Journal of Obstetrics and Gynaecology, May 2015; 35: 432–433 © 2015 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online
OBSTETRIC SHORT COMMUNICATIONS
Consumption of beverages and food during labour in diabetic women S. Kalra1, B. Kalra2 & Y. Gupta3
J Obstet Gynaecol Downloaded from informahealthcare.com by Nanyang Technological University on 08/21/15 For personal use only.
Departments of 1Endocrinology and Metabolism, 2Obstetrics and Gynaecology, Bharti Hospital, Haryana, India and 3Department of Medicine Endocrinology, Government Medical College and Hospital, Chandigarh, India
The intrapartum period is a time of intensive exercise, which in turn poses enhanced nutritional demands upon the body. Enforcing a negative calorie balance, by restricting access to food and drink, may be detrimental to maternal and fetal physiology during labour. Yet, current guidelines state that ‘the oral intake of solids during labour increases maternal complications’ and that ‘solid foods should be avoided in labouring patients’, while magnanimously allowing ‘the oral intake of modest amounts of clear liquids (e.g. water, clear tea, black coffee, and sports drink)’ for ‘uncomplicated labouring patients’ (American Society of Anesthesiologists Task Force on Obstetric Anesthesia 2007). Most obstetric centres restrict access to oral food and beverages during labour. This is done because of concerns that an emergency caesarean section may have to be ordered at any time, and patient’s wellbeing may be compromised by acidic and solid intragastric contents. This concern stems from research which dates back 70 years (Mendelson 1946). Since then, techniques of labour augmentation, assisted vaginal delivery and obstetric anaesthesia have changed dramatically. Most of the drugs and equipment used by obstetric anaesthesiologists were not available to colleagues in preceding generations. It makes sense, therefore, to revisit the concept of food and fluid restriction during labour. This is especially important for women with diabetes, who face a greater risk of metabolic derangement, such as starvation ketosis or dehydration, if adequate calorie and fluid balance is not maintained (Scrutton et al. 1999, Kubli et al. 2002). A recent Cochrane review has identified only five wellconducted studies, including 3,130 subjects, conducted to assess the advantages and disadvantages of oral intake restriction during labour (Singata et al. 2013). No justification was found to support restriction of fluids and fluid in labour for women at low risk of complications. The largest of these studies found no difference in maternal and neonatal outcomes, and no increase in incidence of vomiting, if oral feeds were allowed during labour (O’Sullivan et al. 2009). No study focussed upon women at increased risk of complications or tried to assess patients’ opinion on this matter. While most community-based, community-oriented medical care facilities allow women in labour to consume such beverages and foods, a few hospitals strictly enforce a nil-per-mouth policy in the labour room. A caloric deficit at this time may precipitate starvation ketosis. The information on the amount of calorie deficit in relation to labour and its stages is scarce, however, the studies indicate that ‘accelerated starvation’ can be unmasked during pregnancy, even with minor dietary deprivation, especially in late pregnancy (Metzger et al. 1982).
