60 Eating in labor - Green - Ciardulli (1)

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NURP MISC
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May 27, 2023
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Review Less-Restrictive Food Intake During Labor in Low-Risk Singleton Pregnancies A Systematic Review and Meta-analysis Andrea Ciardulli, MD , Gabriele Saccone, MD , Hannah Anastasio, MD , and Vincenzo Berghella, MD OBJECTIVE: To evaluate benefits and harms of food intake during labor. DATA SOURCES: Electronic databases such as MEDLINE and ClinicalTrials.gov were searched from their inception until October 2016. METHODS OF STUDY SELECTION: We included ran- domized trials comparing a policy of less-restrictive food intake with a policy of more restrictive food intake during labor. The primary outcome was the mean duration of labor. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of either a relative risk or a mean difference with 95% confidence interval (CI). TABULATION, INTEGRATION, AND RESULTS: Ten tri- als, including 3,982 laboring women, were included. All the studies involved laboring singletons considered at low risk because they had no obstetric or medical complications that would increase the likelihood of cesarean delivery. In three studies, women were allowed to select from a low-residue diet throughout the course of labor. One study had honey date syrup as the allowed food intake. Five studies had carbohydrate drinks as food intake in labor. The last one was the only trial that allowed unrestrictive food intake. In the included stud- ies, all women in the intervention group were allowed the assigned food intake until delivery, whereas women in a control group were allowed only ice chips, water, or sips of water until delivery. A policy of less-restrictive food intake was associated with a significantly shorter duration of labor (mean difference -16 minutes, 95% CI 2 25 to 2 7). No other benefits or harms in obstetric or neonatal outcome were noticed. Regurgitation during general anesthesia and Mendelson syndrome did not occur in either group. CONCLUSION: Women with low-risk singleton preg- nancies who were allowed to eat more freely during labor had a shorter duration of labor. A policy of less- restrictive food intake during labor did not influence other obstetric or neonatal outcomes nor did it increase the incidence of vomiting. Operative delivery rates were similar. (Obstet Gynecol 2017;129:473-80) DOI: 10.1097/AOG.0000000000001898 R estricting food intake during labor is common practice across many birth settings, with some women being allowed only sips of water or ice chips. 1 - 6 Work by Mendelson in the 1940s showed high morbidity and high mortality in pregnant women undergoing general anesthesia for cesarean delivery who inhaled either liquids or food from the stomach. 2 Oral intake is often restricted in laboring women as a result of concerns of aspiration in the event that general anesthesia is required. 5 Preventing Mendelson syndrome, although very rare, has been the rationale for oral food intake restriction in women during labor. 3 However, in modern obstetrics, the rate of general anesthesia is very low, approximately 5% in the overall population. 1,4,5 In 2013, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists recommended that " the oral intake of modest amounts of clear liquids may be allowed for From the Department of Obstetrics and Gynecology, Catholic University of Sacred Heart, Rome, and the Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy; and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania. Each author has indicated that he or she has met the journal ' s requirements for authorship. Corresponding author: Vincenzo Berghella, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, 833 Chestnut Street, First Floor, Philadelphia, PA 19107; email: vincenzo.berghella@ jefferson.edu. Financial Disclosure The authors did not report any potential conflicts of interest. © 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/17 VOL. 129, NO. 3, MARCH 2017 OBSTETRICS & GYNECOLOGY 473 Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
uncomplicated laboring patients " but that " solid foods should be avoided in laboring patients. " Moreover, " patients with risk factors for aspiration (eg, morbid obesity, diabetes, and difficult airway, or patients at increased risk for operative delivery) may require fur- ther restrictions of oral intake, determined on a case- by-case basis. " 3 In contrast to American College of Obstetricians and Gynecologists and American Soci- ety of Anesthesiologists recommendations, the World Health Organization recommends that health care providers should not interfere with a woman ' s desire for oral intake during labor. 4 Several randomized controlled trials (RCTs) have been published, providing contradictory results (Laifer SA, Siddiqui DS, Collins JE, Stiller RJ, Moffat SL, Loh EV. A prospective randomized controlled trial of oral intake of liquids during the first stage of labor [abstract]. Anesthesiology 2000; A53 (Poster 12); personal communication, U. Goodall and A.H. Wallymahmed, 2006). 7 - 14 The aim of this systematic review and meta- analysis of RCTs was to assess benefits and harms of a policy of less-restrictive food intake during labor. SOURCES This review was performed according to a protocol designed a priori and recommended for systematic review. 