An Evaluation of Isotonic “Sport Drinks” During Labor

Comparative evaluation of normal saline, 1/3-2/3, and ringer's lactate infusion on labour outcome, PH, bilirubin, and glucose level of the umbilical cord blood in nulliparous women with labour induction: a randomised clinical trial

This study aimed to compare the effects of infusion of normal saline, 1/3-2/3, and Ringer's lactate fluids on labour outcome, pH, bilirubin, and glucose level of umbilical cord blood. In this randomised clinical trial, 450 nulliparous women with Bishop score ˂5 and indication of pregnancy termination were randomly divided into three groups to receive normal saline, 1/3-2/3, or Ringer's lactate infusion at a rate of 125 mL/h for hydration, upon starting induction of labour. Results of this study indicated that the incidence of hypoglycaemia (p = .19), hyper bilirubinemia (p = .87) and acidosis (p = .10) was similar in neonates of the three groups. Also, there were no statistically significant differences between the three groups with regard to the duration of labour; glucose, bilirubin and pH level of cord blood; and mode of delivery. It can be concluded that infusion of Ringer's lactate, normal saline or 1/3-2/3 fluid during labour is not associated with different maternal or foetal/neonatal outcomes, and none of the fluids has superiority to the others.Impact statementWhat is already known on this subject? Several studies have been conducted on the association between type and volume of infused fluid on labour duration and neonatal outcomes. However, there has been some controversy.What do the results of this study add? This is the first study that has investigated the association between infusion of Ringer's lactate, normal saline or 1/3-2/3 fluid during labour with labour outcome and pH, bilirubin, and glucose level of the umbilical cord blood and results showed that these fluids have no effect on maternal or foetal/neonatal outcomes and also none of these fluids has superiority to the others.What are the implications of these findings for clinical practice and/or further research? Due to contradictory results of previous studies, further research with greater sample sizes and different fluids type and volumes may be needed to examine the association between infusion of fluids and neonatal and labour outcomes more precisely.

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.

Women's view on fasting during labor in a tertiary care obstetric unit. A prospective cohort study

OBJECTIVE

Maternal satisfaction and comfort may in part depend on fasting instruction given during labor. This study aimed to assess the satisfaction and the wishes of parturients with regards to fasting during labor.

STUDY DESIGN

This prospective cohort study was conducted among parturients assessing the fasting instructions they were given. We assessed whether women did have any oral intake during labor and focused on women's view of fasting during labor. Maternal discomfort related to thirst and hunger was assessed using 0-10 scales.

RESULTS

A total of 193 women were included, among whom 71 (37 %) received spontaneously given instructions and 60 (31 %) received instruction upon request. One hundred sixteen (60 %) women were allowed to drink clear fluids, in a limited way for 106 women (91 % of those concerned); 119 women did drink clear fluids during labor. One hundred thirty-two (68 %) women had a thirst-related discomfort score ≥ 4 without any statistical difference whether they had or had not drunk clear fluids. Colder water, unrestricted volume of water and sweet drink were desired by 74 (64 %), 38 (33 %) and 28 (24 %) women who had been allowed to drink, respectively.

CONCLUSION

These results emphasize that thirst contributes to maternal discomfort during labor. Permitting limited intake of water does not ensure high maternal satisfaction. Fresh clear fluids, unrestricted amounts of fluids and sweet fluids could contribute to improve maternal comfort.

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.

Investigation on the status of oral intake management measures during labor in China

The World Health Organization recommended that the oral intake of low-risk pregnant women during labor should not be restricted. Hospitals in different countries take different measures to manage the intake during labor, but it is not clear about the current situation of oral intake management measures in the hospital during labor in China. Thus, the objective of this study was to investigate the current situation of oral intake management measures during labor in China, so as not only provide references for developing appropriate midwifery technology training and formulating relevant policies, but also provide a basis for exploring and implementing better oral intake management measures in the future.A cross-sectional survey was conducted. From December 2017 to November 2018, the oral intake management measures of 1213 hospitals in 22 provinces, cities, and autonomous regions in China were investigated by a self-designed questionnaire. χ test was used for statistical analysis.Different hospitals in China have adopted different oral intake management measures. Among the 1213 hospitals, 939(77.4%) hospitals took measures to allow pregnant women to bring the easily digestible food, 813(67.0%) hospitals took measures to allow pregnant women to eat what she wanted to eat. Few hospitals provide pregnant women with oral nutrition solution or provide a suitable diet for pregnant women. Thirty-four (2.8%) hospitals still restrict pregnant women's fluid intake.Oral intake management measures that are more suitable for Chinese pregnant women should be explored to better ensure the women energy needs and they safely go through childbirth.

