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Nutrition in Labour
The practice of restricted intake, and in some cases, fasting during labour has become commonplace in many hospitals The explanation for this is the concern that eating and drinking in labour increases the risk of regurgitation and aspiration of the stomach contents if there is need for general anaesthesia. The most specific worry is of acidic gastric aspiration
(Mendelson’s syndrome). The absolute level of the risk of aspiration has always been low and it is clear that aspiration of gastric contents now plays a very small role in both absolute and relative terms as a cause of maternal death (Johnson et al 1989). It has been frequently noted however that anaesthetic technique is the major reason that deaths from
aspiration still occur (Morgan 1986, Crawford 1986, Ludka 1987, DoH 1991). Johnson et al (p 828) state that most cases of aspiration “could be prevented by a combination of decreasing the frequency of procedures that require anaesthesia, the use of regional anaesthesia wherever feasible, and meticulous attention to safe anaesthetic technique”.
No presently known practices can ensure that a labouring woman’s stomach is empty, or that her gastric juices will have a pH greater than 2.5 (Johnson et al 1989) Fasting during labour does not guarantee an empty stomach should general anaesthesia become necessary: no time interval since the last meal can ensure a stomach volume of less than
100 ml. Nor can fasting during labour be relied on to lower the acidity of the gastric contents (Roberts & Shirley 1976)
Broach and Newton (1988), commenting on the fact that the delay in gastric emptying during spontaneous labour at term in low-risk women has not been demonstrated, state that it is the administration of narcotics that appears to be the major factor in delaying stomach emptying (Nimmo et al 1975, Holdsworth 1978). This would suggest that either other forms of analgesia should be considered or that oral intake of food should cease when narcotics are given (Grant 1990).
Fasting may result in dehydration and acidosis. Recently it has been argued that ketosis is a normal physiological response in labour (Anderson 1998). However, ketosis combined with starvation and fatigue, can lead to inefficient uterine action (Broach & Newton 1988) increase the need for active management ( Foulkes & Dumoulin 1985) and lead to
instrumental delivery (Grant 1990). There has been little published research into allowing nutrition in labour. A frequently cited study however, is that reported by Ludka (1987) from the North Central Bronx Hospital in New York. This was a hospital where women were allowed to eat and drink throughout normal labour as desired. In 10 years and throughout 20,000 births not one case of aspiration was noted. For a 6 month period the liberal practice was discontinued. During this time they had one case of maternal aspiration in a woman who had fasted for 36 hours: instrumental delivery increased by 35%: caesarian
section increased by 38%; the need for intensive care of newborns increased by 69% and the chemical stimulation of labour increased fivefold. It is also important to consider that the withholding food and drink in labour is very much a hospital practice: when women opt
for home confinement there is not such restriction (Baker 1996). As Odent (1994) points out, in the Netherlands where there is a high level of home delivery, caesarian section rate is below 10% and maternal mortality less than 1:10,000
As Baker (1996) suggests, there is insufficient evidence to support the practice of starving women in labour. While there are no risk factors suggesting the need for general anaesthesia, women who wish to eat and drink in labour should be encouraged to do so. Frye (1994) says that eating in labour allows the woman to feel normal and healthy, it keeps
her energy up and can minimalise complications caused by maternal exhaustion. The psycho-social aspect of fasting should also be considered. The provision of food and drink can be reassuring and comforting : denial can be seen as authoritarian and intimidating and
may increase feelings of apprehension. Simkin’s survey into new mother’s assessments of emotional stress associated with obstetric interventions found that 57% of those whose oral fluids were restricted and 27% of those whose oral intake of food was restricted reported
these practices to be ‘moderately’ or ‘most’ stressful ( in Broach & Newton 1988)
The desire to eat, however, would appear to be most common in early labour. As Odent (1994) points out, women do not usually wish to eat in active labour and it is inappropriate to be encouraging them to do so, against their natural instincts. This is another area in which we should be responding to what the woman feels and needs and allowing her to make the decision and take control (Department of Health 1993).
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