No evidence-based recommendations are available to inform choice of foods and beverages during labour. For this, one has to rely on a ‘logical empiricism’ approach. Frequent sips of clear fluids, at least once an hour in early labour, and after every contraction in active labour, can be suggested. Water, coconut water, lemonade and ginger ale can be taken as per taste. ‘Labour foods’ should be easily digestible, complex carbohydrate-rich, caloriedense items that can be consumed in small portions. Easily available examples are fruits, nuts, snack bars, yoghurt, ice cream and boiled eggs. Allowing healthy foods compatible with individual tastes is a person-centred strategy, which supports patient empowerment and involvement in delivery. This issue gains importance in the setting of diabetes mellitus. An intravenous infusion of 5% dextrose provides 5 g dextrose in 100 ml, i.e. 20 calories. A maintenance infusion of 100 ml/h will deliver 20 calories hourly to women in labour, whose moderate to strenuous physical activity consumes much more energy. Dietary advice should be concordant with glycaemic control and insulin administration. Fluid administration may also have to be linked to insulin-doses: a maintenance glucose-insulinpotassium infusion may be used in insulin-requiring women during labour. In our practice, women in labour are usually encouraged to take frequent sips of water, ‘fortified’ with spices, such as cardamom or cinnamon, sugar or jaggery. They are also encouraged to consume small portions of calorie-dense foods, such as almonds, pistachios and raisins. Current knowledge should allow obstetric care providers to encourage women in labour to consume foods and beverages. Evidence is required, however, to define appropriate amounts of oral intake for parturients with diabetes.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References American Society of Anesthesiologists Task Force on Obstetric Anesthesia. 2007. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 106:843–863. Kubli M, Scrutton MJ, Seed PT et al. 2002. An evaluation of isotonic ‘sport drinks’ during labor. Anesthesia and Analgesia 94:404–408. Mendelson CL. 1946. The aspiration of stomach contents into the lungs during obstetric anesthesia. American Journal of Obstetrics and Gynecology 52:191–206.
Obstetric short communications 433 Metzger BE, Ravnikar V, Vileisis RA et al. 1982. ‘Accelerated starvation’ and the skipped breakfast in late normal pregnancy. Lancet 8272:588–592. O’Sullivan G, Liu B, Hart D et al. 2009. Effect of food intake during labour on obstetric outcome: randomised controlled trial. British Medical Journal 338:b784.
Scrutton MJ, Metcalfe GA, Lowy C et al. 1999. Eating in labour. Anaesthesia 54:329–334. Singata M, Tranmer J, Gyte GM. 2013. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews (8): CD003930.
Correspondence: S. Kalra, Department of Endocrinology and Metabolism, Bharti Hospital, Kunjpura Road, Karnal 132001, Haryana, India. E-mail: [email protected]
J Obstet Gynaecol Downloaded from informahealthcare.com by Nanyang Technological University on 08/21/15 For personal use only.
DOI: 10.3109/01443615.2014.960824
Clinical significance of adverse outcomes of placental abruption developing at home S. Suzuki Department of Obstetrics and Gynecology, Japanese Red Cross, Katsushika Maternity Hospital, Tokyo, Japan
We reviewed the obstetric records of 40 singleton deliveries complicated by placental abruption which developed at patients’ homes after 24 weeks’ gestation. Of the 40 cases complicated by placental abruption which developed at home, 13 cases (33%) were defined as showing adverse outcomes (5 cases of IUFD and 8 cases of UA pH⬍7.0). The rate of patients who complained of abdominal pain without bleeding was higher in the adverse outcome group than in the control group (p⫽0.02). The average time interval between the onset and hospital (or clinic) visit in the adverse outcome group was longer than in the control group (p⫽0.03). Adverse outcomes due to placental abruption which developed at home were associated with the symptom of pain without bleeding and a long time interval between the onset and hospital (or clinic) visit. Keywords: Placental abruption, adverse outcomes, emergency.
Introduction Placental abruption is one of the most serious and life-threatening obstetric complications for both the mother and fetus, requiring prompt intervention (Oyelese and Anatth 2006; Tikkanen 2011). However, it often develops at home and patients take a long time before visiting a hospital. In Japan, about half of all deliveries are managed at private clinics; patients with placental abruption managed at private clinics need to be transported to perinatal centres for prompt intervention. The aim of this study was to examine the clinical significance of severe placental abruption developing at patients’ homes in Japan.
Materials and methods We reviewed the obstetric records of 40 singleton deliveries complicated by placental abruption, which developed at patients’ homes, defined as separation of a normally implanted placenta based on massive retroplacental bleeding after 24 weeks’ gestation from 2006 to 2011. There were no cases with prior placental abruption, preterm labour or hypertensive disorders requiring ambulatory management. All cases were delivered by caesarean section because of a non-reassuring fetal status and/or an immature cervix. In this study, we examined: the perinatal characteristics and outcomes of maternal age; parity; gestational
age at delivery; maternal symptoms; time interval between onset and hospital (or clinic) visit; time interval between hospital (or clinic) visit and delivery; intrauterine fetal demise (IUFD); umbilical artery pH (UA pH) ⬍ 7.0; postpartum haemorrhage (PPH) requiring haemotransfusion; and maternal disseminated intravascular coagulation (DIC). In this study, an adverse outcome for the neonate was defined as the occurrence of IUFD before the hospital visit or a UA pH ⬍ 7.0.
