A Menu of Change
Nutrition and Hydration
Nutritional deprivation is cited as one of the factors that disrupts normal, physiologic childbirth, and leading maternity care organization have issued professional opinions regarding nutrition and hydration during labor.1 The American College of Obstetricians and Gynecologists indicated that small amounts of clear liquids may be allowed for low-risk women in labor.2 The American Society of Anesthesiologists suggested that clear liquid intake during labor is appropriate but solid foods are not.3 The American College of Nurse-Midwives concluded that decisions related to nutrition and hydration during labor be made following assessment of risk to the mother and/or the fetus, the risk of surgery, and birth environment factors, such as available anesthesia services.4 In other words, care decisions related to nutritional support should be individualized, and standard protocols do not apply to every woman in labor.
Although practices vary, it is common for women to be deprived of oral nutrition during labor and birth. Nutritional deprivation is defined as not allowing women to have anything by mouth or limiting then to only clear liquids or light solids in early labor.5 The authors of the Listening to Mothers III survey (2013) found that 2 out of 5 laboring women or 40% of the sample drank during labor, and 21% consumed solid food in labor.6In this same survey, among women who had cesarean deliveries, 76% had intravenous (IV) infusion of fluid, and among women who gave birth vaginally, 55% had IV infusion of fluid.6Reasons cited for nutritional deprivation include fear of aspiration of stomach contents in the case of general anesthesia and the risk of increased nausea and vomiting due to sluggish absorption and digestion of nutrients during labor.7 Intravenous fluids are frequently administered to prevent these risks, provide IV access if emergency surgery is needed, or to prevent ketosis.
Evidence to Support Practices
The Cochrane Collaboration has compiled evidence related to nutrition and hydration during labor in three key areas; the first is the restriction of fluid and food during labor. Singata, Tranner, and Gyte reviewed 5 appropriate studies and found no statistical difference in maternal or newborn outcomes related to type of birth or Apgar scores at five minutes.8They concluded that nutritional deprivation provides no benefit or harm, and therefore the evidence does not support this practice. They further stated that nutritional deprivation causes maternal distress, an unbalanced nutritional status, and increased pain in labor. Current study results indicate nutritional deprivation did not ensure low stomach residue or acidity, and when combined with the decreased use of general anesthesia in modern obstetrics, the concern for aspiration risk does not provide a sound basis for the implementation of withholding food or fluid from the woman in labor.8,9
Toohill, Soong, and Flenady reviewed the literature related to interventions such as increased oral fluids and IV fluid administration to prevent ketosis.10Ketosis is common during labor due to the combined effects of physiological stress and nutritional deprivation. During ketosis, the body of the woman in labor must draw from alternative body sources for needed energy. Unfortunately the authors found no appropriate studies and called for future research comparing oral intake, IV administration, or no intervention for the treatment of ketosis. They also suggested that IV administration should be studied closely for its effects on maternal glucose levels, side effects, length of labor, interference with ambulation during labor and initiating breastfeeding, and newborn acidosis.10
Dawood, Dowswell, and Quenby conducted a Cochrane Collaboration Review focused on the effects of intravenous fluid administration on labor duration and maternal and newborn health in women who are low risk and having their first birth.11They identified 9 studies which addressed the question of use of IV hydration compared to oral hydration or nutritional deprivation for women during labor, but only 2 of the study results were noted by the authors to indicate a positive effect from use of IV fluid administration on labor duration. The use of IV fluid administration led to a shorter duration of labor compared to oral fluid restriction in the two trials. The authors concluded that health benefits were not realized overall by the use of IV fluid administration and that the studies did not produce sufficient evidence upon which to base practice. Instead the authors suggested women be encouraged to increase their oral intake to assure adequate hydration rather than having a policies encouraging routine IV fluid administration or not allowing anything by mouth during labor. In addition the authors noted concern with the use of dextrose fluids for IV administration due to potential for increased risk of hyponatraemia and hyperbilirubinaemmia compared to the use of saline.11
Effective strategies to promote physiologic nutrition and hydration include the following:
Screen women in labor for risk of operative birth and aspiration to determine appropriateness of nutritional intake.4
Prevent unnecessary surgical intervention that requires the use of general anesthesia.4
Limit routine IV administration.7
Allow women in labor to drink fluids low in acid, sugar, and salt as they desire.7
Provide women in labor with light food that is low in acid, sugar, fat, and salt.7
Click to view additional resources available in the Promoting Comfort in Labor Resource Toolbox, or search our resource library by clicking here.
American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: a consensus statement by ACNM, MANA, and NACPM.http://www.nacpm.org/documents/Normal-Physiologic-Birth-Statement.pdf. Published May 14, 2012. Accessed March 31, 2014.
American College of Obstetricians and Gynecologists. ACOG committee opinion no. 441: oral intake during labor. Obstet Gynecol. 2009;114(3):714.
American Society of Anesthesiologists. Practice guidelines for obstetrical anesthesia: a report by the American Society of Anesthesiologists task force on obstetrical anesthesia. Anesthesiology. 2007;90(2):600-611.
American College of Nurse-Midwives. Providing oral nutrition to women in labor. Clinical bulletin no. 10. J Midwifery Womens Health. 2008;53(3):276–283.
American College of Nurse-Midwives. Providing oral nutrition to women in labor. J Midwifery Womens Health.2008;53(3):276-283.
Declercq ER, Sakala C, Corry, MP, Applebaum S, Herrlich A.Listening to Mothers III: Report of the Second National Survey of Women’s Childbearing Experiences. New York, NY: Childbirth Connection; 2013.
Goer H, Romano A.Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing; 2012.
Singata M, Tranner J, Gyte, G. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev.2010;1:CD003930.
Toohill J, Soong B, Flenady V. Interventions for ketosis during labour. Cochrane Database Syst Rev.2008;3:CD004230.
Maharaj, D. Eating and drinking in labor: Should it be allowed? European J OBGYN and Repro Bio. 2009; 146: 3-7. doi:10.1016/j.ejogrb.2009.04.019
Dawood F, Dowswell T, Quenby S. Intravenous fluids for reducing the duration of labour in low risk nulliparous women. Cochrane Database Syst Rev.2013;6:CD007715.