The management of the oral intake of parturients seeks to provide adequate hydration and nutrition while maintaining safety for mother and baby. How to achieve this balance remains a controversial subject within midwifery, obstetric, anaesthetic and consumer groups. With a variety of models of care for parturients coordinated by midwives, obstetricians, and general practitioners, oral intake even within a single birth unit can vary from strict nil by mouth protocols to full diet throughout labour. Surveys from the UK, USA and Australia demonstrate the wide variations in policy and practice for oral intake in labour (Hawkins et al 1998; Michael et al 1991; Parsons 2001). Some of the concerns are that fasting may lengthen labour, increase medical intervention and compromise birth outcomes. In this context and with improvements in clinical anaesthesia, including an increase in the use of regional techniques, a recent obstetric editorial has questioned whether we should “permanently retire the outdated nil by mouth policy” (Young 2007). However, since the first reports by Mendelson (1946, Level IV), anaesthetists’ concerns have been with the prevention of aspiration and the associated maternal morbidity and mortality as a major priority.

Fortunately, aspiration pneumonitis causing significant morbidity or mortality is an uncommon occurrence. The subject does not lend itself to rigorous investigation by randomised controlled trial since meaningful trials would require prohibitively large numbers and also probably be unethical because of the outcomes involved. Much of our best evidence therefore emerges from mortality reports and the investigation of surrogate outcomes such as the measurement of gastric volumes and metabolic markers in labour. As the evidence is sparse many possible interpretations emerge, as does the possibility of misinterpretation. The priority must always be to attempt to deliver the safest anaesthetic care while balancing all relevant risks.

This document deals with oral intake during labour. The related specific issues of antacid prophylaxis prior to anaesthesia and the details of anaesthetic technique during pregnancy and in the peripartum period are covered elsewhere. Also, the use of prophylactic drugs routinely in normal labour to reduce gastric aspiration is not covered, although it is worth noting that this has been the subject of a recent Cochrane systematic review (Gyte & Richens 2006, Level I). Whilst this analysis found no evidence to support this practice the rare outcomes of maternal mortality and significant morbidity render this analytical approach somewhat problematic.

1. MORTALITY AND MORBIDITY FROM ASPIRATION

An appropriate clinical risk-management strategy is to identify the population most at risk and those factors which are likely to be associated with adverse outcomes. In this regard, all pregnant women must be considered to be at some risk of requiring anaesthetic intervention. Outcomes recorded in birth centres caring for even low risk pregnancies where all women were allowed to eat and drink as they desired have shown 15.4% required transfer to another hospital and 4.4 % required caesarean delivery (Rooks et al 1989, Level IV). Risk of aspiration is a function of those factors which influence gastric volume and pH, opioid effects, the experience and expertise of the anaesthetist managing the airway, as well as maternal obesity (Lewis 2007; McClure & Cooper 2005).

1.1 Incidence

The incidence of aspiration has changed over recent decades and is now rare. In this context, attempts at stating a specific incidence and defining possible underlying factors are problematic. As a starting point it is widely accepted that parturients are at increased risk from aspiration of gastric contents secondary to hormonal and mechanical factors. Other risk factors for aspiration include the presence of food and opioid analgesia in labour (Murphy et al 1984, Level III-2; O’Sullivan 1987, Level III-2; Wright 1992, Level II). Loss of consciousness and sedation contribute to these risks. The National Sentinel Caesarean Section Audit showed that 1 in 29 women (3.4%) having caesarean section in England and Wales were unconscious during childbirth (Thomas & Paranjothy 2001).

Mendelson first reported maternal death and severe morbidity due to aspiration of stomach contents under general anaesthetic in 1946 (Mendelson 1946, Level IV). This sentinel paper highlighted that there is an increased risk of aspiration of both solids and liquids into the lungs during obstetric anaesthesia. In a series of 44,016 pregnancies, 45 patients aspirated either solid or liquid stomach contents (approximately 1:1000); all had received general anaesthesia. Two deaths were recorded which resulted from obstruction through aspiration of solid material. Significant morbidity was additionally recorded in 40 patients who became “critically ill” from aspiration of liquids. They developed pyrexia, asthma-like symptoms, cyanosis, tachycardia, dyspnoea and expiratory wheezing. Two patients developed pneumonia and two developed lung abscess. This retrospective observational series highlighted firstly the impact of solid material obstruction of the airway and secondly the dangers of fluid aspiration.

