Policy of nil per mouth for women in labour questioned

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At most US maternity units, women in labour are put on nil per os (NPO) status – they are not allowed to eat or drink anything, except ice chips. But new nursing research questions that policy, showing no increase in risks for women who are allowed to eat and drink during labour.

“The findings of this study support relaxing the restrictions on oral intake in cases of uncomplicated labour,” write Anne Shea-Lewis, of St Charles Hospital, Port Jefferson, New York, and colleagues. Adding to the findings of previous reports, these results suggest that allowing labouring women to eat and drink “ad lib” doesn’t adversely affect maternal and neonatal outcomes.

The researchers analysed the medical records of nearly 2,800 women in labour admitted to one hospital from 2008 through 2012. At the study hospital, one practice group of nurses and doctors had a policy of allowing labouring women to eat and drink ad lib (ad libitum, or “as they please”). Another four practice groups kept all patients NPO (nil per os, or “nothing by mouth”).

Recommendations to restrict oral intake during labour reflect concerns over the risk of vomiting and aspiration (inhalation) in case general anaesthesia and surgery are needed. However, with advances in epidural and spinal anaesthesia, the use of general anaesthesia during labour has become rare (and, if needed, much safer than before).

The study compared maternal and child outcomes in about 1,600 women who were kept NPO (except for ice chips) with 1,200 who were allowed to eat and drink ad lib during labour. The two groups were “sufficiently equivalent” for comparison. The women’s average age was 31 years. Before delivery, a “pre-existing medical condition” complicating pregnancy was identified in 14% of the NPO group compared with 20% of the ad lib group.

Even though the women in the NPO group started out with fewer medical problems, they had a significantly higher incidence of complications during labour and birth, compared with the ad lib group. The women in the NPO group were also significantly more likely to give birth via unplanned caesarean section.

Other outcomes – including requiring a higher level of care after delivery and the new-borns’ condition as measured by Apgar score – were not significantly different between groups. Analysis using a technique called propensity score matching, comparing groups of women with similar risk factors, yielded similar results.

The findings add to those of previous studies suggesting that restrictions on eating and drinking during labour could be safely relaxed in uncomplicated cases. “Yet in keeping with current guidelines, most obstetricians and anaesthesiologists in the US continue to recommend restrictions on oral intake for labouring women,” Shea-Lewis and colleagues write.

“Our findings support permitting women who are at low risk for an operative birth to self-regulate their intake of both solid food and liquids during labour,” the researchers add. They note some limitations of their study, especially the fact that the women weren’t randomly assigned to NPO or ad lib groups.

The authors hope their study will lead to reconsideration of current recommendations to keep women NPO during the “often long and gruelling” process of labour and delivery. “Restricting oral intake to a labouring woman who is hungry or thirsty may intensify her stress,” Shea-Lewis and colleagues conclude. “Conversely, allowing her to eat and drink ad lib during labour can contribute to both her comfort and her sense of autonomy.”

Purpose: The purpose of this study was to compare the maternal and neonatal outcomes among laboring women permitted ad lib oral intake with those permitted nothing by mouth except for ice chips.
Design: This was a quantitative retrospective observational cross-sectional study.
Sample: The initial data set consisted of all closed medical records for 2,817 women who were admitted to a suburban community hospital in the northeastern United States between January 2008 and December 2012. Some subjects’ records were missing either covariate data or outcomes data, resulting in final sample sizes of 2,797 women (for comparison across covariates) and 2,784 women (for comparison across outcomes).
Methods: A deidentified limited data set was extracted from the electronic health record for descriptive and inferential comparisons between groups. Demographics and maternal comorbidities present on admission were compared between groups before data analysis. Outcome comparisons were obtained with traditional between-groups analysis and propensity score matching.
Results: The groups were found to be sufficiently equivalent for comparison. The group permitted nothing by mouth was significantly more likely to have unplanned cesarean section births than the group permitted ad lib oral intake. There were no significant differences in unplanned maternal ICU admissions postpartum, in neonate condition as determined by Apgar scores, or in the need for a higher level of care. Allowing women ad lib oral intake during labor caused no increase in morbidity, and there were no mortalities in either group.
Conclusion: Allowing women ad lib oral intake during labor does not increase adverse maternal or neonatal outcomes. It stands to reason that allowing such intake could increase patient satisfaction. Further study is needed to determine what types of food and drink are most beneficial as well as what types are preferred.

Anne Shea-Lewis, Patricia Eckardt, Donna Stapleton

Wolters Kluwer Health material
American Journal of Nursing abstract

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