24h-payday

Restricting food and drink in labor is not justified

January 20th, 2010 by avatar

Listen to this great podcast about the new Cochrane review showing that the policy of restricting food and drink in labor is not justified. It’s a nice summary of how and why the research was conducted.  In addition, I particularly liked these tidbits:

1. Rather than asking “is eating and drinking in labor safe?” the reviewers turned the question around to ask “is there any justification for restricting food and drink in labor?”  This is not just a nuance. How a researcher asks a question can influence both the findings and the conclusions, as I have discussed previously.

2. Since they identified no benefits (nor harms) of restricting oral intake, the reviewers concluded that women should be able to eat and drink according to their preference.

3. It was her experience teaching antenatal classes that led one of the reviewers to study food and drink in labor. Listening to women’s concerns and anxieties made her question the justification for restricting women’s autonomy in labor.

In perusing the web to try to find an image for this post, I came across this heartbreaking picture of a woman begging for a drink in labor and being told no. (I’d post it here but it is copyrighted.) When the researchers said they found “no harms” of restricting food and drink in labor, they pointed out that no one had actually studied women’s preferences or experiences. I’m heartened to know that some of those who tout evidence based care are beginning to recognize that emotional distress is itself a harm. If there is no counterbalancing benefit, the conclusion is clear.

Uncategorized , , ,

  1. January 21st, 2010 at 04:13 | #1

    Can I just add how much I HATE the “you’ll just puke it up” justification? For one, there’s no guarantee of that. (I did get a little spewy around transition with my first, which was in the hospital and super interventive induction, and with my recent home birth never felt that way at all, and I’d been eating and drinking at will. Hmmmmm. I also tend towards the hypoglycemic and getting nauseous if I go too long without eating.) And even if she DOES puke it up later, who cares? I know some women are really not fond of puking but I gotta think that labor trumps all. Not to mention, you know, letting HER make that decision. What a photo.

  2. January 21st, 2010 at 08:11 | #2

    I tell laboring women that if I don’t see it, I don’t know about it (regarding fluid/food intake in labor). Yes, it’s a bit passive-aggressive, but it’s also my way of letting her retain her autonomy in a very patriarchal hospital system.

  3. January 21st, 2010 at 09:39 | #3

    Amy, wouldn’t this be a wonderful topic for the upcoming RHRealityCheck series on “What Choice Means to Me”? Food for thought. :-)

  4. January 21st, 2010 at 13:35 | #4

    Its a interesting topic. I’ve often felt we are a little too restrictive about diet in labor. Clear liquids immediately up to the point of surgery have been shown to be safe in the pediatric literature. Eating solid food right before a emergency cesarean certainly has some small increased risk of aspiration, which can be quite a bad thing. Not giving a patient coffee in labor probably cannot be justified in any evidence.

    I did some work on airway management / diet policies around second trimester surgical abortion, and my ultimate conclusion was that anesthesiologists, in general, are not so evidence based when it comes to presurgical dietary restriction. People are very worried that there would be a big legal liability if a patient had an aspiration event after laxed pre-surgical or in-labor dietary restrictions. Its a tough issue.

  5. January 21st, 2010 at 17:12 | #5

    I’m so glad this study came out now. I get dehydrated really easily [I usually drink around 3 liters of water a day] and one of my big concerns in labor was that I’d end up having to get an IV, and thus be restricted to the bed during labor, because of this. I’ve heard the main reason for the restriction was in case of surgery, but I also realize that even though I’m not planning on a c-section, my weight/BMI puts me in a category where many doctors will assume I’ll need one.

    I know that my hospital’s normal policy is ice chips and “restricted fluids” [ie melted ice chips] once you’re in active labor, but I’ll be bringing a copy of the study abstract to my appointment next week, when we review my birth plan, in hopes that it will help.

  6. avatar
    Veronica
    January 22nd, 2010 at 13:17 | #6

    Add this to the list of stuff that, when teaching and you go over the pros/cons, it gets REALLY hard to tell them Why you would want to do it.

    See also: routine IVs, restricting to bed, not allowing moms to labor in a tub, AROM, episiotomies, lithotomy position for pushing, formula feeding…

    Yes, there might be some pros, but, GOSH they pick up on the fact that it’s hard to find many benefits. I have no problem saying it, but it is hard to appear even-handed. That might lead to larger discussions of childbirth education, though…

  7. January 22nd, 2010 at 13:26 | #7

    I tell women the same thing but always add that if they do need anesthesia they should be truthful about when their last oral intake was. I just hate working the system in this way and midwives (nurses too) take a professional risk when we go against hospital policy, which just adds to stress. My hope is that this Cochrane review will make a difference in hospital policies, but I am sadly a little pessimistic. If a hospital is deeply ingrained in a belief that of denying food and drink protects safety, they may just turn a blind eye to evidence. Even with the Cochrane evidence, we need to keep the pressure on!

