Thursday, March 26, 2009

Eating and drinking during labor

A recent RCT of eating and drinking during labor found that it is safe to do. A lot of us would go "well, duh!" but many hospitals still restrict laboring women from anything but ice ships or sips of water.

This is the case with the two local hospitals I recently toured, although there are ways to get around this rule. In one hospital, you need to do it on the sly when the nurses aren't watching. In the other, they said they'd document that they discussed their policy of nothing but water/ice chips, then it would be up to the woman to decide if she wished to eat or drink. Still, most women are probably not aware that they do not have to follow hospital policies.

The study, Effect of Food Intake During Labour on Obstetric Outcome: Randomised Controlled Trial, concluded that:
Consumption of a light diet during labour did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting. Women who are allowed to eat in labour have similar lengths of labour and operative delivery rates to those allowed water only.
For a more thorough look at the historical restriction on eating and drinking during labor, visit the Cochrane Database's review (PDF). Below is the background information from the review:
Restricting oral food and fluid intake of women in active labour in hospitals is a strongly held obstetric tradition. A survey of labour ward policies in England in 1985 revealed that over a third of consultant maternity units allowed no fluids whatsoever during labour (Garcia 1985). In a more recent survey of 351 units in England and Wales, one third allowed some form of food and drink and over ninety per cent allowed some form of oral intake, usually water (Michael 1991). Restriction of oral intake is not a common practice in home births or birth centers (Rooks 1989) nor is the practice consistent across hospital sites (Haire 1991). Few if any centers have policies that are reflective of women's preferences (Pengelley 1998). Most are based on historical, but important concerns, related to the risks of gastric content regurgitation and aspiration into the lungs during general anaesthesia, a risk first identified by Mendelson in the 1940s. Though rare with modern anaesthetic techniques, the syndrome is potentially fatal.

The rationale for withholding food and fluid during labour is to decrease the risk of maternal morbidity and mortality from Mendelson's syndrome if a general anaesthetic is required, as fasting will ensure small gastric volumes. Recent reviews suggest that there is no evidence to support this belief (O'Sullivan 1994). Interventions to reduce stomach contents or the acidity of the content, both by pharmacological means and by restriction of oral intake, have not proved successful (Taylor 1975). Gastric emptying is delayed during labour (Davidson 1975). Irrespective of whether a woman has been starved or not during labour, anaesthetic precautions are necessary to reduce the risk of gastric content aspiration. These include reducing unnecessary operative interventions; using regional rather than general anaesthesia; and using rapid sequence induction with airway protection for general anaesthesia (Am Soc Anesth 1999). With modern techniques, particularly the use of regional analgesia, the risk of gastric content aspiration has become extremely small (McKay 1988).

Fluid and nutrient needs during labour are not well studied. Glucose metabolism and need are accelerated during pregnancy and labour. Many believe that elevated levels of ketone bodies, which accumulate during exercise or starvation (Williamson 1971), is a physiological response with little clinical significance. However, associations between ketone levels and longer labours and maternal psychological stress have been reported (Chang 1993; Foulkes 1985). It is difficult to determine whether ketone production contributes to the longer labour or whether it is a consequence. The presence of ketonuria should be considered a signal for metabolic imbalance, though the effect of the imbalance is not known (Johnson 1991).

Intravenous therapy instead of oral hydration is common practice during labour. Historically, practitioners administered high dose glucose solutions to combat the development of ketones (Ketteringham 1939). More commonly now, intravenous fluids are isotonic or low dose glucose as high dose glucose solutions are associated with increased incidence of neonatal hypoglycemia (low blood sugar levels) (Mendiola 1982; Grylack 1984). Dextrose only solutions cause a fall in serum osmolality and sodium concentration (hyponatraemia) (Begum 1999). Regardless of solution type, intravenous therapy predisposes women to immobilization, stress, increased risk of fluid overload, and does not ensure a nutrient and fluid balance for the demands of labour (Simkin 1986a; Simkin 1986b). The value and safety of routine intravenous fluid therapy has been questioned (Begum 1999).

Despite these risks, and lack of evidence of benefit, routine restriction of foods and fluids in labour has persisted. This policy is not reflective of women's preferences or cultural expectations (Broach 1988a; Broach 1988b). This systematic review may assist in resolving the clinical uncertainty, which is currently apparent.
Article citation:
O’Sullivan G, Liu B, Hart D, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. Br Med J 2009; 338:b784.