Results Data are presented as the number (%) or mean ⫾ SD. For statistical analysis, the χ2-test with Yates’ correction was used for categorical variables, whereas Student’s t-test was used for continuous variables. Differences of p ⬍ 0.05 were considered significant. Of the 40 cases complicated by placental abruption which developed at home, 13 cases (33%) were defined as showing adverse outcomes (five cases of IUFD and eight cases of UA pH ⬍ 7.0), and 27 cases (68%, control) were defined as showing favourable outcomes. There were no cases requiring maternal intensive care unit (ICU) admission; however, 14 babies (35%) required neonatal ICU admission. The rates of adverse outcomes in the current cases with placental abruption that developed at home suggested the same risks as in cases with placental abruption in general (Oyelese and Anatth, 2006; Tikkanen, 2011). The incidences of PPH requiring haemotransfusion and maternal DIC in the adverse outcome group (77% and 62%, respectively) were higher than those in the control group (11% and 0%, respectively, p ⬍ 0.01); these results are also consistent with some previous studies (Oyelese and Anatth 2006; Tikkanen 2011). Table I shows the perinatal characteristics of the patients who had placental abruption with and without adverse outcomes. There were no significant differences in the maternal age, parity, rate of clinic management, gestational age or neonatal birth weight between the two groups. The rate of patients who complained of abdominal pain without bleeding was higher in the adverse outcome group than in the control group (p ⫽ 0.02). The average time interval between the onset and hospital (or clinic) visit in the adverse outcome group was longer than in the control group (p ⫽ 0.03).
OBSTETRIC SHORT COMMUNICATIONS
Consumption of beverages and food during labour in diabetic women S. Kalra1, B. Kalra2 & Y. Gupta3
J Obstet Gynaecol Downloaded from informahealthcare.com by Nanyang Technological University on 08/21/15 For personal use only.
Departments of 1Endocrinology and Metabolism, 2Obstetrics and Gynaecology, Bharti Hospital, Haryana, India and 3Department of Medicine Endocrinology, Government Medical College and Hospital, Chandigarh, India
The intrapartum period is a time of intensive exercise, which in turn poses enhanced nutritional demands upon the body. Enforcing a negative calorie balance, by restricting access to food and drink, may be detrimental to maternal and fetal physiology during labour. Yet, current guidelines state that ‘the oral intake of solids during labour increases maternal complications’ and that ‘solid foods should be avoided in labouring patients’, while magnanimously allowing ‘the oral intake of modest amounts of clear liquids (e.g. water, clear tea, black coffee, and sports drink)’ for ‘uncomplicated labouring patients’ (American Society of Anesthesiologists Task Force on Obstetric Anesthesia 2007). Most obstetric centres restrict access to oral food and beverages during labour. This is done because of concerns that an emergency caesarean section may have to be ordered at any time, and patient’s wellbeing may be compromised by acidic and solid intragastric contents. This concern stems from research which dates back 70 years (Mendelson 1946). Since then, techniques of labour augmentation, assisted vaginal delivery and obstetric anaesthesia have changed dramatically. Most of the drugs and equipment used by obstetric anaesthesiologists were not available to colleagues in preceding generations. It makes sense, therefore, to revisit the concept of food and fluid restriction during labour. This is especially important for women with diabetes, who face a greater risk of metabolic derangement, such as starvation ketosis or dehydration, if adequate calorie and fluid balance is not maintained (Scrutton et al. 1999, Kubli et al. 2002). A recent Cochrane review has identified only five wellconducted studies, including 3,130 subjects, conducted to assess the advantages and disadvantages of oral intake restriction during labour (Singata et al. 2013). No justification was found to support restriction of fluids and fluid in labour for women at low risk of complications. The largest of these studies found no difference in maternal and neonatal outcomes, and no increase in incidence of vomiting, if oral feeds were allowed during labour (O’Sullivan et al. 2009). No study focussed upon women at increased risk of complications or tried to assess patients’ opinion on this matter. While most community-based, community-oriented medical care facilities allow women in labour to consume such beverages and foods, a few hospitals strictly enforce a nil-per-mouth policy in the labour room. A caloric deficit at this time may precipitate starvation ketosis. The information on the amount of calorie deficit in relation to labour and its stages is scarce, however, the studies indicate that ‘accelerated starvation’ can be unmasked during pregnancy, even with minor dietary deprivation, especially in late pregnancy (Metzger et al. 1982).
