Food and Drink in Labor - Essay Example

Evidence Based Practice - Food and Drink in Labor Introduction Though many nursing interventions during birth and labor are mainly based on physician orders, some care processes are within the realm of nursing and sometimes has descended as tradition (Simpson, 2005). One such tradition is restriction of fluid and solid intake during labor. The practice of oral and liquid intake during pregnancy is not same in all parts of the work. While in some places, fluid restriction is very rigid, in other places, moderate intake of food and drink is allowed. In yet some other places, women are allowed to drink and eat whatever they want during labor. Many clinical centers, especially those which involve midwives for deliveries, are currently implementing policies that encourage and allow the pregnant woman in labor to drink and eat what she likes (Ludka and Roberts, 1993). Adherence to historical starvation of pregnant women in labor continues to be practiced because of anesthesia related deaths and aspiration pneumonitis, in case the woman lands up with a Cesarean section (Maharaj, 2009). Whether to give food and drink during labor is a much debated topic and for appropriate clinical practice, evidence based approach is necessary. According to WHO (cited in Sharts-Hopko, 2010), during labor, women's drinking and eating should not be interfered by health care providers, especially when there are no definite risk factors. Evidence based practice is essential to deliver the most appropriate treatment. While looking for evidence from research articles, those with higher levels of hierarchy have better level of evidence. In this essay, whether or not to allow food and drinks during labor will be ascertained by reviewing suitable literature. Aims and objectives The aim of this literature review is to evaluate studies pertaining to food and drinks during labor and to derive implications for practice. Methodology The commencement of search in electronic databases was based on the inclusion/exclusion criteria and knowledge of the hierarchies of evidence. Research articles were retrieved from electronic databases based on the terms “diet” or “food and drink” or “oral intake” or “starvation” and “labor”. Several articles were displayed. In order to consider what research articles must be included in the literature review to make the review more reliable, authentic and evidence based, it is important for the reviewer to have an optimum knowledge on the different levels of the accorded studies, also known as hierarchy, which provides a certain degree of confidence measure in the end-user (Evans, 2003). The gold standard for any evidence based practice are randomized controlled trials which when performed with optimized research designs can answer pertinent questions. However, meta-analysis and systematic review have topped the hierarchy list and when present, they are preferred to randomized controlled trials. Review Eating and drinking during labor is a controversial topic with different types of practice by different practitioners (O'Sullivan et al, 2009). As early as 1931, the popular text book of Obstetrics stated that "“the patient should be encouraged to take light food during the first stage of labor" (cited in Downe, 2009). However, in 2000, another obstetrics text book Guide to Effective Care in Pregnancy and Childbirth noted that “that food and drink should be withheld once labor has commenced is almost universally accepted in hospital care” (cited in Downe, 2009). According to the CDC (2007; cited in O'Sullivan et al, 2009), 31 percent of all births are through cesarean section in the United States. Of these, only 10 percent receive general anesthesia on an emergency basis (McDonald & Yornell, 2006; cited in O'Sullivan et al, 2009). Also, in those who receive anesthesia, deaths related to anesthesia occur only in 1.6 per million live births and these also occur because of difficulty in intubation (Chang et al., 2003; cited in O'Sullivan et al, 2009). Guidelines by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia (2007; cited in O'Sullivan et al, 2009) include "restriction of oral intake to small amounts of clear liquids for women at low risk up to 2 hours before anesthesia; further restriction for women with identified risk factors for aspiration include morbid obesity, diabetes, a difficult airway or a non-reassuring fetal heart rate pattern; and the avoidance of solid foods." Those who are posted for elective Cesarean section are advised to remain fasting for 6- 8 hours prior to surgery as a measure to prevent aspiration. However, recent guidelines by the American Congress of Obstetricians and Gynecologists (2009; cited in O'Sullivan et al, 2009 recommends intake of liquids that are clear). The American College of Nurse-Midwives (2008; cited in O'Sullivan et al, 2009) advises that women who are at minimal risk for aspiration must be allowed to take diet and drink as they wish. Even the World Health Organization recommends ad lib intake of food and water for the purpose of replenishment of energy, thus ensuring well being of the baby and the mother. Some researchers and experts actually opine that starvation in pregnancy is detrimental both both to the mother and the baby and also the progress of the labor (O'Sullivan et al, 2009). The main reason why food and drink intake is restricted is because epidural opioids delay gastric emptying which can increase the risk of aspiration. There is mounting evidence, actually to ascertain the benefits of fluid intake during labor. But there is not enough evidence to suggest increased risk of aspiration due to it (Maharaj, 2009). Only through research is it possible to ascertain whether restriction of fluids and food during labor is justified or not. Issues related to intake of food and drinks during delivery are risk of aspiration of the gastric contents in case women require administration of general anesthesia for Caesarean section, energy requirements of the woman in labor, effect of ketosis on the mother and the baby, excess intake of fluids that are hypotonic and their effect on hyponatremia, stress involved in being nil per mouth, discomfort due to limitation of movement related intravenous line, maternal vomiting due to oral intake and impact of oral intake on duration of labor and fetal outcomes. While most randomized controlled trials in this regard have demonstrated no negative implications with taking food and drink