Policy or tradition: Oral intake in labour

POLICY OR TRADITION: ORAL INTAKE IN LABOUR

Myra Parsons, Midwife 7 Jodana Place, Castle Hill NSW 2154 emai[, [email protected]

ABSTRACT

fluids to better ensure an efficient tabour and improved maternal and fetal outcome leg., Chern-

Oral intake restrictions have varied over time and

Hughes, 1999; S[eute[ Et Golden, 1999).

around the world with written hospital policies for this issue often being non-existent. As there are differing views on this issue within hospitals overseas, a survey was conducted of 109 maternity units in New South Wales, Australia during early 2000 to identify the trends across the state. In New South Wales 81.7% of hospitals did not have a written policy for oral intake in labour. The remaining 18.3% had written policies which varied in their oral intake allowances from ice only to whatever women feel like eating and drinking. Of the 109 hospitals in this survey 60.5% leave food and fluid requirements to the individual woman's discretion, providing they have no increased risk of genera[ anaesthetic.

LITERATURE REVIEW The practice of fasting women during labour began in the mid-twentieth century when general anaesthesia was commonly used for vaginal births, forceps deliveries and caesarean sections (Kepp[er, 1988). Mendetson (1946) identified aspiration of acidic gastric contents during genera[ anaesthesia as responsible for the complication of aspiration pneumonia and recommended, among other things, a 'Nit By Mouth' policy for a[t labouring women. During the 1980s the avoidance of all but the ingestion of small amounts of clear liquids was recommended once labour was imminent (Basset[ ~t Marx, 1987). The policy of

INTRODUCTION

routinety withholding food and sometimes fluids during labour is now being questioned in many corners of the

What a labouring woman should or should not eat or

globe (e.g., Broach Et Newton, 1988; Etkington, 1991;

drink continues to be the subject of a debate which

Ludka Et Roberts, 1993).

began half a century ago (Mende[son, 1946). In the United States, the United Kingdom and Norway policies, written and verbal, vary from hospital to hospital with some restricting ora[ intake to ice chips throughout labour while others allow women to eat and drink as they desire (Baker, 1996; Michael, Rei[[y Et Caunt, 1991; Soreide, Ho[st-Larson, Et Steen, 1994). A written policy or guideline regardin 8 oral intake during tabour tends to be lacking in many maternity units with a verbal policy controlling this form of tabour management (Baker, 1996; Michael, Reitly ~t Caunt, 1991).

'Nil By Mouth' policies seem to have been replaced by 'clear fluid intake', especially for low-risk parturients, in recent years. This is in line with more recent research into gastric emptyin8 times and gastric pH levels for non-obstetric, elective, general anaesthetic patients. These studies have demonstrated that clear fluids empty rapidly from the stomach in these subjects (Schreiner r~ Nico[son, 1995; Sleute[ Et Golden, 1999; Sutherland, Davies Et Stock, 1985) and gastric pH is increased (Phillips, Hutchinson Et Davidson, 1993). Although pregnancy has no affect on gastric emptying it has been reported that advanced

6

The debate concerns two opposing points of view. One

tabour may cause some delay (O'Sullivan, 1994)

view is opposed to oral intake other than clear fluids for tow-risk labouring women as a strategy for

especially when narcotic analgesia has been used (Ewah, Yau, King, Reynolds, Carson, Et Morgan, 1992;

preventing the incidence of aspiration of gastric

Kelly, Carabine, Hill ~t Mirakheir, 1997; Wright, Allen,

contents should a genera[ anaesthetic be required leg., Boyle, 1997; Gibbs & Mode[[, 1994). The converse view

Moore Et Donnelly, 1992). These reports, however, do

is that women should have free access to food and

opposed to solids.

AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

not distinguish between gastric emptying of fluids as

THE CASE FOR RESTRICTING ORAL INTAKE

potassium with them. This decreases the blood pH and may be the cause of the relationship between ketonuna and prolonged labour (Ludka Et Roberts,

Pulmonary aspiration of gastric contents is one of the most feared complications during general anaesthesia

1993). Women allowed to eat during labour, however, have been found to have lower plasma ketone and non-

(Olsson, et at, 1986) although a rare event these days (Johnson, Keirse, Enkin, Et Chalmers, 1989). It is not

esterified fatty acids and higher glucose levels by the

that this catastrophe is more prevalent in parturients but that these women are usually young, fit and

permitted water (Scrutton, Lowy Et O'Sullivan, 1996).

