly higher satisfaction of women. The active phase of the second stage of labor and the length of stay in the delivery room were significantly shorter in the liberal fluid regime group.

Gastric point-of-care ultrasound (PoCUS) during pregnancy and the postpartum period: a systematic review

Personalised risk assessment of the likelihood of pulmonary aspiration is recommended for pregnant women undergoing general anaesthesia and gastric point-of-care ultrasound (PoCUS) may help to achieve this. Traditionally, risk assessment is based upon adherence to fasting times, but gastric emptying may vary during pregnancy and surgery often needs to be expedited. We systematically reviewed the evidence for gastric PoCUS up to August 2018 in pregnant and postpartum women to determine whether it can identify and quantify stomach contents, provide aspiration risk assessment via qualitative or quantitative means, and determine how gastric emptying is affected by pregnancy. Twenty-two articles comprising 1050 participants were included and studies were classified by qualitative or quantitative findings. The evidence suggests that gastric PoCUS is a reliable and feasible method of imaging the stomach in pregnancy in clinical practice. Qualitative assessment via the Perlas grading system can provide rapid assessment of gastric volume states. If fluid is visible, identification of patients at high risk of pulmonary aspiration requires measurement of antral cross-sectional area. Cut-off values of 608 mm² and 960 mm² are recommended in the semi-recumbent and right lateral semi-recumbent positions, respectively. Validated methods to quantify stomach volumes are available, however their usefulness is currently restricted to research. Gastric PoCUS also provides evidence that gastric emptying of ingested food is delayed by term pregnancy, labour and during the early postpartum period. However, the passage of fluids through the stomach appears unaffected throughout the peripartum period.

Implementation Science in Perioperative Care

There is a 17-year gap between the initial publication of scientific evidence and its uptake into widespread practice in health care. The field of implementation science (IS) emerged in the 1990s as an answer to this "evidence-to-practice gap." In this article, we present an overview of implementation science, focusing on the application of IS principles to perioperative care. We describe opportunities for additional training and discuss strategies for funding and publishing IS work. The objective is to demonstrate how IS can improve perioperative patient care, while highlighting perioperative IS studies and identifying areas in need of additional investigation.

Restriction of oral intake during labor: whither are we bound?

In 1946, Dr Curtis Mendelson suggested that aspiration during general anesthesia for delivery was avoidable by restricting oral intake during labor. This suggestion proved influential, and restriction of oral intake in labor became the norm. These limitations may contribute to fear and feelings of intimidation among parturients. Modern obstetrics, especially in the setting of advances in obstetric anesthesia, does not mirror the clinical landscape of Mendelson; hence, one is left to question if his findings remain relevant or if they should inform current recommendations. The use of general anesthesia at time of cesarean delivery has seen a remarkable decline with increased use of effective neuraxial analgesia as the standard of care in modern obstetric anesthesia. While the American College of Obstetricians and Gynecologists now endorses clear liquids during labor, current recommendations continue to suggest that solid food intake should be avoided. Recent evidence from a systematic review involving 3130 women in active labor suggests that oral intake should not be restricted in women at low risk of complications, given there were no identified benefits or harms of a liberal diet. Aspiration and other adverse maternal outcomes may be unrelated to oral intake in labor and as such, qualitative measures such as patient satisfaction should be paramount. It is time to reassess the impact of oral intake restriction during labor given the minimal risk of aspiration during labor in the setting of modern obstetric anesthesia practices.