[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.

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.

Midwifery dilemma: to fast or feed the labouring woman. Part I: The case for restricting oral intake in labour

This paper presents a literature review which pursues both sides of the labouring woman's oral intake debate--to fast or to feed the labouring woman. Part 1 provides an exploration of the phenomenon of gastric content aspiration associated with general anaesthesia and its historical and physiological underpinnings. Part 2 provides an examination of the literature concerning the benefits of fasting labouring women.

Fasting in labor: relic or requirement

OBJECTIVE

To evaluate the scientific literature on restrictions of eating and drinking during labor.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as historical articles, texts, and references cited in published works. Key words used in the searches included anesthesia in labor, childbirth, eating and drinking, epidural, fasting, fasting in labor, fasting and pregnancy, gastric aspiration, gastric emptying, intrapartum, intravenous fluids, i.v.s in labor, ketonuria, ketonuria in labor, parturition, pregnancy, and stomach contents in labor.

STUDY SELECTION

Articles from indexed journals, excluding single-person case studies.

DATA EXTRACTION

Data were extracted and organized under the following headings: historical review, effects of fasting on labor, research on maternal mortality/morbidity from aspiration, research on gastric emptying in labor, intravenous hydration in labor, and implications for nursing research.

DATA SYNTHESIS

Research does not support restricting food and fluids in labor to prevent gastric aspiration. Restricting oral intake during labor has unexpected negative outcomes.

CONCLUSIONS

Little is known about the differences in labor progress, birth outcomes, and neonatal status between mothers who consume food and/or fluids during labor and women who fast during labor. Research also is needed on the effects of epidural opioids on gastric emptying, nutritional requirements during labor, and the physiologic implications of fasting during labor. Fasting during labor is a tradition that continues with no evidence of improved outcomes for mother or newborn. Many facilities (especially birth centers) do not restrict eating and drinking. Across the United States, most hospitals restrict intake, usually to ice chips and sips of clear liquids. Anesthesia studies have focused on gastric emptying, measured by various techniques, presuming that delayed gastric emptying predisposes women to aspiration. Narcotic analgesia delays gastric emptying, but results are conflicting on the effect of normal labor and of epidural anesthesia on gastric emptying. The effect of fasting in labor on the fetus and newborn and on the course of labor has not been studied adequately. Only one study evaluated the probable risk of maternal aspiration mortality, which is approximately 7 in 10 million births.