end of first stage of labour than women who were only

undergoing what should have been a physiological

It is also believed that the restnction of oral intake

process (Seeley, 1987). Because the need for an

may effect the parturient psychologically by increasing

emergency caesarean section cannot always be

the perception of pain and reducing morale which in

predicted the restriction of oral intake during labour to

turn may adversely effect the progress of tabour and

'clear fluids' is seen to be one of a number of strategies implemented over the years aimed at

result in the snow-batting effect of medical intervention (Chern-Hughes, 1999). Long periods

preventing this catastrophe (Gibbs & Model[, 1994). An

without food is stressful and stress can lead to an

'empty' stomach, or rather a stomach with a volume

increase in circulating catechotamines which may

tess than 50 mrs, is seen as optimal in preventing

increase arterial pressure, increase blood flow to

regurgitated gastric contents being aspirated during general anaesthesia (Roche, Brock-Utne, Et Rout,

active muscles white decreasing blood flow to organs not needed for rapid activity, such as the uterus and

1993). Inhaled stomach contents containing

the placenta (Broach Et Newton, 1988; Guyton, 1986).

particulate matter have been shown to be far more

When circulating catechotamines increase they in turn

damaging to the lungs than non-acidic fluids (Schwartz,

cause an increase in metabolism and the body's

Wynne, Gibbs, Hood, Et Kuck, 1980). Hence, the

demand for glucose which ultimately has an effect on

preference for clear fluids or 'Nit By Mouth' during labour.

muscle strength, concentration and blood coagulation (Guyton, 1986). Fetuses of fasted mothers have been shown to have an overall reduced activity pattern

Adverse anaesthesia-related outcomes are rare today since strict safety procedures for thousands of patients

(Miller, Skiba, Et Ktaphotz, 1978; Richardson, Hohimer, Muegler, Et Bissonette, 1982).

have been implemented, including the restriction of oral intake for at[ labouring women (Sigurdsson E McAteer, 1996). From an anaesthetist's point of view there is little evidence that fasting labouring women is

The anaesthetist prefers the patient's stomach to be empty prior to induction of general anaesthesia, yet fasting does not guarantee an empty stomach (Miller,

harmful (Boyle, 1997) especially when intravenous

Wishart, Et Nimmo, 1983); gastric secretion associated

fluids can be used to compensate the oral intake

with hunger can be as high as 500 mrs per hour

restrictions (Sommer, Norr Et Roberts, 2000; Wasserstrum, 1992). However, Chern-Hughes (1999) believes that intravenous fluids cannot adequately compensate for the large caloric expenditure required

(Guyton, 1986). Even when labouring women have been fasted for many hours they should be assumed to have a full stomach of highly acid fluid when undergoing a general anaesthetic (Cheek Et Gutsche,

for labour and birth. Another consideration is the inherent risks of intravenous therapy for the mother

1987). Research has yet to demonstrate a relationship between oral intake and aspiration of gastric contents

and her fetus (Fisher Et Huddteston, 1997).

(Jacob, 1998; Michael, Re[fly, Et Caunt, 1991). Many believe more research should be directed towards anaesthetic technique for prevention of aspiration, or,

THE CASE FOR NOT RESTRICTING ORAL INTAKE

greater use of regional blocks for anaesthesia (Kruger Et Short, 1999; Oberoi Et Phillips, 2000).

For many labouring women the restriction of oral intake poses no problem as many do not want to eat but for those who are denied food when hungry it can

EVIDENCE-BASED PRACTICE FOR MIDWIVES

be a highly unpleasant experience (Enkin, Keirse, Renfrew Et Neitson, 1995). Prolonged abstinence from

This debate leaves midwives in a quandary; should

food is detrimental to the optimal nutritional state

they allow the intake of food and free fluids for low-

(Chapman, 1996) and may result in ketosis (Dumoutin Et Foutkes, 1984). When ketone bodies are excreted in the urine they take large quantities of sodium and

risk parturients in order to improve their labour outcomes or should they restrict oral intake to clear fluids or 'Nit By Mouth' just in case a general

VOL 14

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SEPTEMBER2001

7

anaesthetic is required. The basis of both arguments is 'the best outcome for the patient and fetus'. Despite evidence to suggest that fasting in tabour does not reduce the risk of acid aspiration and, in fact, is more likely to increase the risk, it is stilt recommended by some health professionals (Michael et al, 1991; Sharp, 1997). As Elkington eloquently stated:

Written policies or clinical guidelines regarding oral intake for tabour do not exist in many maternity units so staff oversee this form of labour management by word-of-mouth (Baker, 1996; Michael, ReiUy Et Caunt, 1991 ). Michael et al (1991) found in their survey of 351 maternity units in England and Wales in 1989 that 20.5% of units had no written policy regarding oral intake for women during tabour.