  8. January 22nd, 2010 at 13:35 | #8

    I thought the reviewers made an interesting point in one of the articles I read online:

    “However, Singata concludes that there may be better ways to approach studies of eating and drinking during labour. “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. It might be better to look at ways of preventing regurgitation during anaesthesia for those patients who do require it,” she said.”

    I agree that focusing efforts on a policy that affects so many women to prevent something that is such a small risk is probably the wrong tactic.

  9. January 23rd, 2010 at 12:38 | #9

    But if eating in labor has no medical benefit, why do it?

    “Natural” childbirth advocates are constantly pointing out that epidurals have “no medical benefit” and therefore oppose them. But many women find that epidurals have a massive benefit for them: relief of pain.

    I don’t understand the double standard. Women should endure excruciating pain because pain relief has “no medical benefit” but they shouldn’t have to experience hunger even though eating in labor has “no medical benefit.”

    Isn’t that rather hypocritical?

  10. avatar
    Augusta
    January 23rd, 2010 at 14:25 | #10

    I’ve had three births and never vomited in labor. I do, however, feel very nauseous if I don’t eat for long periods of time. One of the problems with the recommendations changing is that it seems (from what I read) they are advocating allowing foods like jello, broth, sports drinks, etc. Those are all things which contain very little in the way of actual nutritional value (like protein). Additionally, drinks like juice and sports drinks contain high levels of sugar. For me personally, if I’d eaten the diet they are suggesting, I would have felt awful. I can’t imagine going through labor without having the option to eat.

  11. January 23rd, 2010 at 14:45 | #11

    Um, I think you’re confusing a thing or two, Amy — nobody denies that epidurals (in general) relieve pain, and that in particular instances, that they can even make the difference between a woman having a vaginal birth, as opposed to being subjected to a C-section (necessarily, or unnecessarily). The point, though, is whether there is enough benefit to epidurals to outweigh their risks and downsides, and to outweigh the benefits of laboring without medication. [Why did you choose not to have an epidural those two times? And why did you choose an epidural the other two times? Just curious. Or did you have a choice? After all, some women are not good candidates for an epidural, or have labors that are too quick to get them, or she's too far along before the anesthesiologist gets there, etc. And in the reverse, some women are coerced into accepting medication they'd really rather do without, because they can't stand up to their husbands or mothers who "can't stand to see them in pain."]

    Anyway, you are the one that says that having a natural labor has no benefits; I don’t know that anyone says that an epidural has *no* benefits. Only that it has risks that should be considered; and that the benefits of an undrugged labor (which you deny or minimize) might be more than the benefits of an epidural for some women. Including me.

  12. January 26th, 2010 at 01:29 | #12

    Amy, I’m not sure there was anything in here that stated that epidurals don’t have benefits, and this article never mentioned anything about epidurals anyways, so I’m not so sure where you got the hypocritical thing from…so umm..back to the issue..

    I have been working hard at one of the hospitals I work at, to get them to allow drinking fluids(two of the other ones I work at already do). I think they may come around, but it definitely is a long road. We need people in the system to help move this along. I myself have offered research to show that women should be allowed fluids. And this cochrane review will certainly help with that. Thanks for showing this.

  13. January 27th, 2010 at 03:49 | #13

    Amy Tuteur, MD :
    But if eating in labor has no medical benefit, why do it?
    “Natural” childbirth advocates are constantly pointing out that epidurals have “no medical benefit” and therefore oppose them. But many women find that epidurals have a massive benefit for them: relief of pain.
    I don’t understand the double standard. Women should endure excruciating pain because pain relief has “no medical benefit” but they shouldn’t have to experience hunger even though eating in labor has “no medical benefit.”
    Isn’t that rather hypocritical?

    Why do it? Are you really serious?
    Because you are starving women when they NEED nutrition and calories for the lard work of laboring…. dur….

    Kim Mosny, CPM

  14. January 27th, 2010 at 16:03 | #14

    “when they NEED nutrition and calories for the lard work of laboring”

    Evidently you missed the part of the paper that stated that eating in labor has NO BENEFITS. The don’t “need” nutrition and calories for labor. “Natural” childbirth advocates simply made that up. There was never any data to support that claim.