  1. Very interesting! I think its a ridiculous pity to do all of the horrid counter-intuitive stuff they do to the mothers, but this one REALLY bothers me.

    Especially in a long labor, how "Duh!" to offer nourishment to the mother........

  2. What, you mean I won't puke into my lungs and die if I eat during labor?!?!?!?!!1!!1

    Sorry. Feeling snarky today. That was one of the worst things about my labor with Jameson. 46 hours and they would not let me have even a drink of water. When I was pushing, I was focusing on the big mug of ice water I would chug down after it was all over. Not my baby, but the water. That's how thirsty I was. It's freakin' barbaric I tell ya.

  3. I drank Gatorade right in front of everyone in the middle of pushes with my one hospital birth. I did have to get my doula to remind me to take sips of it between contractions so that I would not end up dehydrated.

    I also ate a bowl of cereal at home about six hours before she was born but didn't really want anything else once labor was rolling.

  4. I've always been a bad patient... I snuck in White Castle and Burger King during my hospital labors. The nurse walked in when I had just stuffed my mouth and she asked, "Are you eating something?" and like a kid who just got caught I answered by shaking my head no... stuffed hamster cheeks and all. :-)

  5. Rixa--

    I am an anesthesiologist preparing to birth my second in the next couple of weeks after delivering my first by cesarean for breech. So I'm wrapping my head around instinctual labor and birth, and have been avidly following your blog...

    Just a comment on this one. Geraldine O'Sullivan is a proponent of eating in labor for maternal comfort. Her paper does NOT show that eating is safe per se, but that there is no objective benefit to eating in active labor (no increase in vaginal delivery, no decrease in duration of labor, no decrease in cesarean delivery, no decrease in instrumental vaginal delivery, no increase in APGAR scores, no decrease in NICU admissions). Nice that the press spun that one around 180 degrees to conclude that her paper shows eating is safe in labor. With < 2200 participants, it is substantially underpowered to demonstrate safety, and states that fact in the limitations section.

    However, in the discussion section, she points out that recent data from the Confidential Enquiry into Maternal and Child Health in the United Kingdom (the system that meticulously tracks and codes all maternal deaths in the UK) has noted a decline in the number of women dying from aspiration, at the same time that more maternity centers have liberalized their oral intake policies.

    The following is not in the BMJ paper. Between 1979 and 1987, there were 16 MATERNAL deaths from aspiration of gastric contents in the UK. Between 1989 and 1996, there were 3. Between 1997 and 2005, there were 2. One of the two was critically ill, and the other was obese with a difficult airway (the anesthesiologists had trouble intubating her for general anesthesia for emergency cesarean delivery). If you don't fall into any of those categories (critically ill, significantly obese (>250#), or with a known difficult airway), then your risk of aspiration in a hospital labor is probably teeny tiny --(<1/50,000?).

    In it's guidelines for obstetric anesthesia, (Anesthesiology 2007) the American Society of Anesthesiology actually recommends moderate intake of clear liquids (including tea, gatorade, non-pulp juices) for low risk women in labor.

    Birthing units with water- and ice-chip-only policies, or complete nothing-by-mouth policies are medically out of date. Bring them a copy of the ASA guidelines. They are free on

    The BMJ study concludes that while there is no objective benefit to eating in labor, that some women and maternity providers will conclude that the risk to benefit analysis favors eating in labor--given that the risk is so low (based on info from CEMACH), and that other studies have shown a benefit for women's comfort and control. But this paper by Geraldine O'Sullivan and other studies have failed to demonstrate an objective benefit with respect to obstetric outcomes in hospitals / birth centers. (One exception--one study showed decreased ketonuria among women who drank balanced sports drinks (gatorade) in labor. It wasn't powered sufficiently to look at mode of delivery or other birth outcomes).

    For home births or unassisted / autonomous births, the risk of aspiration must approach zero. I am not sure if one can extrapolate the lack of an objective benefit to eating food in labor, or speculate as to some possible objective benefit. Certainly, the subjective benefit (control & comfort) is self-evident.