"There are no data demonstrating the medical relevance of any particular policy [regarding oral intake in labour] from a risk-reduction perspective ... these policies are the result of tradition rather than thoughtful decision. These policies may persist on the basis of anecdotal experience, institutional inertia to change policies begun in the 1940's, compromise with anesthesia department policy to ensure adequate coverage, exaggerated notions of risk, or fear of litigation" (Etkington, 1991, p.305).

In the United Kingdom between 1989 and 1997 the approach to orat intake changed dramatically. In 1989 Garcia Et Garforth's survey found that 86% of hospitals limited labouring women to ice chips or water throughout tabour while only 7% permitted food. By the second half of the 1990s very few hospitals in Britain restricted women to ice chips during labour, most hospitals encouraged clear fluids and over half 'allowed' food (McKay Et Mahan, 1988). A survey conducted of Norwegian hospitals in 1993 noted only

Midwives attempting to implement evidence-based

half the hospitals restricted food intake during labour

practice may find themselves restrained by entrenched

(Soreide, Holst-Larson, Et Steen, 1994).

hierarchies and institutional constraints (Walsh, 2001) which includes tightly-guarded traditional written or verbal policies. It has been suggested that the reason policies and protocols are being used by health professionals within health care systems, according to Mold and Stein (1986), is to place the responsibility for patient care on the institution rather than the individual practitioner. Although it is recommended that midwifery practice be based on written policies, there is little information regarding the content of the policies or on what information they are based (Garcia, Garford, Et Ayers, 1985). Anecdotally, many policies

Surveys of maternity units over the last decade in the United States regarding their policy for oral intake during labour have found that although oral intake is primarily limited to clear fluids, there are greatly varying policies from ice chips throughout tabour to a light diet and free fluids (Elkington, 1991; Hawkins, Gibbs, Martin-Salvaj, Orleans Et Beaty, 1998). Hawkins et al's (1998) very large survey found that hospitals with fewer deliveries allowed significantly more oral intake during the early phase of first stage labour. Because there is such variation in the oral intake

related to midwifery practice are verified and

policies overseas a survey was conducted to investigate

authenticated by statements such as, 'That's the way

the situation in New South Wales, Australia. The aim of

we've always done it', which has the effect of

this survey was to identify the current standing

dismissing any other option or suggestion (CaroseUi,

regarding oral intake for both low and high-risk

1995). Routine practice performed without question

parturients within maternity units in New South Wales.

does not justify its continued acceptance (Thomas, 1987). Policies are supposed to influence and inform good practice, not to deny choice (Report of the Expert

METHOD

Maternity Group, 1993). Many midwives do not have

A combined postal and telephone survey was

the necessary educational background to implement

conducted between December 1999 and January 2000

research findings (Lobiondo-Wood Et Haber, 1986), but

of all hospitals (n=156) in the state of New South

those who do are often prevented from practicing

Wales, Australia listed by the Australian College of

according to research evidence (Watsh, 2001 ) because

Midwives, New South Wales Branch Database. Of the

'it is not hospital policy'.

156 hospitals contacted 27 no longer have a maternity unit, therefore 129 hospitals were surveyed. A total of

POLICY OR TRADITION

109 hospitals responded giving a response rate of 85%. Only 95 (87%) of the surveyed hospitals have the

Herein ties two concerns. Firstly, the absence of a written

8

facilities to cater for women with high-risk

policy outlining the oral intake requirements for

pregnancies, the other 14 (13%) hospitals transfer all

labouring women and, secondly, the variations in written

women with high-risk pregnancies to their nearest

policy and traditional practice relating to the oral intake of labouring women within hospitals worldwide.

referral hospital. Information, therefore, for women

AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

with low-risk pregnancies was gathered from 109

hospitals, with 95 hospitals providin8 information for

RESULTS

women with hish-risk presnancies. Of the 109 surveyed hospitals 89 (81.7%) stated that they had no 'written' policy regarding oral intake for

INSTRUMENTS

labouring women, practice being based on 'verbal'

A questionnaire was developed specifically for the purpose of this survey and provided data regarding the presence of a written policy for oral intake in labour, the

policy, while 20 (18.3%) stated that they did have a written policy. The results are reported separately for women with

usual practice regardin8 oral intake for low and hish-risk

low- and high-risk labours. The policy regarding oral

parturients, the reason for any restriction of food and /

intake for low-risk parturients within 109 hospitals in

or fluids durin 8 labour, and the annual birth rate.