Aspiration, when it occurs, remains an important cause of death and morbidity. In the US between 1979 and 1990, 23% of maternal deaths were found to be due to aspiration (Hawkins et al 1997, Level IV). Some of the most useful data come from the UK maternal mortality triennial reports (now identified as CEMACH) which in various forms go back to the 1950s (McClure & Cooper 2005). These reports continue to highlight airway problems which frequently precipitate pulmonary aspiration as the commonest causes of anaesthetic death in mothers. In addition, American Society of Anesthesiologists closed claims data identify aspiration pneumonia as the cause of maternal injury in 6% of obstetric files compared to 2% of non-obstetric files reviewed (Chadwick et al 1996, Level IV).

Over the last 50 years, the introduction of several measures designed to reduce the risk of aspiration have been associated with a profound effect in reducing mortality from aspiration of which the control of oral intake is but one. Fasting in labour, antacid premedication, cricoid pressure, intubation with cuffed endotracheal tubes and popularisation of regional anaesthesia have all been identified as contributing to the dramatic fall in maternal mortality (Cooper et al 2002), although it is acknowledged that specific definitive randomised controlled trials of appropriate power are currently lacking. This latter consideration has in some cases encouraged units to implement contrary changes in clinical practice in the absence of positive supportive evidence. Hence, there has been a recent liberalisation of policies for oral intake during labour in some centres in the UK; to date these have not been associated with a detectable increase in mortality (Hawkins et al 1997, Level IV). Likewise, mortality figures from The Netherlands where oral intake is left to the discretion of the parturient are comparable to those of other countries where there is strict adherence to protocols (Schuitemaker et al 1997, Level IV).

1.2 Risk factors

Critical values for volume and acidity

Gastric content values of volume and pH are considered surrogate measures of risk for pneumonitis, should aspiration occur. The accepted criterion for defining the risk of pneumonitis is a combination of pH less than 2.5 and a volume greater than 25 mL of stomach contents. These arbitrarily set critical values, originally extrapolated from animal work by Mendelson’s 1946 rabbit experiment, were validated by Roberts and Shirley (1974, Level III-2). This work set critical values of gastric contents for an adult human female as a pH value of <2.5 and a volume of >0.4 mL/kg.

The clinical significance of these criteria has not been well investigated. The introduction of solid undigested food into the lungs produces complete obstruction. The introduction of 20 mL of 1/10 HCL or unneutralized liquid vomitus produced demise within hours and histological changes including perivascular oedema, peribronchial haemorrhage and necrotic bronchiolar epithelium (Mendelson 1946).

Opioids

Administration of parenteral opioids during late pregnancy and labour is associated with delayed gastric emptying (La Salvia & Steffen 1950, Level III-2; Murphy et al 1984, Level III-2; Nimmo et al 1975, Level III-2). Opioids administered epidurally or intrathecally in labour may also have this effect, although it would appear to be dose-dependent. Porter et al (1997, Level II) showed that gastric emptying was only delayed in women who had received more than 100 μg fentanyl by epidural infusion.

Obesity

The decline in incidence of aspiration and maternal mortality needs to be considered against the background of changing population demographics. Obesity is a major public health issue and a major obstetric and anaesthetic risk factor. Problems may arise due to increased difficulty with tracheal intubation and respiratory problems including regurgitation and aspiration. Patient weight has been found to be a significant factor in gastric content volume during labour with those patients over 72 kg having a significantly higher gastric volume in labour than those below that weight (Roberts & Shirley 1974).

Obese patients featured prominently in the most recent CEMACH report (Lewis 2007, Level IV) in which respiratory problems following anaesthesia resulted in death. Aspiration was not cited as the direct cause of death in these particular cases but with greater risk of airway problems, aspiration is a prominent danger. It is noteworthy that the body mass index (BMI) of women described in this report is by current norms relatively low, with 27% of mortalities involving a BMI of only 30 or greater.