  15. January 27th, 2010 at 20:08 | #15

    @Amy Tuteur, MD
    Gee, I guess that the WHO is simply a “natural” childbirth advocate: Care in Normal Birth, p.13, “Labour requires enormous amounts of energy. As the length of labour and delivery cannot be predicted, the sources of energy need to be replenished in order to ensure fetal and maternal well-being. Severe restriction of oral intake can lead to dehydration and ketosis.”

    Perhaps you missed the part of the paper that said, “the meta-analysis was dominated by one study undertaken in a highly medicalised environment.” Perhaps being in a highly medicalized environment was enough to erase any positive benefits that could have been attributed to eating or drinking at will during labor. You also fail to point out that women weren’t asked what they thought about eating and drinking during labor. You said above, “Natural” childbirth advocates are constantly pointing out that epidurals have “no medical benefit” and therefore oppose them. But many women find that epidurals have a massive benefit for them: relief of pain. Is not relief from the pain of hunger and of thirst a benefit, if not “massive”? I don’t know about you, but I don’t like it when I get hungry or thirsty. As Daffy Duck says, “I’m not like other people — I don’t like pain — it hurts me!”

  16. January 27th, 2010 at 20:28 | #16

    “I guess that the WHO is simply a “natural” childbirth advocate”

    Interesting how you quote a few sentences from an out of date WHO publication. The publication also recommends strict use of the partogram (based on the Friedman curve). Do you favor that, too, or do you merely pick and choose what you like?

    “you missed the part of the paper that said”

    Either you are going to take the recommendations of the paper or you are not. “Natural” childbirth advocates are crowing about the fact that the study found no deaths, but of course it was grossly underpowered to do so. It was not underpowered to determine whether eating had any benefits in labor and it had none. Where are the studies that demonstrate a benefit of eating in labor? Are there any or did “natural” childbirth advocates simply fabricate “benefits” to suit themselves?

    “You also fail to point out that women weren’t asked what they thought about eating and drinking during labor.”

    What difference does it make to you what they thought? You think severe pain is “empowering.” So if women are “empowered” by agonizing pain, shouldn’t a little hunger add to their “empowerment”?

  17. January 27th, 2010 at 22:00 | #17

    @Amy Tuteur, MD
    Find a more recent one and see if it’s changed at all, to see if it’s really out-of-date.

    From p.26, “Deviation from an arbitrarily defined normal rate of
    dilatation should be an indication for review of the labour management plans. In the partograph method of WHO (WHO 1993) the alert line is passed if the dilatation is slower than 1 cm per hour; if the woman is in a health centre this is reason to refer her to a hospital. The action line is passed if delay in progress continues for four more hours.” [How many US hospitals would have already sectioned after 1-2 hours of no progress? This sounds like they would just be starting the Pitocin.] “The relationship between prolonged labour and adverse maternal and fetal outcome is the reason why it is so important to monitor the progress of labour accurately. The extent to which that relationship is causal is by no means certain. Slow progress should be a reason for evaluation rather than for intervention.” Um, yeah, I think I favor that.

    What difference does it make to you what they thought? A helluva lot, thank you very much! In fact, don’t you frequently complain about and blame NCB advocates of putting a woman’s feelings and her “experience” over the health and safety of her baby? And now you say that the way she thinks and feels and her experience means jack-$#*t to me?

    You think severe pain is “empowering.” No, I don’t. I think that having an unmedicated birth by choice can be empowering, particularly when well-supported by attendants. For the record, I did *not* feel particularly “empowered” by my second labor, which was much more painful than my first, though they were both at home. In my first, I was well-supported by my husband, midwife, and her assistant. There was one time when I thought “epidural,” and that was when I was on my back during a contraction while she checked my dilation, and I knew by experience why women in hospitals beg for epidurals, being made to be on their backs all the time. In my second, the ctx were so widely spaced apart and with no rhythm or pattern that I never called the midwife until it was too late; also, my husband was on the road. For some, an unassisted birth may seem to be the epitome of birth or something; for me, it was rather the reverse. Actually, the “birth” part was no big deal, but labor sucked.

    And in my first labor, I threw up the large supper I had eaten just prior to the onset of labor, and didn’t want anything else, and threw up the sips of juice the CNM made me drink. But I started to get shaky (probably low blood sugar) about half-way through pushing, so asked for and received and kept down the apple juice. So, it helped me. In my second labor, I ate what I wanted and drank what I wanted with little thought about it, because I was waiting for “real” labor to start. And I didn’t throw up. Not every woman is going to want to eat or drink in labor; but some will.