New South Wales is demonstrated in Table 1. Variations for oral intake practices also exist for women with high-risk pregnancies within the 95

DATA ANALYSIS

hospitals surveyed (see Table 2).

Data contained within the completed questionnaires were coUated and descriptive statistics derived.

TABLE 1 Hospital Policy for Oral Intake in Labour for women with LOW RISK Pregnancies within New South Wales, Australia POLICY

Hospitals with NO Written Policy n=89

Total No. of Hospitals N=109

Hospitals with a Written Policy n=20

Eat as Desired

50

(56%)

7

(35%)

57

(52%)

Fluids Only

7

(8o/o)

1

(5%)

8

(~)

Clear Fluids

12

(14%)

4

(z~)

16

(15%)

Ice and Water

7

(8~)

5

(25%)

12

(11%)

Ice Only

10

(11%)

1

(5%)

11

(10%)

MO's Decision

3

(3%)

1

(5%)

4

(4%)

Nil By Mouth

0

1

(5%)

1

(1%)

Percentages based on individual column sample size

TABLE 2 Hospital Policy for Oral Intake in Labour for women with HIGH RISKPregnancieswithin New South Wales, Australia

POLICY

Hospitals with NO

Hospitals with a

Total No. of

Written Policy n=78

Wntten Policy n=17

Hospitals N=95

Eat as Desired

3

(4%)

1

Fluids Only

11

(14%)

0

Clear Fluids

18

(23%)

Ice and Water

10

(13%)

Ice Only MO's Decision

7

(9%)

2

(3%)

Nil By Mouth

27

(3570)

(6%)

4 11

5

(29%)

23

3 3

(18%) (18%o)

13

1 4

(6%)

3

(24%)

31

10

(4%) (12%) (24%) (147o) (107o) (3%) (33%)

* Percentages based on individual column sample size

VOL 14

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SEPTEMBER2001

9

Of the 65 hospitals which allowed women to eat during

only one or two 'older' obstetricians who insisted on

labour, 38 had less than 500 births per year, 17 had

their patients being restricted to ice and water when

between 500 and 1000 per year, and 11 had greater

an epidura[ was in place. A 'Nil By Mouth' policy was

than 1000 births per year (4 of these having greater

in place in 33% of hospitals for those women with high

than 2000 births per year).

risk pregnancies with some, not all, being given

The majority of hospitals allowed low-risk parturients

intravenous therapy as a substitute.

to eat (59%). The majority of women with high-risk

Routine practices, which form the basis of midwifery

labours were either kept 'Nil By Mouth' (33%) or

care, vary widely from facility to faciUty. Restricting

permitted dear fluids, water, or ice only (51%) with a

oral intake during labour should be evidence-based

further 12% being permitted any fluids.

especially when these restriction are so severe (e.g. ice to suck) (Elkington, 1991) and may increase ketosis.

DISCUSSION

hungry during labour has the potential to contribute

tabour, whether written or verbat, varies among the

negatively to the woman's birth experience (Garcia, Garforth Et Ayers, 1985). Garcia et at (1985) noted

hospitats in New South Wales with 59% of hospitals

that although policies have their place in a maternity

attowing food during tabour for low-risk pregnancies,

unit, they can be restrictive, they need updating more

4% even encouraging women with high-risk

regularly and they should involve the cUnicai midwives

pregnancies, with no risk factors that may predispose

in their formulation. The midwife should also consider

them to a caesarean section, to eat and drink as they

the needs and wishes of the informed patient,

desire during their tabour. A number of these hospitals

individualising care according to the most current

provided food and snacks at the usual mealtimes (e.g.

research evidence.

breakfast, morning tea, etc.) allowing the women to

Despite the reintroduction of food and fluids during

consume whatever they feet they want.

The poticy regarding ora[ intake for women during

It is not known whether poUcies and protocols used

tabour in more and more hospitals during the past decade, the incidence of aspiration pneumonia has

within these institutions are research based (Smeltzer

decreased. This decrease can be attributed to the skit[

Et Hinshaw, 1993) or validated by tradition and

of the anaesthetists and the ongoing improvements in

subjective observations (Ludka Et Roberts, 1993). It was

anaesthetic drugs, techniques and practice

commonly acknowledged, however, that often once

(Department of Health, 1991, 1998; NHMRC, 1991,

tabour was established women were tess likely to eat and fluid consumption decreased as birth drew nearer.