2. EFFECTS OF FASTING AND CALORIFIC DRINKS

Considerations for oral intake involve an understanding of natural eating behaviour in labour and the effects that fasting or other forms of intake may have on gastric emptying and acidity plus other potentially adverse metabolic impacts such as ketosis.

2.1 Natural eating behaviour in labour

When left to choose whether to eat in labour in low-risk pregnancy, more than 50% of women consume clear fluids only during the latent phase (Tranmer et al 2005, Level III-1). In a highly select group of low-risk women who ultimately progressed to vaginal birth, Parsons et al (2007, Level III-2) observed a progressive decline in food intake as labour progressed, with only 17% eating a full meal and only in the early part of first stage. Similar findings have also been obtained by Scrutton et al (1999, Level II).

2.2 Fasting

Effects of fasting on gastric contents and pH in labour

The aim of controlling oral intake in labour has been to minimise the volume of stomach contents, thus decreasing the risk of aspiration of solid material or large volumes of fluid. Fasting times do not appear to provide a reliable estimate of gastric volumes in parturients. However, the cross sectional area of the gastric antrum at delivery in fed patients has been shown to be greater than the starved group suggesting that much of this food remained unabsorbed (Scrutton et al 1999, Level II). High gastric volumes and low pH can not be excluded in parturients regardless of the fasting time or the onset of labour (Roberts & Shirley 1974, Level III-2). No significant differences in pH < 2.5 or gastric volumes > 60 mL were found in postnatal patients fasted for tubal ligation, irrespective of fasting times (one and 45 hours) (James et al 1984, Level III-2).

Effects of fasting on metabolism in labour

In early pregnancy, rising progesterone levels increase the maternal appetite, insulin secretion is suppressed, and excess glucose is laid down in fat stores (Elliot 1975, Level III-1). Late in pregnancy, there appears to be a significant rise in free fatty acids and ketone levels compared to non-pregnant subjects (0.43 mmol/L versus 0.13 mmol/L) (Paterson et al 1967, Level III-3). Greater utilisation of fat stores in the mother serves to spare maternal glucose for fetal growth (Hay et al 1984, Level III-3). Pregnant women appear to be prone to ketosis and pregnancy has thus been described as a state of "accelerated starvation" that is accentuated by fasting and muscular exertion. Metzger et al (1982, Level III-3) found a significant inverse correlation between plasma glucose and free fatty acids during an 18-hour fast, with lipolysis and ketogenesis increasing as circulating glucose decreased.

Ketosis in labour

The fasting of women in labour raises concerns with some professionals about the build up of ketones (Lewis 1991). The evidence for ketosis producing detrimental effects on the progress of labour is based upon a single study in which acetone in the circulation of guinea pigs was associated with reduced uterine contractility (Winkler & Hebeler 1939).

The true cause-and-effect relationship between ketosis and the progress of labour has not been rigorously investigated, and its relevance is in doubt. The increase in beta-hydroxybutyrate and acetoacetic acids during fasting in labour has not been shown to have a correlation with either maternal or fetal acid base balance (Bencini & Symonds 1972, Level III-3). The practice in the 1970s of administering glucose intravenously in labour to supplement energy stores and avoid ketosis led to considerable problems with fluid overload and lactic acidosis in mothers and neonatal hyponatraemia (Ames et al 1975, Level III-2; Singhi & Chookang 1984, Level III-2; Tarnow-Mordi et al 1981, Level III-2). This practice has subsequently been ceased.

2.3 Energy supplementation and calorific drinks

Labour entails an expenditure of energy similar to that of continuous moderate aerobic exercise (Eliasson et al 1992, Level III-2). Concerns about energy supplementation and patient comfort have been addressed in a recent study which showed that fasted patients have higher beta-hydroxybutyrate, non-esterified fatty acid levels and lower glucose levels. In fed patients, the mean oral intake in labour was found to be about 330 kJ/hr and appeared to be sufficient to prevent ketosis and low blood sugar levels (Scrutton et al 1999, Level II).

