Research has not reported any detrimental effects on maternal or neonatal outcomes from allowing food and fluids during labour (CNM Data Group, 1999; Newton & Champion, 1997; O'Reilly, Perrone-Hoyer, & Walsh, 1993). However, hesitancy in instituting changes in regard to this practice persists. Midwifery focuses on the normalcy of childbirth; therefore, if childbirth is a normal physiological process, midwives should not interfere by restricting basic nourishment to a woman in labour. Indeed, it has been suggested that fasting or restricting oral intake in labouring women may cause them to harbor a preoperative attitude to childbirth (Hazle, 1986).

The practice of restricting oral intake during labour was originally introduced in the 1940s to prevent gastric aspiration pneumonitis in the event of operative intervention requiring general anaesthetic (Mendelson, 1946). With advances in midwifery and obstetric practice and refinements of analgesia and anaesthesia, the validity of this practice can be questioned.

With the increased use of regional anaesthesia, researchers report these findings as discouraging (DOH, 1991–1993; Hawkins, Koonin, Palmer, & Gibbs, 1997; James, 1992; Morgan, 1987), although perhaps this can be explained by an increase in cesarean births. The majority of deaths attributed to anaesthesia have occurred during induction of GA for cesarean birth, with unsuccessful intubation and inhalation of gastric contents being the noted causes of operative maternal death (Hawkins, et al., 1997; James, 1992; Morgan, 1987).

Physiological changes in pregnancy contribute to difficulties in intubating obstetric patients. Increased girth-exerting pressure on the stomach and oedema of soft tissue, including the larynx and oropharynx, add to the difficulty in visualising vocal cord structures necessary for successful tracheal intubation (Conklin, 1991; Rasmussen et al., 1994). Deaths related to complications during anaesthesia still occur despite advances in administration and technique (Hawkins, et al, 1997). Anaesthetist experience is an integral part of airway management in the obstetric patient.

In an attempt to change their policy of routine intravenous hydration for all labouring women, Tourangeau and colleagues (1999) conducted a trial in Toronto, Canada, where women received intravenous therapy only if individually required. Women were encouraged to drink and eat small snacks throughout labour. In the convenience sample of 219 women, 162 (74%) received intravenous therapy at some stage during labour for antibiotics, oxytocinon administration, or pre-epidural fluid bolus. Ketonuria was assessed during labour and following delivery. Ketonuria was found to be more frequent in the group of women who did not receive intravenous therapy (50% vs. 36.4%). Following delivery, no extreme ketone values were reported. The study concluded that a serious increase in ketosis did not eventuate when intravenous therapy was withheld. This finding challenges the routine practice of restricting oral intake in labour and the practice of administering intravenous fluids. Clinicians involved in the study agreed that encouraging adequate oral intake and withholding intravenous hydration—unless required—enhanced maternal and neonatal psychological and physiological outcomes (although these outcomes were not mentioned). These findings support Anderson (1998) who considers ketonuria a physiological indication of the body's use of fatty acids as an alternative energy source when oral intake is restricted. Physiologic ketonuria involves no change in maternal blood pH and primarily occurs during excessive exercise and starvation. Due to these findings, labouring women have been compared to competing athletes (Hazle, 1986). Hazle (1986) contends that similarities between labouring women and athletes include a reduction in gastric emptying times (this occurs in the athlete secondary to strenuous exercise). Both utilise glucose stores and oral fluids to sustain blood glucose levels when food is restricted. Hazle (1986) classifies labour as a moderate-to-severe exercise from a cardiovascular perspective, with an increase in cardiac output similar to the competing athlete. However, through his observation of labouring women, Odent (1998) disputes this comparison, theorising that women have a tendency to be immobile in the first stage of labour. Skeletal muscles are at rest and energy expended is minimal. The smooth, involuntary uterine muscle is energy efficient and uses fatty acids deposited during pregnancy as a fuel when intake is restricted. The end products of the metabolism of fatty acids are ketones. Odent (1998) concurs that the excess ketones are excreted in the urine and are a physiological indication of the body's utilisation of fat stores for energy, rather than an indication of dehydration.

No data could be found for Australian units. A limitation of the analysis in Figure 2 is that three of the surveys were conducted in England and all may have involved some of the same maternity units (Berry, 1997; Garcia & Garforth, 1989; Michael et al., 1991). A survey conducted by Michael and colleagues (1991) included maternity units in Wales. It is difficult to approximate the increase in units allowing oral intake over the 10-year period; however, the results reveal approximately one-third of the units in each study allowed any food in labour. The reviewed surveys were replications of postal questionnaires and derived similar findings, substantiating the results (Mitchell, 1994).

Much of the research on policies for oral intake during labour was conducted during the 1980s. Except for Berry's (1997) survey, which was conducted in England in 1993, and a survey conducted in The Netherlands in 1998 by Scheepers and colleagues (1998), no further research was found in the 1990s literature regarding policies for oral intake. This highlights a gap in research regarding oral intake in labour. In the 1980s, oral intake in labour was questioned, researched, and reviewed extensively. During that time, the overwhelming finding was that a restriction of oral intake in labour could not be justified.

Comparing policies in England in the mid- to late-1980s to Berry (1997) it seems apparent that little has changed. Policies remain restrictive and the majority stipulate only fluids once labour has been established. Although Berry's (1997) sample of hospitals was small, (n = 70 maternity units) and therefore cannot be generalised, these policies do not reflect evidence-based practice, which again emphasises the hesitancy of maternity units to instigate policy change.

Oral intake during labour remains controversial. A review of available literature reveals the majority of units allow fluids in labour; however, food remains restricted. Limited research reports on what constitutes appropriate intake. The physiological and psychological needs of labouring women are poorly understood. Recognising and accepting labour and birth as a normal physiological process is not always inherent in the research. The process is unique and cannot be compared or associated with any other “condition” or “situation.” Nutritional needs should not be determined according to energy expended. Women are encouraged to listen to and follow their instincts during labour. Their choice of intake during this time should be observed and respected.

Collaboration and cooperation of anaesthetists, obstetricians, and midwives are required if progress is to be made not only in research but also in the development of unit policy. Policies are needed that allow and support flexibility to follow both a woman's individual body preferences and any particular health issues surrounding her labour. Development of unit policy and education of care providers regarding oral intake are essential to elicit a change in practice. Midwives are an excellent resource for observing, instigating, monitoring, and evaluating policy change; however, awareness of current policy and research is imperative to elicit change.

Education of pregnant women throughout antenatal clinics and classes about the importance of maintaining adequate intake during labour and the existence of policies and research governing this intake will create a heightened awareness of their physiological and psychological needs in labour. This awareness will empower women to make informed decisions regarding intake and may contribute to practice change.