Restricting Food and Fluid in Labor May Not Be Helpful

Published by MedScape
Author: Laura Barclay

January 20, 2010 — Restricting food and fluid intake during labor may not be helpful or necessary for women at low risk for complications, according to the results of a systematic review reported online January 20 in the Cochrane Database of Systematic Reviews.

"Since the evidence shows no benefits or harms, there is no justification for nil by mouth policies during labour, provided women are at low risk of complications," lead author Dr. Mandisa Singata, from the East London Hospital Complex in East London, South Africa, said in a news release. "Women should be able to make their own decisions about whether they want to eat or drink during labour, or not."

The authors note that in many birth settings, fluid and food restriction during labor are common and that some women are only permitted sips of water or ice chips. These restrictions may adversely affect the experience of labor for some women.

The goal of this review was to evaluate the benefits and harms of oral fluid or food restriction during labor. The reviewers searched the Cochrane Pregnancy and Childbirth Group's Trials Register through April 2009 for randomized controlled trials and quasi-randomized controlled trials of fluid and food restriction for women in labor vs women permitted to choose what they ate and drank. Two reviewers independently evaluated the studies to see if they met selection criteria, determined risk for bias, and extracted data.

Five trials were identified, enrolling a total of 3130 women, all of whom were in active labor and at low risk of potentially requiring a general anesthetic. One study looked at complete restriction vs liberty to eat and drink as desired, 2 studies compared water only vs specific fluids and foods, and 2 studies compared water only vs carbohydrate drinks.

The meta-analysis was dominated by 1 study performed in a highly medicalized environment. No statistically significant differences were found in cesarean deliveries (average risk ratio [RR], 0.89; 95% confidence interval [CI], 0.63 - 1.25; 5 studies; n = 3103), operative vaginal births (average RR, 0.98; 95% CI, 0.88 - 1.10; 5 studies; n = 3103), Apgar scores of less than 7 at 5 minutes (average RR, 1.43; 95% CI, 0.77 - 2.68; 3 studies; n = 2574), nor in any of the other outcomes examined.

The pooled data were not sufficient to determine the incidence of Mendelson's syndrome, nor were women's views evaluated. One study did show a significant increase in cesarean deliveries for women drinking carbohydrate solutions vs water only, but the sample size was small.

"While it is important to try to prevent Mendelson's syndrome, it is very rare and not the best way to assess whether eating and drinking during labour is beneficial for the majority of patients," Dr. Singata said. "It might be better to look at ways of preventing regurgitation during anaesthesia for those patients who do require it."

Limitations of this study include domination of the meta-analysis by a single study, failure to assess women's views, and potential bias in the review process.

"Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications," the review authors conclude. "No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. Conflicting evidence on carbohydrate solutions means further studies are needed and it is critical in any future studies to assess women’s views."

See multiple professional views regarding this new recommendation on Newsy.com

Induction for Pregnancy-Induced Hypertension and Preeclampsia After 36 Weeks Gestation

In a recent article published on line by the Lancet, there is now evidence to support induction of labor after the 36th week of pregnancy if a woman develops pregnancy-induced hypertension (PIH) or mild preeclampsia.

Study design: This multi-centered, parallel, open label, randomized study (HYPITAT) was conducted in the Netherlands. Koopman, et al recruited 756 women who presented with PIH or mild preeclampsia between the 36th and 41st weeks of pregnancy. 379 patients were expectantly monitored and 377 underwent labor induction. Another 397 women were approached to join the study and declined, but allowed their medical information to be utilized for the purposes of the study.

Question: Is it better to intervene to avoid serious complications? Which group fairs better of those women who are diagnosed after 36 weeks gestation with new-onset high blood pressure or mild pre-eclampsia: Those whose labor is induced or those who are observed?

"Serious complications" included eclampsia (seizures), HELLP syndrome, pulmonary edema, thromboembolic disease, placental abruption, severe hypertension, proteinuria or postpartum hemorrhage.

Findings: 31% of women whose labor was induced developed severe complications while 44% of those not induced developed severe complications. The findings were statistically significant.

(Relative risk 0.71, 95% CI 0.59-0.86, p<0.0001)

Implication: When a woman develops hypertension or mild preeclampsia after 36 weeks' gestation, labor induction will decrease her risk of developing severe complications by 30%.

Comment: In general, we are trying to limit labor inductions in the United States. ACOG has recently issued a Revision of Labor Induction Guidelines. However, when a woman develops hypertension or mild preeclampsia after the 36th week of pregnancy, it appears safer to induce her labor rather than await more serious complications to evolve.

Reference:
Koopmans CM, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial. Lancet, 2009;374(9694):979-88