  6. I showed up to the hospital at 8am after not eating breakfast (I was to excited - it was our first!) not realizing they really were not going to let me eat the whole time. He wasn't born till 3am and I never did get food until the 7am breakfast. So from friday at 8pm, till sunday at 7am - NO FOOD! Ridiculous! No wonder I felt so exhausted!! This time, I'm sneaking my own food in. :-)

  7. what about the three large U.S. studies totaling 78,000 laboring women who ate and drank freely, and found that not one woman choked under anesthesia?
    I've been trying to find the specific studies... but alas all I can find is the mention of them.
    Maybe you could help me with that?

    Myself.. with my first, I had a PB&J sandwich.. and smoothie throughout the rest of the birthing.. I was pretty tired by the end, and as soon as he was born I ate and ate and ate.

    With my second, when I first woke up I had eggs, toast, yogurt, breakfast potatoes, and red raspberry leaf tea.

    then for lunch i had eggs and pancakes. apparently i was on a breakfast kick.
    It was SO NICE eating and not having a growling stomach.

  8. During my first and only birth, I arrived at the hospital 10 cm dilated and ready to push. This hadn't exactly been my plan, but I didn't realize that my labor had progressed to that point. Anyhow, I had the benefit of NO medical interventions during labor, but I don't remember even THINKING about food or drink for at least 10 hours before my baby was born. The labor was way too intense and consuming for food to even cross my mind once. Honestly, how could other unmedicated folks be thinking about food or even drink when labor is really rolling??? I'm curious!

  9. Well both my babies were home births. i was eating the smoothie cause was so cold and felt good.

    my second.. i dunno. i was so relaxed, i had no problem eating. i felt starving for whatever reason. it was just what i wanted. i mean imagine if i hadn't been allowed? how would that have helped? i say do what u want to do... if mom is getting weary and hasn't eaten.. offer food. it will probably help

  10. Jill #2--thanks for those comments. At a certain point whether eating or drinking is safe/not dangerous, or not eating and drinking is not safer, gets down a bit to semantics and base assumptions. Do you assume that eating and drinking is normal and reasonable/safe unless proven otherwise, or do you need to assume it's dangerous (in our current obstetrical culture of spinal/epidural anesthesia for most c-sections and improved anesthetic technique, etc) unless proven otherwise?

    Anyway, to answer Sarah's question--my labor was 10 hours start to finish and, subjectively speaking, pretty intense from the get-go. I don't think I ate or drank anything the first half because it was in the middle of the night. Once it was morning, I had a bowl of plain yogurt with some raw sugar mixed in, and I was downing water and apple juice fairly regularly because I was thirsty! So I think it's really an individual thing as far as thirst/hunger/desire to eat goes while in labor.

  11. I just look at it in a fairly simple way. Most of the interventions/precautions hospitals pose upon laboring Moms is for the "what if" factor. And the reason they deny food and nourishment is because "what if" you end up needing c-section or sedation. They basically treat every laboring Mom as a potential C-section.

    I had 3 homemade chicken enchiladas about 4 hours before my labor started. Baby born 2½ hrs later. It was a short, however VERY INTENSE labor. I was glad to be nourished, it gave me the strength to weather the storm.

  12. The hospital where I gave birth had a no food policy. But my sweet husband snuck out and found the hospital snack bar that's open 24 hours and brought me a giant soft pretzel and a big lemonade at 3:00 am without me even asking! I had been stalled at 6 cm and that little surprise gave me the energy and lift I needed at a time when I was starting to get discouraged. Seems like things picked up after that and by 4:30 I had my sweet baby girl in my arms!

  13. Is there any research on eating and drinking during labor/early postpartum and breastfeeding success rates? I didn't feel like eating anything during labor, then transferred soon after the birth and was not well fed at the hospital. I think these contributed to my milk being late to come in. This time, if I have to transfer, I will be bringing my own food.

  14. You know what is interesting. The same anesthesia Docs who tell me epidurals do not increase the risk of C-sections, tell me that the woman should not have anything to eat after her epidural is placed in case she needs a c-section because now she is at a higher risk of c-section. You can't have it both ways! Either the epidural increases risk of c-section or not. If not, why don't we let them eat? We do let folks eat when they do not have epidurals. We are all about the food at my hospital.

    I personally would rather not see a pregnant woman eating when she has an epidural. I know research says the epidural does not increase the incidence of C-secton. but I would not want to see someone need to be intubated and aspirate her bagel. It is just too risky.

  15. I'm confused. when a woman is intubated, that means there's a tube down her throat correct?

    wouldn't that tube protect her from food going into her lungs?


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