during labor, one interesting trial, a randomized controlled one opined that women who consumed food and drink during labor had longer labor hours. However, no other negative effects were noted in this study (O'Sullivan et al, 2009). O'Sullivan et al (2009) conducted a prospective randomized controlled trial in which the researchers evaluated the effect of taking light diet during labor on implications for spontaneous normal delivery. The main outcome measured was rate of spontaneous delivery. Secondary outcomes that were measured were need for augmentation of labor, duration of labor, rates of instrumentation application need, rate of Caesarean section, vomiting incidence and neonatal outcomes. Only women with no-risk pregnancy were recruited. From the results of the study it was evident that the rate of spontaneous delivery was same in both the study and control group. Even in the secondary outcomes, no clinical differences were observed. This study proved that consumption of light diet during pregnancy does not adversely affects the outcomes of pregnancy and also does not cause any complications whatsoever. In a study by O'Reilly and others (1993), the researchers examined oral intake patterns in low risk pregnant women in labor In this study, 106 women were studied and when they were allowed to eat and drink whatever they wanted, they chose varieties of food and drink during labor. 80 percent of these women did not have any emesis after eating and drinking. Of those who vomited, 40 percent vomited more than once. From this, it is clear that those who did not have any foot or drink restriction during labor were not at much risk of vomiting. Thus, it is not justifiable to curtail on drink and food for women in labor. Sleutel and Golden (1999) evaluated scientific literature to ascertain evidence and justification on eating and drinking during labor. They conducted a systematic review on articles retrieved from electronic databases. In their review, not much information was provided with regard to impact of food and drink on the progress of labor, outcomes of birth and status of the neonate. There is also little evidence about nutritional requirements of women in labor, effects of epidural opioids on the gastric emptying and physiological implications of fasting during labor. Singata et al (2010) conducted a systematic review to ascertain the benefits and disadvantages of food and food restriction in labor. From their review, it was evident that such a practice neither caused any benefit nor caused any harm and hence there was no sufficient justification for the practice. Their review did not find any studies which looked into implications in those with high risk pregnancy and increased risk of complications and hence there is no evidence to support restriction of food and drink in this population. the review however, opined that some conflicting evidence regarding the intake of carbohydrate solutions exist and further research is warranted to ascertain the role of these in labor. On interesting feature noted in all the studies was that the views of the women in labor was not taken into account. Also, from the pooled data, there was not enough evidence to ascertain the incidence of gastric aspiration in relation to food and drink intake. It is recommended that nurses working in intrapartum centers be encouraged to work in teams which are multidisciplinary and revise policies that causes unnecessary restriction of oral intake during labor in women with low-risk pregnancy. O'Sullivan et al (2009) conducted a prospective randomized controlled trial in which the researchers evaluated the effect of taking light diet during labor on implications for spontaneous normal delivery. The main outcome measured was rate of spontaneous delivery. Secondary outcomes that were measured were need for augmentation of labor, duration of labor, rates of instrumentation application need, rate of Cesarean section, vomiting incidence and neonatal outcomes. Only women with no-risk pregnancy were recruited. From the results of the study, it was evident that the rate of spontaneous delivery was same in both the study and control group. Even in the secondary outcomes, no clinical differences were observed. This study proved that consumption of light diet during pregnancy does not adversely affects the outcomes of pregnancy and also does not cause any complications whatsoever. From these studies, it is evident that intake of oral diet and drink during labor does not impact maternal or fetal outcomes, or the course of labor and thus there is no justification Conclusion Practice with respect to food and drink intake during labor is a varied and a much debated topic. While traditionally and historically, starving during a labor is a common practice, the WHO has advised against such a practice and suggested non-interference with food and drink intake of women during delivery. The current review of literature has not demonstrated any evidence to prevent women in labor from eating and drinking during pregnancy. The risk of complications like aspiration pneumonia is very low and insignificant. On the other hand, intake of food and drink provides energy to the mother and the baby, allows mobility of the mother and decreases stress and distress. References Downe, S. (2009). Eating a light diet during labour. BMJ, 338:b732. Evans, D. (2003). Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing, 12(1), p. 77 – 84. Ludka, L.M., and Roberts, C.C. (1993). Eating and drinking in labor. A literature review. J Nurse Midwifery, 38(4), 199-207. Maharaj, D. (2009). Eating and drinking in labor: should it be allowed? Eur J Obstet Gynecol Reprod Biol., 146(1), 3-7. O'Reilly, S.A., Hoyer, P.J., Walsh, E. (1993). Low-risk mothers. Oral intake and emesis in labor. J Nurse Midwifery, 38(4), 228-35. O’Sullivan G, Liu B, Hart D, Seed P, Shennan A. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ2009;338:b784. Sleutel, M., and Golden, S.S. (1999). Fasting in labor: relic or requirement. J Obstet Gynecol Neonatal Nurs., 28, (5), 507-12. Simpson, K.R. (2005). The context & clinical evidence for common nursing practices during labor. MCN Am J Matern Child Nurs., 30(6), 356-63. Singata, M., Tranmer, J. & Gyte, G.M.L. (2010). Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews (1), CD003930. doi:10.1002/14651858.CD003930. Sharts-Hopko, N.C. (2010). Oral intake during labor: a review of the evidence. MCN Am J Matern Child Nurs., 35(4), 197-203. Read More