Effect of Oral Carbohydrate Intake During Labor on the Rate of Instrumental Vaginal Delivery: A Multicenter, Randomized Controlled Trial

BACKGROUND

Carbohydrate intake during physical exercise improves muscle performance and decreases fatigue. We hypothesized that carbohydrate intake during labor, which is a period of significant physical activity, can decrease the instrumental vaginal delivery rate.

METHODS

In a multicenter, prospective, randomized, controlled trial, healthy adult pregnant women presenting with spontaneous labor were assigned to a "Carbohydrate" group (advised to drink 200 mL of apple or grape juice without pulp every 3 hours) or a "Fasting" group (water only). The primary outcome was the instrumental vaginal delivery rate. Secondary outcomes included duration of labor, rate of cesarean delivery, evaluation of maternal hunger, thirst, stress, fatigue, and overall feeling during labor by numeric rating scale (0 worst rating to 10 best rating), rate of vomiting, and hospital length of stay. Statistical analysis was performed on an intention-to-treat basis. The primary outcome was tested with the "Fasting" group as the reference group. The P values for secondary outcomes were adjusted for multiple comparisons. The differences between groups are reported with 99% confidence interval (CI).

RESULTS

A total of 3984 women were analyzed (2014 in the Carbohydrate group and 1970 in the Fasting group). There was no difference in the rate of instrumental delivery between the Carbohydrate (21.0%) and the Fasting (22.4%) groups (difference, -1.4%; 99% CI, -4.9 to 2.2). No differences were found between the Carbohydrate and the Fasting groups for the duration of labor (difference, -7 minutes; 99% CI, -25 to 11), the rate of cesarean delivery (difference, -0.3%; 99% CI, -2.4 to 3.0), the rate of vomiting (difference, 2.8%; 99% CI, 0.2-5.7), the degree of self-reported fatigue (difference, 1; 99% CI, 0-2), self-reported hunger (difference, 0; 99% CI, -1 to 1), thirst (difference, 0; 99% CI, -1 to 1), stress (difference, 0; 99% CI, -1 to 1), overall feeling (difference, 0; 99% CI, 0-0), and the length of hospitalization (difference, 0; 99% CI, -1 to 0).

CONCLUSIONS

Carbohydrate intake during labor did not modify the rate of instrumental vaginal delivery.

A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes

Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.

Effects of date fruit consumption on labour and vaginal delivery in Tabuk, KSA

Objectives

The date fruit has been shown to possess several health benefits. This study aims to determine the effects of date fruit consumption on the onset and progression of labour.

Methods

A randomised controlled clinical study was conducted on 89 participants to assess the effects of date fruit consumption on the onset and progression of labour. Twenty-six participants consumed date fruits alone, and 32 consumed date fruits followed by drinking of water. Thirty-one served as controls.

Results

There was a significant positive impact of consuming (rutab) date fruits on maternal outcomes in both the first and third stages of labour (p < 0.05 and p < 0.001, respectively). In addition, there was a significant relationship with the foetal well-being factors, such as healthy liquor, foetal heart rate, presence of caput, and Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score at 5 min (p < 0.05). The other maternal and foetal well-being factors showed no significant relationship with consumption of date fruits during labour.

Conclusion

The present study showed a promising effect of (rutab) date fruit consumption on the duration of the stages of labour. No significant differences were observed between the date fruit consumers and their counterparts regarding cervical dilatation; rupture of membranes; strength, frequency, and regularity of uterine contractions; tocometric reports; and maternal progression factors. Additionally, the APGAR score at 5 min was better among the infants whose mothers consumed date fruits.

The effects of intravenous dextrose 5%, Ringer's solution, and oral intake on the duration of labor stages in nulliparous women: a double-blind, randomized, controlled trial