    So if women are “empowered” by agonizing pain, shouldn’t a little hunger add to their “empowerment”? Being denied food when you’re hungry or drink when you’re thirsty is not empowering. In fact, if she were a convicted murderer in a prison cell and was denied food or drink for hours on end, such as happens on a daily basis in labor wards across the country, that would be considered by some to be “cruel and unusual punishment.” One might even wonder if she was being starved into submission.

  18. January 27th, 2010 at 22:12 | #18

    “So if women are “empowered” by agonizing pain, shouldn’t a little hunger add to their “empowerment”? Being denied food when you’re hungry or drink when you’re thirsty is not empowering.”

    And forgoing pain relief when in agonizing pain is empowering?

    The double standard highlights the hypocrisy of “natural” childbirth advocates.

    The fact is that “natural” childbirth is all about defying authority. Doctors recommend pain relief; natural childbirth advocates pretend the pain is empowering. Doctors point out that eating in labor has no benefits and carries a risk of death in certain circumstances and “natural” childbirth advocates insist that they simply cannot withstand a few hours without food and that they “need” calories have a successful vaginal delivery. They’re just making it all up as they go along.

  19. January 28th, 2010 at 09:22 | #19

    @Amy Tuteur, MD
    Amy, sometimes you just make me sigh and shake my head. You didn’t even read what I wrote. Or else you just refused to understand it. Spin it however you want in your own mind; nothing I could say would make a difference to you. Fine, we’re all about defying authority. Whatever. Maybe we are — defiance is a form of empowerment. Maybe we’re just getting high on defiance when we think we’re getting high on oxytocin and endorphins. Maybe when we stand up and walk around in labor, working with the sensations of our body and being supported by those who care, hearing them tell us that we are strong and powerful, and pushing out our babies under our own strength, in whatever positions we choose, we’re not feeling empowered by those things — we’re really just getting off on thumbing our noses at the doctor. How silly of me to ever think otherwise. We’re masochists. Yeah, that explains it. Of course, empowerment is all about getting back at “the man,” and subjecting ourselves to unceasing and relentless pain just to make the doctor mad. Uh, yeah.

    Did you go against your doctor’s recommendation to have pain relief? Were you “defying authority” when you opted not to have drugs those two times you gave birth without an epidural? Just because you suffered “severe pain” in your labors without drugs and had “agonizing” and “excruciating” labors doesn’t mean that everyone does. I’m sorry you had such awful birth experiences, and wish it could have been different for you.

  20. January 28th, 2010 at 11:43 | #20

    “Maybe we’re just getting high on defiance when we think we’re getting high on oxytocin and endorphins. Maybe when we stand up and walk around in labor, working with the sensations of our body and being supported by those who care, hearing them tell us that we are strong and powerful, and pushing out our babies under our own strength, in whatever positions we choose, we’re not feeling empowered by those things — we’re really just getting off on thumbing our noses at the doctor.”

    Exactly!. None of this is really about birth or babies. It’s all about how “natural” childbirth advocates want to view themselves.

  21. January 28th, 2010 at 12:48 | #21

    Well, at least I can say with confidence, “you don’t get it… you just don’t get it.” I’ve always suspected it, but now you’ve confirmed it.

  22. January 28th, 2010 at 13:03 | #22

    “at least I can say with confidence, “you don’t get it”

    “You just don’t get it” is not an acceptable debate response, just a way of avoiding a response. How about addressing the claim?

  23. January 28th, 2010 at 16:25 | #23

    Amy, I’m confused. What is your claim?

    That “the don’t “need” nutrition and calories for labor”? That “eating in labor has no medical benefit”? “The don’t “need” nutrition and calories for labor. “Natural” childbirth advocates simply made that up”

    We need to eat to do anything. Do we need to study this? Do we really need a study to say that women in labor needs energy and calories. That’s just basic physiology. When a women is in labor she is burning calories, she is using energy. Her body is working. Even with an epidural, a woman’s body is using a lot of calories that should be replenished.

    “The fact is that “natural” childbirth is all about defying authority.”

    No evidence for this but antedotal.

    “Doctors recommend pain relief;”

    Some do, some don’t. In my experience, most are willing to do what the woman wants, but don’t always provide labor support.

    “Doctors point out that eating in labor has no benefits”

    I guess that depends on what your definition of what benefits are. This study did look at comfort, energy levels, level of exaustion, or desire to nurse or be with the infant afterwards.