15 Electronic databases (ie, MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Con- trolled Trials, Scielo) were searched from their incep- tion until October 2016. Search terms used were the following text words: " food, " " drink, " " labor, " " labor, " " restriction, " " Mendelson, " " aspiration, " " general anes- thesia, " " morbidity, " " mortality, " " meta-analysis, " " metaanalysis, " " review, " " randomized, " " water, " " ice chips, " " randomised, " " effectiveness, " " guidelines, " " carbohydrate, " " sugar, " and " clinical trial. " No restric- tions for language or geographic location were applied. In addition, the reference lists of all identified articles were examined to identify studies not captured by elec- tronic searches. The electronic search and the eligibility of the studies were independently assessed by two au- thors (A.C., G.S.). Differences were discussed with a third reviewer (V.B.). STUDY SELECTION We included all RCTs comparing a policy of less- restrictive food intake (ie, study group) with a policy of more restrictive food intake (ie, comparison group) during labor. Food was defined as any nutritious substance that women eat or drink. Randomized controlled trials on oral food intake and quasi-RCTs (ie, trials in which alloca- tion was done on the basis of a pseudorandom sequence, eg, odd and even hospital number or date of birth, alternation) were eligible for inclu- sion. Studies on intravenous (IV) feeding were excluded. We considered studies comparing any two or more of the following regimens for inclusion: 1) Unrestrictive intake of oral food and fluids 2) Allowing particular oral food or fluid regimens 3) Food intake restricted to oral carbohydrate-based fluids 4) Food intake restricted to only water 5) Complete restriction of food intake (other than sips of water or ice chips) The risk of bias in each included study was assessed by using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Seven domains related to risk of bias were assessed in each included trial because there is evidence that these issues are asso- ciated with biased estimates of treatment effect: 1) ran- dom sequence generation, 2) allocation concealment, 3) blinding of participants and personnel, 4) blinding of outcome assessment, 5) incomplete outcome data, 6) selective reporting, and 7) other bias. Review authors ' judgments were categorized as " low risk, " " high risk, " or " unclear risk " of bias. 15 Two authors (A.C., G.S.) independently assessed inclusion criteria, risk of bias, and data extraction. Disagreements were resolved by discussion with a third reviewer (V.B.). All analyses were done using an intention-to- treat approach, evaluating women according to the treatment group to which they were randomly allocated in the original trials. Primary and second- ary outcomes were defined before data extraction. The primary outcome was the mean of duration of labor (in minutes), defined as time from randomiza- tion to delivery. The secondary outcomes were cesarean delivery, operative vaginal delivery (ie, either forceps or vacuum), Apgar score less than 7 at 5 minutes, maternal ketoacidosis, maternal vomit- ing, augmentation of labor, epidural analgesia, regurgitation during general anesthesia, Mendelson syndrome, and admission to the neonatal intensive care unit. We planned to assess the primary outcome in subgroup analyses according to the type of food regimens used by the original trials. All authors were contacted for missing data. The data analysis was completed independently by two authors (A.C., G.S.) using Review Manager 5.3. 474 Ciardulli et al Food Intake in Labor OBSTETRICS & GYNECOLOGY Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The completed analyses were then compared, and any difference was resolved by discussion with a third reviewer (V.B.). Data from each eligible study were extracted without modification of original data onto custom- made data collection forms. A two-by-two table was assessed for relative risk; for continuous outcomes, mean 6 standard deviation were extracted and im- ported into Review Manager 5.3. Meta-analysis was performed using the random- effects model of DerSimonian and Laird to produce summary treatment effects in terms of either a relative risk or a mean difference with 95% confidence interval (CI). Heterogeneity was measured using I 2 (Higgins I 2 ). For outcomes with zero events for both groups, 95% CIs were calculated by using the Poisson method. Potential publication biases were assessed statisti- cally by using Begg ' s and Egger ' s tests. P , .1 was con- sidered statistically significant for publication bias. The meta-analysis was reported following the Preferred Reporting Item for Systematic Reviews and Meta-analyses statement. 16 Before data extrac- tion, the review was registered with the PROSPERO International Prospective Register of Systematic Reviews (registration No. CRD42016049205). RESULTS Ten trials, including 3,982 laboring women, were identified as relevant and included in the meta- analysis (Appendix 1, available online at http:// links.lww.com/AOG/A926) (Laifer et al. Anesthesiol- ogy 2000; personal communication, U. Goodall and A.H. Wallymahmed, 2006). 7 - 14 One study was pub- lished only as abstract (Laifer et al. Anesthesiology 2000) and one as a personal communication (U. Goodall and A.H. Wallymahmed, 2006). No quasirandomized trials were included. Publication bias, assessed using Begg ' s and Egger ' s tests, was not significant ( P 5 .75 and .84, respectively). Five of the 10 included trials (Laifer et al. Anesthesiology 2000) 8 - 10,14 were judged as " low risk " of bias in most of the seven Cochrane domains related to the risk of bias (Fig. 1). All the included studies but one 13 had " low risk " of bias in " random sequence generation. " Adequate methods for allocation of women were used in all the included trials except for three in which details on the methods used to conceal allocation were not reported. 7,11,13 In two double-blind placebo-controlled studies, 9,14 which used colored water as a placebo, neither the Fig. 1. Assessment of risk of bias. A . Summary of risk of bias for each trial. The plus sign indicates low risk of bias, the minus sign indicates high risk of bias, and the question mark indicates unclear risk of bias. B . Risk of bias items presented as percentages across all included studies. Ciardulli. Food Intake in Labor. Obstet Gynecol 2017. VOL. 129, NO. 3, MARCH 2017 Ciardulli et al Food Intake in Labor 475 Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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