Background and objectives: Childbirth consists of a three-stage period beginning with uterine contractions and ending in the expulsion of the placenta. The present study was conducted to compare the effects of Ringer's solution, dextrose solution 5%, and oral intake on the duration of total labor and labor stages (primary outcome) and the frequency of oxytocin administration and prolonged labor (secondary outcome) in nulliparous women with spontaneous vaginal delivery.Materials and methods: The present randomized clinical trial was conducted on 201 nulliparous women in labor assigned with a randomized block design to three groups, each receiving either Ringer's solution plus oral fluids, dextrose solution 5% solution plus oral fluids or oral fluids alone. The solutions were intravenously administered at a rate of 125 ml/h in the groups receiving the solutions and the subjects in the oral fluids group could consume liquids of their choice (water, orange juice, and apple juice). The duration of total labor and labor stages (the active stage, the second, and third stages of labor) were recorded by the researcher in minutes. Furthermore, the frequency of oxytocin administration and prolonged labor were recorded by the researcher by using a checklist. Data were analyzed using the Kruskal-Wallis test, Mann-Whitney's U-test, chi- square test and Fisher exact test.Results: The mean (±SD) duration of total labor was 301.2 (±50.0) minutes in the Ringer group, 171.9 (±36.4) in the dextrose 5% group, and 524.8 (±103.4) in the oral fluids group, suggesting a statistically significant intergroup difference (p < .001). The mean (±SD) duration of the active stage of labor was 276.7 (±91.3) minutes in the Ringer group, 150.6 (±78.5) in the dextrose 5% group, and 302.4 (±136.8) in the oral fluids group, suggesting a statistically significant intergroup difference (p < .001). A significant difference was also observed between the three groups in terms of the duration of the third stage of labor (p < .001); however, no significant differences were observed in terms of the duration of the second stage of labor (p = .058). Furthermore, a significant difference was observed between the three groups in terms of the need for oxytocin administration (p ≤ .001) and the frequency of prolonged labor (p = .001).Conclusion: The results suggest that the consumption of dextrose solution by nulliparous women reduces the duration of labor, the need for oxytocin administration and the frequency of prolonged labor compared to when Ringer's solution and oral fluids are used.

Ultrasound assessment of gastric content in the immediate postpartum period: a prospective observational descriptive study

INTRODUCTION

Pulmonary aspiration of gastric contents in pregnant women undergoing general anesthesia or sedation/analgesia in the peripartum period is a feared complication in obstetric anesthesia. We assessed the changes in antral cross-sectional area (CSA) with ultrasonography in laboring women and in the immediate postpartum period.

PATIENTS AND METHODS

In an observational study in a university-affiliated maternity, gastric ultrasonography examinations were performed in non-consecutive laboring women, after epidural analgesia insertion and after childbirth. Assessment of antral CSA, difficulty of performance on a numerical scale, and factors that could influence gastric content were noted. A cut-off value of 381 mm² was taken for the diagnosis of empty stomach.

RESULTS

One hundred women were enrolled in the study. Median antral CSA was 469 mm² [25th-75th] [324-591] after epidural insertion and 427 mm² [316-574] after delivery. Antral CSA was ≥ 381 mm² in 59 of 90 women (65%) after epidural insertion vs. 48 of 100 women (48%) after delivery (P = 0.59). Median variation of antral CSA between two measurements was 36 mm² [-42 to 114]. Gastric ultrasonography was significantly more difficult to perform during labor than immediately post-delivery (median difficulty score 5 [2-7] vs. 2 [1-4], P < 0.0001). No risk factors (pain, anxiety, diabetes, smoking) were significantly associated with the occurrence of full stomach post-delivery.

CONCLUSION

This study demonstrated that 48% of parturients in the immediate postpartum period presented an antral CSA ≥ 381 mm² , cut-off being accepted for diagnosis of empty stomach and emphasizes the need for re-assessing before any general anesthetic procedure.

Reduction of total labor length through the addition of parenteral dextrose solution in induction of labor in nulliparous: results of DEXTRONS prospective randomized controlled trial

BACKGROUND

Prolonged labor is a significant cause of maternal and fetal morbidity and very few interventions are known to shorten labor course. Skeletal muscle physiology suggests that glucose supplementation might improve muscle performance in case of prolonged exercise and this situation is analogous to the gravid uterus during delivery. Therefore, it seemed imperative to evaluate the impact of adding carbohydrate supplements on the course of labor.

OBJECTIVE

We sought to provide evidence as to whether intravenous glucose supplementation during labor induction in nulliparous women can reduce total duration of active labor.

STUDY DESIGN

We performed a single-center prospective double-blind randomized controlled trial comparing the use of parental intravenous dextrose 5% with normal saline to normal saline in induced nulliparous women. The study was conducted in a tertiary-level university hospital setting. Participants, caregivers, and those assessing the outcomes were blinded to group assignment. Inclusion criteria were singleton pregnancy at term with cephalic presentation and favorable cervix. Based on blocked randomization, patients were assigned to receive either 250 mL/h of intravenous dextrose 5% with normal saline or 250 mL/h of normal saline for the whole duration of induction, labor, and delivery. The primary outcome studied was the total length of active labor. Secondary outcomes included duration of the active phase of second stage of labor, the mode of delivery, Apgar scores, and arterial cord pH.

