Food intake in labour: the benefits and drawbacks

VOL: 98, ISSUE: 21, PAGE NO: 42

Sue Speak, RGN, RM, is clinical midwifery manager, delivery suite, Airedale General Hospital, Airedale NHS Trust, Keighley, West Yorkshire

To prevent this occurring, Mendelson made the following recommendations for managing women in labour:

• Women should not eat or drink during labour;
• If required, energy should be provided intravenously;
• Local anaesthesia should be the preferred method;
• The woman’s stomach contents should be made alkaline not acidic;
• Anaesthesia should be administered by specialists.

However, Elkington (1991) and Ludka et al (1993) claim that there is a lack of evidence to support constraining practices. This paper analyses the benefits and hazards of withholding food and fluids from women in labour.

Historical context
Over the centuries, attitudes to women in labour eating and drinking have differed. Hippocrates recommended that prolonged third-stage labour be treated with a mixture of dried placenta, stallion testicle and urine from the husband (Broach et al, 1988). Chinese, Thai and pre-1600 Mexican cultures encouraged the use of herbal remedies and food to heat up the woman’s body and strengthen the contractions (Broach and Newton, 1988). In 1904, an American doctor recommended that women should be encouraged to drink in labour, and he suggested wine, strychnine, coffee and tea to preserve strength for the ordeal of the delivery (Pengelley and Gyte, 1996).

Current research
Crawford (1984) recommends a low fat and high-fibre diet for women at low risk of inhalation during labour. Ludka (1987) supports this, claiming that in The Netherlands women in labour are encouraged to eat and drink freely. Wesson (1990) suggests that restricting food and drink could be why women in the UK opt for home births. Frye (1994) encourages midwives to advise women to eat during labour, but Odent (1994) argues that a woman’s nutritional needs during labour are too complex and suggests that midwives should not make such recommendations.

Confidential inquiry into maternal deaths
Mendelson’s approach to withholding food and drink from women during labour persists in many UK hospitals. The number of women dying from aspiration pneumonia is falling (Department of Health, 1989). The Confidential Enquiry into Maternal Deaths in England and Wales reported that in 1970-1972, 14 women died of Mendelson’s syndrome. A later report (DoH, 2001) found that in 1997-1999 only one woman died of it.

The drop could be attributable to the earlier inquiry’s recommendations for the use of local anaesthesia during childbirth, having experienced anaesthetists in the delivery suite and advances in anaesthesia.

The reports do not comment on whether women should be allowed to eat and drink during labour (Pengelley and Gyte, 1996). Past recommendations from the DoH (1989), however, have advised a nil-by-mouth policy, effectively advocating Mendelson’s recommendations. Lewis (1991) challenges midwives to become the guardians of women, rather than supporting doctors’ wishes that all women should fast. Nowadays women, midwives and doctors are all questioning Mendelson’s guidelines.

Intervention
If a woman neither eats nor drinks during labour her body will need to compensate for the lack of energy. This will often lead to a slowing down of labour and increase the need for intervention. This may involve the use of oxytocin to speed up labour, be it a vaginal birth, an assisted delivery (using forceps or ventouse, a vacuum extractor intervention) or a Caesarean section.

There has been little research into this area but three studies stand out. Haire (1986) carried out a large study in New York and found that the rates of Caesarean section and instrumental delivery were higher when women were denied food. As a result, the policy of not allowing women to eat and drink during labour was reversed.

Yiannouzis (1994) found that women who ate had a slightly longer labour. However, the women commented that they liked being offered the choice of whether or not to eat. Newton and Champion’s Nottingham study (1997) also reported that women appreciated having the option of eating and drinking, even if they did not exercise it.

Gastric motility
Gastric motility is the movement of food and fluids from the stomach to the intestinal tract for absorption and further digestion. The effects of labour on gastric motility are not well documented. Mendelson (1946) argued that during labour the stomach empties more slowly than it does normally. But this has since been disputed, with evidence to suggest that gastric motility is reduced as a result of apprehension, pain, exhaustion and the use of narcotic drugs (Crawford, 1978).

Ketonuria and treatment
Yiannouzis (1994) argues that not allowing women food during labour causes stress, especially if she is hungry and thirsty. Simplin (1986) supports this, arguing that an increase in adrenaline and noradrenaline levels affects the labour and the baby through a longer labour, owing to decreased efficiency of the uterine contractions, which may in turn adversely affect fetal heart rate and increase the need for medical intervention. Winkler et al (1939) supported the supposition that ketonuria leads to prolonged labour, claiming that the accumulation of ketones reduces the efficiency of uterine activity.

Research suggests that ketonuria in the later stages of pregnancy could be normal (Keppler, 1988; Anderson, 1998). Keppler (1988) further claims that ketones in labour are not harmful and may provide energy for all types of muscles. Dumoulin and Foulkes (1984) support this, saying that ketonuria may occur in normal labour. Although the research points to a link between ketonuria and prolonged labour, it does not clarify which is the cause and which the effect (Dumoulin and Foulkes, 1984).

Odent (1994) believes comparisons between athletic endurance and labour are inappropriate, as women in labour are not using skeletal muscles but smooth uterine muscle. The argument is that if labour is progressing well, adrenaline levels are low and the skeletal muscles are relaxed, there is little need for glucose for energy, unlike a marathon runner whose adrenaline level is high.

To counteract ketosis during labour Mendelson (1946) recommended the use of intravenous glucose, which remains part of the treatment for ketonuria in labour (Broach and Newton, 1988). The rationale for using IV therapy, according to Pengelley and Gyte (1996), is that it allows the continuing metabolism of glucose as a main energy source that in turn may limit fat metabolism and subsequently restrict the production of ketones.

Dumoulin and Foulkes (1984) argue that it is not necessary to use IV therapy in the first 12 hours of labour regardless of whether ketonuria is present, as it is a physiological condition. Labour suites are often hot and women perspire as a result of their exertions. If fluid is withheld, a woman may become dehydrated and need an IV infusion (Pengelley and Gyte, 1996).

Fluid overload in labour can cause significant harm as a pregnant woman already carries 7-10L more fluid than usual. It can cause cerebral oedema, leading to fits and coma. Many authors urge careful management of fluid intake in labour but there is a lack of published data on the nutritional requirements of women in labour (Enkin et al, 2000). However, IV therapy is widely used to counteract ketonuria.

Newton et al (1988) argue that intravenous feeding in labour can cause unnecessary discomfort, making the woman and her carers view her as a patient. The researchers also stress that it inhibits breastfeeding after birth, and question the value of IV therapy as a source of nutrition. However, forcing women in labour to eat may be detrimental because elevated ketone and free fatty acid plasma levels in fact benefit the progress of labour (Scrutton et al, 1996).

Implications for practice
The most appropriate care, according to research, is to give women in labour the choice of whether to eat or not. Women continue to be treated inappropriately which, in the current climate of evidence-based care, is indefensible. The management of women in labour should not continue to be based on guidelines dating from 1946. In practice, the decision on whether to allow a woman food or drink in labour depends solely on an individual professional’s opinion. More research is required to enable midwives to base care on appropriate and up-to-date evidence.

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