Published 24 March 2009, doi:10.1136/bmj.b732
Cite this as: BMJ 2009;338:b732

Editorials

Eating a light diet during labour

Does not seem to worsen obstetric outcomes

The obstetric textbook Midwifery by Ten Teachers, published in 1931, states that "the patient should be encouraged to take light food during the first stage of labour."¹ In 2000, the Guide to Effective Care in Pregnancy and Childbirth noted, "that food and drink should be withheld once labour has commenced is almost universally accepted in hospital care."²

In the linked randomised controlled trial (doi:10.1136/bmj.b784), O’Sullivan and colleagues assess the effect of allowing women to eat a light diet during labour on the spontaneous vaginal delivery rate.³ The authors provide evidence in their introduction that professional attitudes and clinical practices in relation to eating during labour still vary greatly within and between countries. Some maternity units limit oral intake to ice chips and drinks of water for all women in labour. This is to minimise the risk of pulmonary aspiration (Mendelson’s syndrome) in women who may require an emergency caesarean under general anaesthesia. Other units permit non-particulate carbohydrate intake, such as sports drinks. Yet others advocate free access to food and drink during labour, on the basis that labour requires intense physical activity, and that restriction of nutritional intake will inhibit its progress. It is generally accepted now that minimal use of general anaesthetics during labour, and the application of the correct anaesthetic technique, are the best ways to minimise the risk of Mendelson’s syndrome. The most recent guidelines on intrapartum care for healthy women and babies from the National Institute for Health and Clinical Excellence (NICE) conclude that women in established labour may eat a light diet unless they have received opioids, or they develop risk factors that make a general anaesthetic more likely.⁴

However, little good quality evidence is available to support or refute this conclusion. The only Cochrane review in this general area focuses specifically on the treatment of ketosis in labour, and it found no relevant good quality trials.⁵ As O’Sullivan and colleagues note, five trials of calorific intake in labour were undertaken before their study, but the results of none of them were conclusive. Given the uncertainty in this area, their study is long overdue.

These authors found no significant difference in spontaneous vaginal delivery (44% in intervention and control groups; relative risk 0.99, 95% confidence interval 0.90 to 1.08) or duration of labour.³ The results reinforce what has already been shown in many observational studies. The study is therefore an excellent starting point for future clinical policies, but it should not stop future debate.

Clinicians may worry that the changing health profile of pregnant women, and particularly rising rates of obesity, may increase the very small but real risk of Mendleson’s syndrome in the future. People who are keen to promote women’s choice will note that women’s views and experiences are not reported in the trial. Although a light diet during labour may have no obvious clinical benefit, women may find that the morale boost of eating and drinking is a positive component of their labour experience.

Some factors pertaining to the trial itself may limit the generalisibility of the findings. The authors based the sample size for their primary outcome on a baseline spontaneous vaginal delivery rate of 60%. In the event, the rate of spontaneous vaginal delivery in both arms of the study was 44%. This rate is very low and much lower than the United Kingdom’s national average of around 65% in 2005-6, when the trial was in progress.⁶ The study participants also had higher rates of caesarean section, epidural usage, and use of oxytocin for induction or augmentation of labour than is seen in many settings in the UK today. Although these data may partly be attributed to the women being nulliparous, policies and practices in the unit where the study was undertaken may have limited the incidence of spontaneous vaginal delivery to a level that was beyond the influence of nutritional policies.

O’Sullivan and colleagues’ findings offer the best evidence yet in this area, even if it is in a particular type of maternity context. The results reinforce the guidance in the NICE intrapartum guidelines, but they may not fully resolve the clinical debate. Future research could investigate women’s views and experiences of eating and drinking in labour, and the effect of a policy of a light diet on outcomes in settings where rates of normal birth, and of intrapartum interventions, are likely to be closer to the national average.

Cite this as: BMJ 2009;338:b732

¹ Research in Childbirth and Health Group (ReaCH), University of Central Lancashire, Preston PR1 2HE

Research, doi:10.1136/bmj.b784

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Berkeley C, Fairbairn JS, White C, eds. Midwifery by ten teachers. 4th ed. London. Arnold, 1931.
2. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, et al, eds. A guide to effective care in pregnancy and childbirth. Oxford: Oxford University Press, 2000.
3. O’Sullivan G, Liu B, Hart D, Seed P, Shennan A. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ 2009;338:b784.[Abstract/Free Full Text]
4. National Institute of Clinical Excellence. Intrapartum care—care of healthy women and their babies during childbirth. 2007. www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf.
5. Toohill J, Soong B, Flenady V. Interventions for ketosis during labour. Cochrane Database Syst Rev 2008;(3):CD004230.
6. Information Centre for Health and Social Care. NHS Maternity Statistics, England: 2005-06. 2007. http://www.ic.nhs.uk/statistics-and-data-collections/hospital-care/maternity/nhs-maternity-statistics-2005-06.

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Effect of food intake during labour on obstetric outcome: randomised controlled trial

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