RESULTS

In all, 100 patients were randomized into each group. A total of 193 patients (96 in the dextrose with normal saline group and 97 in the normal saline group) were analyzed in the study. The median total duration of labor was significantly less in the dextrose with normal saline group (499 vs 423 minutes, P = .024) than in the normal saline group. The probabilities of a woman being delivered at 200 minutes and 450 minutes were 18.8% and 77.1% in the dextrose with normal saline group vs 8.2% and 59.8% in the normal saline group (Kolmogorov-Smirnov test P value = .027). There was no difference in the rate of cesarean delivery, instrumented delivery, Apgar score, or arterial cord pH.

CONCLUSION

Glucose supplementation significantly reduces the total length of labor without increasing the rate of complication in induced nulliparous women. Given the low cost and the safety of this intervention, glucose should be used as the default solute during labor.

The Use of Ultrasonography in Obstetric Anesthesia

This article provides an overview of the use of ultrasonography in obstetric anesthesia. It discusses the indications, benefits, and techniques of using ultrasonography to optimize the delivery of anesthesia and provide safe and efficacious clinical care. More specifically, it discusses the use of ultrasonography to facilitate neuraxial anesthesia, abdominal field blocks, central and peripheral vascular access, as well as the assessment of the lung fields and gastric contents, and identification of the cricothyroid membrane.

Interrater reliability of qualitative ultrasound assessment of gastric content in the third trimester of pregnancy

BACKGROUND

Pulmonary aspiration of gastric contents in pregnant women undergoing general anaesthesia is one of the most feared complications in obstetric anaesthesia. Bedside gastric ultrasonography is a feasible imaging tool to assess the gastric content. The purpose of this study was to investigate the reliability of qualitative bedside assessment of the gastric content performed by anaesthesiologists on third trimester pregnant women.

METHODS

Pregnant women (≥32 weeks gestational age) were randomized to undergo ultrasound (US) assessments of their stomach in a fasting state (>8 h), or after ingestion of clear fluids only, or solid food. Three anaesthesiologists trained in gastric ultrasonography performed the assessments using a low-frequency curved-array US transducer (5-2 MHz). Primary outcome of the study was the consistency of raters in diagnosing the correct status of the gastric content, which was used to determine the interrater reliability among the three anaesthesiologists. Secondary outcomes were overall proportion of correct and incorrect diagnoses and the specific proportions of correct diagnosis across the three gastric content groups.

RESULTS

We analysed 32 pregnant women. The interrater reliability displayed a kappa statistic of 0.74 (bias corrected 95% CI: 0.68-0.84). The overall proportion of correct diagnosis was 87.5% (84 of 96). The odds of correct diagnosis for 'solid contents' were 16.7 times the odds for 'empty', and 14.3 times for 'clear fluid'.

CONCLUSIONS

Our results show the consistency of the qualitative US assessment of gastric contents of pregnant women in the third trimester by anaesthesiologists. A kappa of 0.74 suggests substantial agreement in terms of interrater reliability for this diagnostic measurement.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01564030.

[Contribution of ultrasonography for the preoperative assessment of gastric contents]

The assessment of the risk of pulmonary aspiration of gastric contents may be difficult in the preoperative period, apart from typical circumstances. The development of ultrasonography in anesthesia and critical care has led to consider ultrasonic imaging of gastric contents for preoperative risk assessment of "full" stomach in clinical practice. Ultrasonography of the body of the stomach allows direct visualization of the gastric contents. However, the stomach is often difficult to identify, particularly when it is empty. Moreover, quantitative assessment of gastric volume is delicate, and no standardized method of ultrasonography of the body of the stomach for preoperative assessment of gastric contents was described. On the contrary, ultrasonography of the antral cross-sectional area, which was initially described for the assessment of gastric emptying as an alternative method to repeated measurements of the variations of antropyloric volume after ingestion of a test meal, is easy to perform and is highly reproducible through using the aorta and the left lobe of the liver as internal landmarks. Qualitative assessment of the gastric antrum allows easily diagnosis of a "full" stomach. The measurement of antral area may allow a more accurate estimate of the presence or absence of gastric contents at risk of lung injury in the event of regurgitation and aspiration (gastric volume >0.8 ml/kg and/or with solid particles), defining the "risk" stomach. The use of antral ultrasonography may help the anesthesiologist to assess the risk of pulmonary aspiration according to clinical history of the patient, in order to choose an appropriate strategy minimizing the occurrence of this complication.

