Effect of Food Intake During Labor

There is an ongoing international debate about food consumption during labor. The current rationale for women fasting during labor is to protect them from pulmonary aspiration should general anesthesia be needed for an emergency cesarean delivery. Other concerns include increased cesarean rate (Scheeper, 2002) or prolongation of labor (Tranmer, 2005) should women be allowed to eat while laboring.

On March 24, 2009 the British Medical Journal published a well-done randomized controlled trial (O'Sullivan, 2009) of over 2000 women suggests we should revisit current practices of not allowing women to eat while in labor.

Historical perpective:
1946: CL Mendelson published a paper in The American Journal of Obstetrics and Gynecology (1946) entitled: The aspiration of stomach contents into the lungs during obstetric anesthesia. Mendelson described acid pulmonary aspiration and an increase in maternal death due to choking if women consumed solid food while in labor and needed a cesarean delivery.

2007: The American Society of Anesthesiologists published obstetric guidelines stating that "the oral intake of solids during labor increases maternal complications....solid foods should be avoided in laboring patients and that the oral intake of modest amounts of clear liquids (e.g. water, clear tea, black coffee and sports drinks) may be allowed for uncomplicated laboring patients."

Recent advances in intrapartum care (e.g. increased use of epidural anesthesia, antacids and better training of obstetric anesthetists) have caused a dramatic decline in pulmonary aspiration.

Some countries now challenge the practice of mandatory fasting for all laboring women - more so in Europe than in the United States.


O'Sullivan study:

• This study was performed in a London hospital between June 2001 and April 2006.
• 2426 women were randomized to eating vs. water-only group.
• All women were experiencing their first delivery.
• Primary outcome was the rate of spontaneous vaginal delivery.
• Secondary maternal outcomes included the duration of labor, use of IV oxytocin, use of inhaled or epidural analgesia.
• Secondary neonatal outcomes included fetal weight, Apgar scores and admission the the neonatal intensive care unit.
• Women in the eating group were advised to consume a low fat, low residue diet at will during labor. Suggested foods included fruits and vegetables, breads, soup, low fat yogurt, fruit juices and sports drinks.

Results:

• No difference in vaginal delivery vs. cesarean delivery rate between the two groups (30% cesarean delivery rate in both groups).
• No difference in length of labor.
• No difference in Apgar scores or admission to the neonatal ICU.
• No cases of aspiration pneumonia (However, because aspiration is so rare, a much larger study would have been needed to see one case.)
• One maternal death occurred in the water-only group due to a brain hemorrhage.

Interpretation:

• Feeding in labor does not increase or decrease risk of cesarean delivery.
• Feeding in labor does not shorten or lengthen labor.
• Obstetrical and neonatal outcomes are not altered based upon whether women are allowed to eat during labor.
• Some clinicians may decide, in low risk laboring women, that the consumption of a light diet could be left to the woman's discretion.

Side note:
The UK Confidential Enquiries into Maternal and Child Health reviewed 2,113, 831 deliveries between 2003-2005. Six anesthesia-related deaths occurred, none of which was associated with pulmonary aspiration. Similar findings were reported by the Australian Anesthesia Incident Monitoring Study. This supports the statement that aspiration pneumonia is exceedingly rare.

References:

1. O'Sullivan G, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ 2009;338:b784

2. American Society of Anesthesiologist’s Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia. Anesthesiology 2007;106:843-63.

3. Mendelson CL. The aspiration of stomach contents into the lungs during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.

4. Scheepers HCJ, Thans MCJ, de Jong PA, Essed GG, Le Cessie S, Kanhai HH. A double-blinded randomised, placebo controlled study on the influence of carbohydrate solution intake during labor. Br J Obstet Gynecol 2002;109:178-81.

5. Tranmer JE, Hodnett ED, Hannah ME, Stevens BJ. The effect of unrestricted oral carbohydrate intake on labor progress. J Obstet Gynecol Neonatal Nurs 2005;34:319-28.

6. Lewis G, ed. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer—2003-2005. The seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: CEMACH, 2007.