In sports medicine, the intake of carbohydrate drinks during exercise has proved to enhance capacity and reduce fatigue (Dennis et al 1997, Level III-1). Isotonic calorific drinks (e.g. Gatorade® 105 kJ/100 mL) administered in labour reduce the incidence of maternal ketosis without increasing gastric volumes (Kubli et al 2002, Level II).

3. MATERNAL AND LABOUR OUTCOMES FROM ORAL INTAKE

3.1 Vomiting in labour

Women who have solid food in labour are twice as likely to vomit as those who are fasted (Scrutton et al 1999, Level II). There is, however, no significant difference in vomiting between women fed in labour and those who choose to take only fluids (Parsons et al 2006, Level III-2; Lui et al 2007, Level II). The administration of isotonic calorific drinks in labour does not increase the risk of vomiting (Kubli et al 2002, Level II).

3.2 Duration of labour

Eating food during labour is likely to increase the duration of the labour (Parsons 2007, Level III-2). Several studies have also found an increase in duration with calorific intake in various forms (Scheepers et al 2002, Level II; Scrutton et al 1999, Level II; Yiannouzis & Parnell 1994, Level II), although Lui et al (2007, Level II) found no difference in the duration of labour. The one trial in which labour duration was decreased was where caloric intake was in fluid form only (Kubli et al 2002, Level II).

3.3 Caesarean birth

No difference in caesarean birth percentage is found between those patients who receive calorific intake during labour and those who do not (Lui et al 2007, Level II; Kubli et al 2002, Level II; Scrutton et al 1999, Level II). Two studies which suggested an increased caesarean percentage in women who ate in labour fed groups (Scheepers et al 2002, Level II; Tranmer et al 2005, Level III-1). In the latter study, in which higher risk women were included, it was found that nulliparous women given calorific drinks in labour were three times more likely to have a caesarean birth compared to controls. However the findings were inconsistent in that the number of caesareans was much lower than would normally be expected for the high-risk groups recruited, and in the control group this was found to be less than half of that historically expected in that particular unit.

KEY MESSAGES

Pulmonary aspiration of solids or liquids is a rare but significant cause of morbidity and mortality for pregnant women (Level IV).
Women who are fed in labour may be at a greater risk of aspirating since gastric volumes are increased (Level II) and are unpredictable (Level III-2).
Opioid analgesia is associated with a delay in gastric emptying (Level II, III-2).
Obesity is a predictor of increased gastric volumes in labour (Level III-1).
Obesity increases the risk of airway difficulties (Level IV).
Multiple changes in anaesthetic and obstetric practice including fasting in labour, use of antacids, use of cuffed endotracheal tubes, cricoid pressure and the widespread adoption of regional techniques have been associated with a dramatic reduction in maternal mortality from aspiration over the last 50 years (Level IV), but the independent effects of each of these is difficult to establish.
There have to date been no cases of aspiration reported where low-risk parturients have been allowed to eat in labour (Level IV).
Women fed solid food in labour are more likely to vomit (Level II) and have longer labours but this does not influence obstetric outcome (Level II).
Women fasted in labour are more prone to ketosis and elevated non-esterified fatty acid levels and low glucose (Level II). However, there is no evidence that ketosis has any influence on maternal or fetal acid-base balance and no evidence that ketosis interferes with the progress of labour (Level II).
Mode of delivery is not significantly influenced by the type of oral intake in labour (Level II).
Isotonic calorific drinks consumed during labour reduce the incidence of maternal ketosis without increasing gastric volumes (Level II; Level III-3).
Administration of intravenous glucose to fasting parturients in labour causes fluid overload and lactic acidosis in the mother and hyponatraemia in the fetus (Level III-2).
On the balance of maternal comfort, obstetric outcome and risk of aspiration, an approach to management consistent with the available evidence could include:

Pregnant women who are not in established labour and/or are unlikely to require a surgical procedure may eat a full diet.
Women in established labour may take ice-chips, water and clear fluids.
Maintaining energy and fluid balance is an important supportive care strategy and can be achieved safely with the use of isotonic energy drinks.

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