Restricting oral fluid and food intake during labour

BACKGROUND

Restricting fluids and foods during labour is common practice across many birth settings with some women only being allowed sips of water or ice chips. Restriction of oral intake may be unpleasant for some women, and may adversely influence their experience of labour.

OBJECTIVES

To determine the benefits and harms of oral fluid or food restriction during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2013) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of restricting fluids and food for women in labour compared with women free to eat and drink.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

MAIN RESULTS

We identified 19 studies of which we included five, involving 3130 women. We excluded eight studies, one awaits classification and five are ongoing studies. All the included studies looked at women in active labour and at low risk of potentially requiring a general anaesthetic. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.When comparing any restriction of fluids and food versus women given some nutrition in labour, the meta-analysis was dominated by one study undertaken in a highly medicalised environment. There were no statistically significant differences identified in: caesarean section (average risk ratio (RR) 0.89, 95% confidence interval (CI) 0.63 to 1.25, five studies, 3103 women), operative vaginal births (average RR 0.98, 95% CI 0.88 to 1.10, five studies, 3103 women) and Apgar scores less than seven at five minutes (average RR 1.43, 95% CI 0.77 to 2.68, four studies, 2902 infants), nor in any of the other outcomes assessed. Women's views were not assessed. The pooled data were insufficient to assess the incidence of Mendelson's syndrome, an extremely rare outcome. Other comparisons showed similar findings, except one study did report a significant increase in caesarean sections for women taking carbohydrate drinks in labour compared with water only, but these results should be interpreted with caution as the sample size was small.

AUTHORS' CONCLUSIONS

Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. Conflicting evidence on carbohydrate solutions means further studies are needed and it is critical in any future studies to assess women's views.

Increased intravenous hydration of nulliparas in labor

OBJECTIVE

To assess the effects of intravenous hydration on the duration of active labor in nulliparous women also allowed unrestricted oral consumption of fluids.

METHODS

In a randomized clinical trial 120 nulliparous women with uncomplicated singleton pregnancies at term were randomly assigned to drink fluids at will and receive either no intravenous hydration (group 1) or a Ringer lactate solution at rates of 60 mL, 120 mL, or 240 mL per hour (groups 2-4) throughout active labor.

RESULTS

There were differences in duration for the active phase of the first stage of labor (252.3 ± 40.9 min in group 1 vs 206.7±38.3 min in group 4; P<0.001) and for the second stage (64.3 ± 13.9 in group 1 vs 49.8 ± 11.4 min in group 4; P=0.01), but not for the third stage. The percentage of participants who needed labor augmentation with oxytocin was less when intravenous hydration was provided (53.3% in group 1 vs 20.0% in group 4; P=0.02).

CONCLUSION

Intravenous hydration significantly decreased the duration of active labor and reduced the frequency of both prolonged labor and oxytocin administration in nulliparous women. htpp://www.irct.ir registration number: IRCT201105256575N2.

Bedside ultrasound assessment of gastric content: an observational study

PURPOSE

There is a growing interest in the use of bedside ultrasonography to assess gastric content and volume. It has been suggested that the gastric antrum in particular can be assessed reliably by sonography. The aim of this observational study was to provide a qualitative description of the sonographic characteristics of the gastric antrum when the stomach is empty and following the ingestion of clear fluid, milk, and solid content.

CLINICAL FEATURES

Six healthy volunteers were examined on four different occasions (24 scanning sessions): following a period of eight hours of fast and following ingestion of 200 mL of apple juice, 200 mL of 2% milk, and a standard solid meal (sandwich and apple juice). Examinations were performed following a standardized scanning protocol by two clinical anesthesiologists with previous experience in gastric sonography. For each type of gastric content, the sonographic characteristics of the antrum and its content are described and illustrated with figures.

CONCLUSIONS

Bedside sonography can determine the nature of gastric content (nil, clear fluid, thick fluid/solid). This qualitative information by itself may be useful to assess risk of aspiration, particularly in situations when prandial status is unknown or uncertain.

Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology

This guideline aims to provide an overview of the present knowledge on aspects of perioperative fasting with assessment of the quality of the evidence. A systematic search was conducted in electronic databases to identify trials published between 1950 and late 2009 concerned with preoperative fasting, early resumption of oral intake and the effects of oral carbohydrate mixtures on gastric emptying and postoperative recovery. One study on preoperative fasting which had not been included in previous reviews and a further 13 studies published since the most recent review were identified. The searches also identified 20 potentially relevant studies of oral carbohydrates and 53 on early resumption of oral intake. Publications were classified in terms of their evidence level, scientific validity and clinical relevance. The Scottish Intercollegiate Guidelines Network scoring system for assessing level of evidence and grade of recommendations was used. The key recommendations are that adults and children should be encouraged to drink clear fluids up to 2 h before elective surgery (including caesarean section) and all but one member of the guidelines group consider that tea or coffee with milk added (up to about one fifth of the total volume) are still clear fluids. Solid food should be prohibited for 6 h before elective surgery in adults and children, although patients should not have their operation cancelled or delayed just because they are chewing gum, sucking a boiled sweet or smoking immediately prior to induction of anaesthesia. These recommendations also apply to patients with obesity, gastro-oesophageal reflux and diabetes and pregnant women not in labour. There is insufficient evidence to recommend the routine use of antacids, metoclopramide or H2-receptor antagonists before elective surgery in non-obstetric patients, but an H2-receptor antagonist should be given before elective caesarean section, with an intravenous H2-receptor antagonist given prior to emergency caesarean section, supplemented with 30 ml of 0.3 mol l(-1) sodium citrate if general anaesthesia is planned. Infants should be fed before elective surgery. Breast milk is safe up to 4 h and other milks up to 6 h. Thereafter, clear fluids should be given as in adults. The guidelines also consider the safety and possible benefits of preoperative carbohydrates and offer advice on the postoperative resumption of oral intake.

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.

No effect of energy supply during childbirth on delivery outcomes in nulliparous women: a randomised, double-blind, placebo-controlled trial

The effect of providing oral energy supplements of energy on duration of labour and labour outcomes remains to be clarified. The purpose of this study was to examine whether extra energy supply beyond a self-regulated dietary intake during labour would shorten duration of labour in nulliparous women. A total of 213 healthy women at gestational age >36 weeks received either 1 litre of isotonic energy-drink (n = 111) or placebo-drink (n = 102) at the start of labour. A total of 61% in the intervention group gave birth within the hospital median of 9 hours, compared with 58% in the placebo group (p = 0.68). The mean (SD) durations of labour were 528 (240) minutes and 506 (233) minutes in the intervention and placebo group (p = 0.50), respectively. Extra oral supply of 1 litre energy drink beyond self-regulated intake of food and drink to healthy nulliparous women in birth does not affect the duration of labour.

Ultrasound in obstetric anaesthesia: a review of current applications

Ultrasound equipment is increasingly used by non-radiologists to perform interventional techniques and for diagnostic evaluation. Equipment is becoming more portable and durable, with easier user-interface and software enhancement to improve image quality. While obstetric utilisation of ultrasound for fetal assessment has developed over more than 40years, the same technology has not found a widespread role in obstetric anaesthesia. Within the broader specialty of anaesthesia; vascular access, cardiac imaging and regional anaesthesia are the areas in which ultrasound is becoming increasingly established. In addition to ultrasound for neuraxial blocks, these other clinical applications may be of value in obstetric anaesthesia practice.

Restricting oral fluid and food intake during labour

BACKGROUND

Restricting fluids and foods during labour is common practice across many birth settings with some women only being allowed sips of water or ice chips. Restriction of oral intake may be unpleasant for some women, and may adversely influence their experience of labour.

OBJECTIVES

To determine the benefits and harms of oral fluid or food restriction during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of restricting fluids and food for women in labour compared with women free to eat and drink.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction.

MAIN RESULTS

We identified five studies (3130 women). All studies looked at women in active labour and at low risk of potentially requiring a general anaesthetic. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.When comparing any restriction of fluids and food versus women given some nutrition in labour, the meta-analysis was dominated by one study undertaken in a highly medicalised environment. There were no statistically significant differences identified in: caesarean section (average risk ratio (RR) 0.89, 95% confidence interval (CI) 0.63 to 1.25, five studies, 3103 women), operative vaginal births (average RR 0.98, 95% CI 0.88 to 1.10, five studies, 3103 women) and Apgar scores less than seven at five minutes (average RR 1.43, 95% CI 0.77 to 2.68, three studies, 2574 infants), nor in any of the other outcomes assessed. Women's views were not assessed. The pooled data were insufficient to assess the incidence of Mendelson's syndrome, an extremely rare outcome. Other comparisons showed similar findings, except one study did report a significant increase in caesarean sections for women taking carbohydrate drinks in labour compared with water only, but these results should be interpreted with caution as the sample size was small.