  24. January 28th, 2010 at 17:19 | #24

    “Do we need to study this?”

    That’s the rationale that they used when they first pumped high concentrations of oxygen into incubators. It never occurred to anyone that concentrations of oxygen that were perfectly safe, indeed beneficial, for adults could and would cause blindness in premature babies.

    If you make a claim, you need scientific evidence to support it. So, yes, you do need to study whether adding calories through eating and drinking during labor promotes better outcomes. That’s just what the authors of this study were looking at … and they found not merely that eating in labor is not necessary for successful outcomes, they found that it has no benefit at all.

  25. January 28th, 2010 at 17:39 | #25

    So Amy, why shouldn’t we allow women to eat or drink if they want? Again, I’m not sure what your claims are. And no I don’t think we need to study that we need to eat for energy…that’s been established. These study showed that there are no bad outcomes…so what are you claiming Amy?

  26. January 28th, 2010 at 19:15 | #26

    “that’s been established.”

    No, it has NOT been established. There is no scientific evidence that shows that women need to eat DURING labor to have enough calories to complete labor. If you want to make that claim, you must provide proof.

  27. avatar
    Dr. Amy Tuteur’s doppelganger
    January 28th, 2010 at 22:50 | #27

    “In our relentlessly competitive society, it is often difficult not to set goals for ourselves, even in the most intimate of circumstances. It is important to remember that childbirth is not an athletic event. No team of judges will award the perfect score to the woman who refused an episiotomy, or deduct points from the woman who requested an epidural.

    Childbirth is a deeply personal experience. You should feel comfortable making the choices that are right for you; do not judge yourself by someone else’s standards.” (Tuteur, 1994)

    Tuteur, Amy B.MD. How Your Baby is Born. Ziff Davis Press, Emeryville, 1994.

  28. January 29th, 2010 at 14:01 | #28

    @Amy Tuteur, MD
    “You just don’t get it” is not an acceptable debate response, just a way of avoiding a response. How about addressing the claim?
    Which claim? That NCB’ers are just about defying authority? Or that NCB is just about “how we want to view ourselves”? All I can do is say, “No, it isn’t,” and you’ll rejoin, “Yes, it is” — it’s a pointless argument, not a debate. I’ve already given you examples of how it’s not about defying authority — if it were, I should have had a pinnacle experience with my unplanned UC, defying not just the authority of doctors such as yourself in having a homebirth with a midwife but in defying the authority of my midwife in not calling her when I was in labor. [Though the reason I did not call is that I had already called her for one false alarm, and with the ctx so widely spaced apart, I wanted to make sure it was "real" labor before I called her to come again.] And another example is that in my first labor which was an empowering birth (CNM-attended water-birth), I did whatever the mw asked me to do, without thought or hesitation — get in the tub, out of the tub, sip some juice (although I absolutely did not want it and knew I would throw up [but I remember thinking though not saying to the midwife, "It's your own fault if you have to clean up my vomit because you made me drink this when I don't want to!"]), take my bp, temp or listen to the baby’s heartbeat (with a Doptone, not even with a fetoscope!). You’d think that if I were getting off on defying authority, I’d have at least mentioned **something** when she thought my labor had stopped and was wanting to give me something to make the ctx stronger. You’d think that I would have said something along the lines of what I was thinking — “Stronger?? They’re supposed to be *stronger*??” or even, “I’m still having strong ctx, thankyouverymuch.” Instead, I meekly said, “Ok,” but before she got done with taking my vitals, I started spontaneously pushing. Oh, wait — maybe I defiantly caused my cervix to fully dilate in those few minutes so that I could defy my midwife’s wishes in giving me herbs or whatever to strengthen the ctx.

    I was being sarcastic about “getting off on thumbing our noses at the doctors,” but that is what you believe about it, so there is no debate, and argument is fruitless, because it’s already come down to “Nuh-uh,” and “Yeh-huh!” Pointless.

    I’ve come to realize something, though. Talking to you on this topic is like talking to an abused wife about how wonderful husbands are; or talking to a rape victim about how wonderful sex is. For whatever reason, regardless of how many stories you read about empowering births or good birth experiences, you just don’t believe it, so you say it can’t be… or if it is, it has “nothing to do with birth and babies,” but with something else — defying authority, or how women view themselves. [Although I have to wonder -- what's so wrong with women seeing themselves as powerful?]

  1. February 2nd, 2010 at 23:42 | #1