No evidence-based recommendations are available to inform choice of foods and beverages during labour. For this, one has to rely on a ‘logical empiricism’ approach. Frequent sips of clear fluids, at least once an hour in early labour, and after every contraction in active labour, can be suggested. Water, coconut water, lemonade and ginger ale can be taken as per taste. ‘Labour foods’ should be easily digestible, complex carbohydrate-rich, caloriedense items that can be consumed in small portions. Easily available examples are fruits, nuts, snack bars, yoghurt, ice cream and boiled eggs. Allowing healthy foods compatible with individual tastes is a person-centred strategy, which supports patient empowerment and involvement in delivery. This issue gains importance in the setting of diabetes mellitus. An intravenous infusion of 5% dextrose provides 5 g dextrose in 100 ml, i.e. 20 calories. A maintenance infusion of 100 ml/h will deliver 20 calories hourly to women in labour, whose moderate to strenuous physical activity consumes much more energy. Dietary advice should be concordant with glycaemic control and insulin administration. Fluid administration may also have to be linked to insulin-doses: a maintenance glucose-insulinpotassium infusion may be used in insulin-requiring women during labour. In our practice, women in labour are usually encouraged to take frequent sips of water, ‘fortified’ with spices, such as cardamom or cinnamon, sugar or jaggery. They are also encouraged to consume small portions of calorie-dense foods, such as almonds, pistachios and raisins. Current knowledge should allow obstetric care providers to encourage women in labour to consume foods and beverages. Evidence is required, however, to define appropriate amounts of oral intake for parturients with diabetes.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References American Society of Anesthesiologists Task Force on Obstetric Anesthesia. 2007. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 106:843–863. Kubli M, Scrutton MJ, Seed PT et al. 2002. An evaluation of isotonic ‘sport drinks’ during labor. Anesthesia and Analgesia 94:404–408. Mendelson CL. 1946. The aspiration of stomach contents into the lungs during obstetric anesthesia. American Journal of Obstetrics and Gynecology 52:191–206.
Obstetric short communications 433 Metzger BE, Ravnikar V, Vileisis RA et al. 1982. ‘Accelerated starvation’ and the skipped breakfast in late normal pregnancy. Lancet 8272:588–592. O’Sullivan G, Liu B, Hart D et al. 2009. Effect of food intake during labour on obstetric outcome: randomised controlled trial. British Medical Journal 338:b784.
Scrutton MJ, Metcalfe GA, Lowy C et al. 1999. Eating in labour. Anaesthesia 54:329–334. Singata M, Tranmer J, Gyte GM. 2013. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews (8): CD003930.
Correspondence: S. Kalra, Department of Endocrinology and Metabolism, Bharti Hospital, Kunjpura Road, Karnal 132001, Haryana, India. E-mail: [email protected]
J Obstet Gynaecol Downloaded from informahealthcare.com by Nanyang Technological University on 08/21/15 For personal use only.