AUTHORS' CONCLUSIONS

Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. Conflicting evidence on carbohydrate solutions means further studies are needed and it is critical in any future studies to assess women's views.

Management and communication problems in a patient with succinyl-CoA transferase deficiency in pregnancy and labour

Succinyl-CoA transferase deficiency is a high-risk condition that pre-disposes the sufferer to severe and life-threatening ketoacidosis. An 18-year-old woman with succinyl-CoA transferase deficiency was admitted to the delivery suite for induction of labour at 38 weeks of gestation. Her management included adequate calorie intake in order to avoid fatty acid metabolism and adequate hydration along with rigorous electrolyte balance and minimisation of physiological stress by the use of epidural analgesia. The needs of the woman's condition had to be balanced against the desire to minimise gastric volume in case emergency obstetric intervention was required.

A randomized, double-blinded, controlled trial comparing parenteral normal saline with and without dextrose on the course of labor in nulliparas

OBJECTIVE

The objective of the study was to compare intravenous normal saline with and without dextrose on the course of labor in nulliparae.

STUDY DESIGN

In a double-blinded, controlled trial, term, nulliparae with singletons in active labor were randomized into 1 of 3 groups receiving either normal saline (NS), NS with 5% dextrose (D5NS), or NS with 10% dextrose (D10NS) at 125 mL/h. The primary outcome was total length of labor from onset of study fluid in vaginally delivered subjects. Maternal and neonatal outcomes were also analyzed.

RESULTS

Of 300 subjects enrolled, 289 met inclusion criteria and completed the study. In vaginally delivered subjects, significant differences were noted in the second stage (P = .01) and total length of labor (P = .02). No significant differences were observed in the cesarean section rates between the groups (P = .21). No differences were noted in maternal or neonatal secondary outcomes.

CONCLUSION

Administration of a dextrose solution, regardless of concentration, was associated with a shortened labor course in term vaginally delivered nulliparae subjects in active labor.

Hyponatremia complicating labour--rare or unrecognised? A prospective observational study

Objective

The aim of this study was to investigate the occurrence of hyponatraemia following delivery, with a hypothesis that hyponatraemia has a high prevalence in labouring women.

Design

Prospective observational study.

Setting

Consultant-led delivery suite in County Hospital, Kalmar, Sweden.

Sample

A total of 287 pregnant women at term (37 full gestational weeks).

Methods

Oral fluids were allowed during labour. Blood samples were collected on admission, after delivery, and from the umbilical artery and vein.

Main outcome measure

Hyponatraemia defined as plasma sodium ≤130 mmol/l after delivery.

Results

Hyponatraemia was found in 16 (26%) of the 61 mothers who received more than 2500 ml of fluid during labour. Two-thirds of fluids were orally ingested. Decrease in plasma sodium concentration during labour correlated with duration of labour and the total fluid volume administered. Analysis by multivariate logistic regression showed that hyponatraemia was significantly correlated with fluid volume (P < 0.001) but not with oxytocin administration or epidural analgesia. Hyponatraemia correlated significantly with prolonged second stage of labour, instrumental delivery, and emergency caesarean section for failure to progress (P = 0.002).

Conclusions

Hyponatraemia is not uncommon following labour. Tolerance to a water load is diminished during labour; therefore, even moderate fluid volumes may cause hyponatraemia. Women should not be encouraged to drink excessively during labour. Oral fluids, when permitted, should be recorded, and intravenous administration of hypotonic fluids should be avoided. When abundant drinking is unrecognised or intravenous fluid administration liberal, life-threatening hyponatraemia may develop. The possibility that hyponatraemia may influence uterine contractility merits further investigation.

Intrapartum maternal glucose infusion and fetal acid-base status

OBJECTIVE

To compare the effects of an intrapartum infusion of a lactated Ringer solution or a glucose-boosted saline solution on the acid-base status of umbilical arterial blood.

METHOD

In a prospective clinical trial 178 women in labor were randomized to receive intravenously either a lactated Ringer solution or a saline solution boosted with 5% glucose. Umbilical arterial blood was then assessed for acid-base status.

