The standard policy of limiting food intake during labor began in 1946, when general anesthesia was commonly used in vaginal deliveries. With changes in obstetric anesthesia over the past several decades, aspiration during labor has become so rare that it is difficult to even quantify, and general anesthesia is almost never used in vaginal deliveries. When general anesthesia is used for cesarean deliveries, it is performed much differently than in 1946 and in such a way as to prevent aspiration.
Limitations in this study included the exclusion of parturients who had received systemic opioids, which can delay gastric emptying. Women with initially unempty stomachs were excluded from the study, and future studies should include these patients. The study was also small in size, and larger studies are needed before allowing liberal food intake during labor.
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Many guidelines exist for the management of oral intake in the parturient. Practice guidelines from the American Society of Anesthesiologists (ASA)/Society for Obstetric Anesthesia and Perinatology (SOAP) recommend against solid foods during labor, an approach that is more conservative than some European guidelines. More recently, a statement written by the ASA Committee on Obstetric Anesthesia and accepted by the society’s House of Delegates in October 2022 addressed oral intake during labor based on available evidence. They again did not support the ingestion of solid food during active labor. This paper’s aim was to examine the effects of labor and epidural analgesia on gastric emptying. The researchers questioned the necessity of strict withholding of solid food, citing a maternal mortality rate associated with aspiration of <1 in 1 million pregnancies in the United States. The researchers, using gastric ultrasound examination, found that gastric emptying was indeed delayed in laboring women compared with nonpregnant women and pregnant women not in labor. Perhaps the most intriguing result, however, was that women receiving epidural analgesia during labor had faster gastric emptying than laboring women who did not receive epidural analgesia.
These results are interesting as they suggest that relaxing strict rules regarding no solid food during labor in certain patients may be reasonable. The patient population studied included women who had fasted for solid food at least 6 hours before study participation and women without any significant past medical history. Several exclusion criteria were noted. In addition, although obesity was not an exclusion criterion, it seems unlikely any of the participants were morbidly obese since the mean weights for study groups ranged from 56 to 64 kg. The data, therefore, would not be generalizable for many patient populations, especially for anesthesiologists practicing in the United States where a substantial number of parturients are obese. The women enrolled in the study were fasting on presentation, but most women do not intentionally fast before presenting for labor and delivery. We also know that different types of meals and variable gut health can alter the speed of gastric emptying. In this study, the light meal these women received was yogurt only. Finally, the unpredictable nature of labor can result in precipitous delivery or urgent/emergent cesarean deliveries that may require general endotracheal anesthesia. Allowing women to consume solids could then lead to detrimental consequences. This study does note the stage of labor that patients were in when obtaining an epidural but looking at the effects of various stages of labor on speed of gastric emptying was not an outcome of the study. Perhaps future studies could examine the safety of light meals in labor when comparing the latent and active stages of labor.
Many patients presenting for labor request the relaxation of strict oral intake guidelines. Exhaustion and hunger during a prolonged labor course certainly contribute to poor birth experiences. This article suggests that light meals may ultimately be considered appropriate in select patients This would require strict adherence to and further definition of the composition and volume of a light meal and also risk stratification based on patients’ medical, obstetric, and labor characteristics.
It is very encouraging to see the potential additional benefit of faster gastric emptying associated with epidural labor analgesia. However, there is not yet enough evidence to make policy changes to oral intake guidelines due to the small study size and the lack of generalizability. Additional studies are warranted for determining the risk associated with more liberal oral intake during labor Developing gastric ultrasound skills to use in conjunction with epidural placement may be beneficial to help evaluate risk moving forward. This study shows that with additional evidence, we may be able to improve the experience of laboring women by allowing light meals in fasting women at the beginning of labor if delivery is not imminently expected.
Comment by James Damron, MD and Regina Fragneto, MD
