The positive thing is that the midwife explained to Kate the reason why she could not eat and drink for the duration of her labour because she has the right to know the advantage and disadvantage of eating and drinking in labour in her situation. She did consent to the decision. The subsequent changing Childbirth report, Department of Health (1993) recommends a service that provides women-centred care facilitating choice, continuity and control. The midwife gave Kate informed information and she made an informed choice. The negative thing in Kate’s situation is that she may experience a variety of emotions and being denied food might be an unpleasant experience for her.
The physiological changes and effect of restricting oral intake during pregnancy is as follows, the uterus undergoes a remarkable and unique changes, blood flow to the uterine increase, the vessel diameter increase and vascular resistance fall. The hormonal changes that accompany pregnancy affect the gastrointestinal tract; the gastrointestinal tract is affected by oestrogen and progesterone. The lower oesophageal sphincter is compromised by raised progesterone level and the steady increase in intra-abdominal pressure, whilst the tone in both the upper and lower sphincters is reduced by general anaesthesia. The progesterone relaxes the pregnant women smooth muscle, especially the uterus, alimentary tract and skeletal system. It also affects the gastrointestinal function and relaxation of the smooth muscle results in reduced peristalsis and delayed gastric emptying (Coad and Dunstall, 2001).
Furthermore, during pregnancy glucose and glycogen are most energy substrates and glucose turnover is increased during labour, if glucose is diminished the mother have to use fatty acids for her energy supply. Eating and drinking during labour helps to keep energy levels up and reduces dehydration. (Gibbs and Moddell, 1994). Parsons (2004) emphasize that dehydration is a significant cause of mild ketosis seen in labour. Severe ketosis may progress to ketoacidosis which is life threatening. High level of ketones is related with an increased on the length of labour and an increased need for induction, forceps and blood loss.
In analysing the issue of encouraging Kate to eat and drink during labour. Pengelley and Gyte (1998) stated that the issue around eating and drinking in labour is very controversial in the western world. Michael et al. (1991) demonstrated the variation in a survey of maternity units in England and Wales. Most of the unit that replied, 79.5% had written policy for oral intake in labour and approximately one–third permitted drinks to be taken by all women without a selection criteria the remaining two third was determined by a risk assessment of the woman. The author did not realise there is policies on performing the skill on eating and drinking in labour, it has become just like routine encouraging women to eat and drink but looking from available evidence from 1940s to 1990s most hospital advised to keep women “nil by mouth” or on “only fluids” during labour; to reduce or eliminate Mendelson’s syndrome (1946). The policies now seem to have been replaced by ‘clear fluids’, especially for low-risk labouring women.
However, it was noted in Myles Textbook for midwives that opinions vary widely within different hospitals with some restricting women to ice chips once labour is established while others allow a light diet and free fluids throughout labour (Bennett and Brown, 1996). Furthermore, all the literature reviewed by the author has controversy on the issue whether pregnant woman should eat or drink during labour. Broach and Newton (1988a) states that some women experience hunger or thirst during labour when they are not allowed to eat or drink. The author encourages Kate to eat and drink regularly during her early stage. Champion and McCormick (2002) explained that during labour the muscular activity of the labour is greater therefore, they need adequate oral intake about 700 – 1100 calories per day, like a marathon runner she needs energy to reach her goal. Chern-Hugh (1999) states that physical exertion of labour and birth might be required for a large caloric expenditure. As Kate was not progressing in her labour the policy of nil by mouth was instigated with informed consent. Gibbs and Moddell (1994) stated that an emergency caesarean section couldn’t always be predicted. Oberoi and Phillips (2000) explained that in an attempt to prevent the incidence of aspiration during general anaesthesia, fasting labouring women is the solution. They further explained that is to ensure and empty stomach ‘if’ a general anaesthetic is required during labour. Gibbs and Moddel (1994) state looking at the physiology of pregnancy is such that reflux appears to occur more readily, evidenced by some 80% of women reporting symptom of indigestion and heartburn.
The pregnant woman may suffer from regurgitation if emergency caesarean is needed. However, Ludka and Robert (1993) disagree and state that an attempt to keep the stomach empty is impossible task and fasting itself cannot guarantee an empty stomach or a reduction in acidic gastric content. Glosten (2000) explained that aspiration of gastric content still occur with general anaesthetic to woman who have fasted because gastric aspiration is a problem of poor anaesthetic techniques not with having food in stomach. Michael et al. (1991) emphasize that there is lack of evidence to support the view that fasting during labour reduces the incidence of aspiration.
Aspiration is considered to be a significant cause of maternal mortality and morbidity. However the latest Report on Confidential Enquiries into Maternal Deaths for 1988-1990 reported one death and one late death possibly attributed to aspiration of gastric contents. It was concluded that the maternal death was attributed to a lot of factors (Department of Health, 1994). Further evidence suggest that some especially those enduring long labour, longer than 24 hours for nulliparous and 18 hour for multipaous fasting can be detrimental for the mother and baby and progressing of labour (Kristensen et al. 1991). Robert and Ludka (1993) have found the presence of ketosis during labour to be the key issue and that; it was directly related to prolonged lengths of labour. Boyle (1997) states there is no significant research to substantiates the belief that restricting oral intake for labouring women is detrimental. Enkin et al. (2000) explained that many women restricted oral intake poses no problem because many do not want to eat, but for those who might want to eat when hungry can be a highly unpleasant experience.
Champion and McCormick (2000) state that food is more than fuel and is associated with comfort and security. Newton and Champion (1997) also emphasize that finding have shown from Nottingham study in 1995 that women who could choose to eat and drink during labour felt they had more control over their labour. Chern-Hughes (1999) believed that restriction of oral intake might affect the labouring women psychologically by increasing her perception of pain and reducing the morale, which in turn may adversely affect the progress of labour and result in snowballing effect of medical intervention. Kate had a caesarean section performed under and epidural.
The author have realised that the vast majority of women, starving makes no sense if its only purpose is to minimise the risks of regurgitation under general anaesthetic. It could be argued that far fewer women wouldn’t need a caesarean anyway if they were allowed and encouraged to keep their energy up by eating as they pleased during labour. Lewis (1998) state that it appears that professional attitude determine policy for oral intake in labour. Lewis (1998) went on to say that some obstetricians and anaesthetist prefer to treat all labouring women as presurgical patients. The Department of Health (1993) emphasis the value of research based practice and states that practice should be based on evidence based. However, Sloutel and Golden (1999) states that restriction of oral intake for labouring woman is still a tradition that continues without evidence of improved outcomes for women. Sharp (1997) states despite this is not supported by research women are still denied oral intake guided with variation of hospital policies of maternity unit in England and Wales. Reflection is about understanding and changing practice. The author felt participating in the skill has broadened her knowledge and information on eating and drinking in labour. The skill had given the author the ability to encourage and advice women on eating and drinking during their labour.
In conclusion the essay has reflected on the skill practised in encouragement of women to eating and drinking during labour. The policy on eating and drinking was discussed. The author has review what was learnt from available evidence on eating and drinking in labour and a case study on Kate. The evidence have clearly shown that the system in the UK is inconsistent and illogical and it is hardly surprising that midwives and trainee anaesthetists feels no compulsion to follow the different local protocol. Furthermore, the reviews highlight the need for more evidence about the obstetric risks and benefits of feeding. Finally the author will recognise key elements of similar experience and combine them into innovative solutions individually designed for new problem. The author is confident that she will be able to handle similar situation if it should arise again.
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