RESULTS

There were significant differences between the lactated Ringer group and the glucose group in umbilical artery pH values (7.25+/-0.07 vs. 7.28+/-0.06; P=0.008), pCO2 values (44.8+/-5.6 mm Hg vs. 41.6+/-4.1 mm Hg; P=0.001), and base excess (-7.3+/-2.1 mEq/L vs. -6.6+/-1.8 mEq/L; P=0.02).

CONCLUSION

Intrapartum intravenous fluid containing a 5% glucose solution reduces umbilical cord acidemia and hypercarbia.

Actual versus instructed fasting times and associated discomforts in women having scheduled cesarean birth

OBJECTIVES

To measure actual and instructed preoperative fasting durations in women undergoing scheduled cesarean birth, to compare these times with national guidelines for healthy patients undergoing elective procedures, and to describe discomforts associated with preoperative fasting.

DESIGN

One group, nonexperimental, comparative, descriptive.

SETTING

Nonprofit private medical center in Texas with 6,000 births/year.

PATIENTS

Convenience sample of 51 hospitalized postpartum women.

INTERVENTIONS

Participants were interviewed an average of 44 hours after their cesarean birth, and their medical records were reviewed for fasting information.

MAIN OUTCOME MEASURES

Duration of actual and instructed fasting, comparison with national guidelines, and ratings of thirst and hunger.

RESULTS

The participants fasted from liquids and solids an average of 11 and 13 hours, respectively. Both actual and instructed fasting durations were significantly longer than national guidelines. Most participants (70%) were instructed to be nulla per os after midnight whether they were to have a.m. or p.m. surgery. Thirst and hunger scores averaged 5 and 4, respectively, on a 0-10 scale.

CONCLUSION

Patients having scheduled cesarean birth fast for unnecessarily long periods. Nurses should be knowledgeable about evidence-based preoperative fasting practices and collaborate with physicians to implement them.

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.

The effect of unrestricted oral carbohydrate intake on labor progress

OBJECTIVE

To determine if unrestricted oral carbohydrate intake during labor reduced the incidence of dystocia in low-risk nulliparous women.

DESIGN AND SETTING

A randomized clinical trial at a university-affiliated hospital in southeastern Ontario. Low-risk nulliparous women were randomized between 30 and 40 weeks gestation to either an intervention or usual care group.

INTERVENTION

Women in the intervention group received, prenatally, guidelines about food and fluid intake during labor and were encouraged to eat and drink as they pleased during labor. Women in the usual care group received no prelabor information and were restricted to ice chips and water during labor in the hospital.

MAIN OUTCOME MEASURE

The incidence of dystocia, defined as a cervical dilatation rate of less than 0.5 cm/hr for a period of 4 hrs after a cervical dilatation of 3 cm.

RESULTS

Three hundred twenty-eight women were randomized to the intervention (n = 163) or usual care (n = 165) groups. Women in the intervention group reported a significantly different pattern of oral intake during early labor in the hospital (chi(2) = 40.7, p < .001). The incidence of dystocia was 36% (n = 58) in the intervention group and 44% (n = 72) in the usual care group and was not significantly different (OR = 0.71, 95% CI = 0.46, 1.11). There were no significant differences in the other secondary outcomes or in the incidence of adverse maternal or neonatal complications.

CONCLUSION

Eating and drinking early in labor had no significant impact on the incidence of dystocia and/or adverse maternal or neonatal outcomes.

A midwifery practice dichotomy on oral intake in labour

OBJECTIVE

to assess the views and practices of midwives regarding oral intake in labour for women with low-risk pregnancies.

DESIGN

an exploratory survey design including open- and closed-ended questions.

SETTING

four hospitals in Sydney, Australia.

PARTICIPANTS

89 practising midwives who provided care for labouring women.

FINDINGS

midwives were divided on the issue of what and when labouring women should, or should not, be allowed to eat and drink. The views and practices of these midwives were influenced by the accepted practice in the hospital in which they were employed and the types of midwifery models in which they have practised.

KEY CONCLUSIONS

there is insufficient conclusive research evidence to support any stance on oral intake for labouring women. Most information purported by supporters of oral intake is based on anecdotal evidence and assumptions based on the physiology of the body. 'Nil by mouth' policies have never been researched while clear fluid policies are based on research performed with non-obstetric patients.

IMPLICATIONS FOR PRACTICE

without reliable research evidence for the management of oral intake for labouring women no hospital practice or policy is valid. This leaves midwives with the responsibility of deciding what they believe is the best management for the oral intake of labouring women in their care.