1998). Skirted anaesthetic technique has been suggested to be the most important factor in avoiding

Often the meats provided were eaten by the partner

aspiration of gastric contents (Pengettey Et Gyte, 1998,

with the labouring woman only eating one or two

Sigurdsson E McAteer, 1996). Reduction in aspiration

mouthfuls of food. A few hospitals preferred the

incidents may also be attributed to midwives' ability to

women to only drink fluids during their tabour but if

identify risk factors which may predispose a woman to

food was requested by a woman it was given along

caesarean section and the practice of Umiting these

with a caution regarding the high tikeUhood of vomitin~

women to ice, sip of water or 'Nit By Mouth'.

in response to eating. This caution, however, does not

Further research is needed to investigate the tabour

seem to have any research basis. Four hospitals

and birth outcomes for women who are 'allowed' to

reported that low-risk women were only permitted ice

eat as desired throughout their tabour. A prospective,

to suck during labour. Smatter hospitals with fewer

observational study is being conducted at four

births, particularly those which did not cater for

hospitals in Sydney, Australia, to examine this issue.

women with high-risk pregnancies, were found to allow significantly more oral intake during the first stage of

10

For some women, being refused nourishment when

labour than larger hospitals; this is consistent with the

CONCLUSION

study by Hawkins eta[ (1998) in the United Kingdom.

This paper reported the current standing of oral intake

Variations of opinion also occur among hospitals

for labouring women within New South Wales.

catering for women with high-risk pregnancies (Table

Controversy exists in New South Wales, as it does in

2). Three hospitals allowed women to eat as desired

United Kingdom, United States, and Norway, as to what

unless caesarean section was definite. One hospital

labouring women should and should not eat or drink.

reported that women with an epidura[ block during labour were permitted to eat as desired by the anaesthetists. According to one respondent, it was

More and more hospitals are aUowing tow-dsk women

AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

to choose what they feel they need in the way of nourishment during their tabour rather than simply

following a traditional, and sometimes non-researched 'hospital policy'. If unrestricted oral intake has a positive effect on labour progress and maternal and

Enldn, M., Keirse, M.J., Renfrew, M., Et Neilson, J. (1995) A Guide to Effective Care in Pregnancyand Childbirth, 2nd edn. Oxford Medical, Oxford.

neonatal outcomes then all women, who are not a general anaesthetic risk, should have free access to food and fluids during labour. However, research to date, although providing a wealth of information to support a more lenient approach to the parturients

Ewah, B., Yau, K., King, M., Reynolds, E, Carson, R. J. Et Morgan, B. (1992) Effect of epidura[ opoids on gastric emptying in labour. International Journal of Obstetric Anesthesia. 2 125-128.

oral intake debate, has not provided substantial evidence with which to change practice. Therefore, further research is needed to investigate the safety and efficacy of feeding low-risk parturients so that policies and practices may be more soundly based.

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Soreide, E., Ho[st-Larsen, H., ~ Steen, RA. (1994) Acid aspiration syndrome prophylaxis in gynaecolo~ca[ and obstetric patients. A Norwegian Survey. Acta Anaesthesiolegica Scandinavica. 38 863-868.

Pengeltey, L., Et Gyte, G. (1998) Eating and drinking in labour (I). A Summary of medical research to facilitate informed choice about the care of mother and baby. The Practising Midwife. 1(7/8) 34-37. Phillips, S., Hutchinson, S., F, Davidson, T. (1993) Preoperative drinking does not affect gastric contents. British Journal of Anaesthesia. 70 6-9. Report of the Expert Matemity Group. (1993) Changing Childbirth. OHMS,London. Richardson, B., Hohimer, A.R., Muegg[er, R, ~t Bissonette, J. (1982) Effects of glucose concentration on fetal breathing movements and electrocortica[ activity in feta[ iambs. American Journal of Obstetrics F, Gynecology. 142(6 Pt 1) 678-683. Roche, D.A., Brock-Utne, J.G., ~t Rout, C.C. (1993) At risk for aspiration: New criUca[ values of votume and pH. Anesthesia Et Analgesia. 76(3) 666. Schreiner, M.S., & Nico[son, S.C. (1995) Pediatric

12

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AUSTRALIAN COLLEGE OF MIDWIVES INCORPORATED

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