DOI: 10.3109/01443615.2014.960824
Clinical significance of adverse outcomes of placental abruption developing at home S. Suzuki Department of Obstetrics and Gynecology, Japanese Red Cross, Katsushika Maternity Hospital, Tokyo, Japan
We reviewed the obstetric records of 40 singleton deliveries complicated by placental abruption which developed at patients’ homes after 24 weeks’ gestation. Of the 40 cases complicated by placental abruption which developed at home, 13 cases (33%) were defined as showing adverse outcomes (5 cases of IUFD and 8 cases of UA pH⬍7.0). The rate of patients who complained of abdominal pain without bleeding was higher in the adverse outcome group than in the control group (p⫽0.02). The average time interval between the onset and hospital (or clinic) visit in the adverse outcome group was longer than in the control group (p⫽0.03). Adverse outcomes due to placental abruption which developed at home were associated with the symptom of pain without bleeding and a long time interval between the onset and hospital (or clinic) visit. Keywords: Placental abruption, adverse outcomes, emergency.
Introduction Placental abruption is one of the most serious and life-threatening obstetric complications for both the mother and fetus, requiring prompt intervention (Oyelese and Anatth 2006; Tikkanen 2011). However, it often develops at home and patients take a long time before visiting a hospital. In Japan, about half of all deliveries are managed at private clinics; patients with placental abruption managed at private clinics need to be transported to perinatal centres for prompt intervention. The aim of this study was to examine the clinical significance of severe placental abruption developing at patients’ homes in Japan.
Materials and methods We reviewed the obstetric records of 40 singleton deliveries complicated by placental abruption, which developed at patients’ homes, defined as separation of a normally implanted placenta based on massive retroplacental bleeding after 24 weeks’ gestation from 2006 to 2011. There were no cases with prior placental abruption, preterm labour or hypertensive disorders requiring ambulatory management. All cases were delivered by caesarean section because of a non-reassuring fetal status and/or an immature cervix. In this study, we examined: the perinatal characteristics and outcomes of maternal age; parity; gestational
age at delivery; maternal symptoms; time interval between onset and hospital (or clinic) visit; time interval between hospital (or clinic) visit and delivery; intrauterine fetal demise (IUFD); umbilical artery pH (UA pH) ⬍ 7.0; postpartum haemorrhage (PPH) requiring haemotransfusion; and maternal disseminated intravascular coagulation (DIC). In this study, an adverse outcome for the neonate was defined as the occurrence of IUFD before the hospital visit or a UA pH ⬍ 7.0.
Results Data are presented as the number (%) or mean ⫾ SD. For statistical analysis, the χ2-test with Yates’ correction was used for categorical variables, whereas Student’s t-test was used for continuous variables. Differences of p ⬍ 0.05 were considered significant. Of the 40 cases complicated by placental abruption which developed at home, 13 cases (33%) were defined as showing adverse outcomes (five cases of IUFD and eight cases of UA pH ⬍ 7.0), and 27 cases (68%, control) were defined as showing favourable outcomes. There were no cases requiring maternal intensive care unit (ICU) admission; however, 14 babies (35%) required neonatal ICU admission. The rates of adverse outcomes in the current cases with placental abruption that developed at home suggested the same risks as in cases with placental abruption in general (Oyelese and Anatth, 2006; Tikkanen, 2011). The incidences of PPH requiring haemotransfusion and maternal DIC in the adverse outcome group (77% and 62%, respectively) were higher than those in the control group (11% and 0%, respectively, p ⬍ 0.01); these results are also consistent with some previous studies (Oyelese and Anatth 2006; Tikkanen 2011). Table I shows the perinatal characteristics of the patients who had placental abruption with and without adverse outcomes. There were no significant differences in the maternal age, parity, rate of clinic management, gestational age or neonatal birth weight between the two groups. The rate of patients who complained of abdominal pain without bleeding was higher in the adverse outcome group than in the control group (p ⫽ 0.02). The average time interval between the onset and hospital (or clinic) visit in the adverse outcome group was longer than in the control group (p ⫽ 0.03).
