• Implementation of Carbohydrate-Based Liquid Nutrition in Labor

    Author(s): Richard Conley MS, CRNA, Elain Bundy, DNP, CRNP, FNP-C University of Maryland School of Nursing David Sinopoli, MD, MPH, MBA, Natasha Belanger, BSN, RNC-OB, David Ghadisha, MD

    According to the literature, allowing women carbohydrate-based clear liquids in labor can decrease stress, labor pain, and increase satisfaction with the birth experience.


    Problem Statement

    At a large community hospital in the mid-Atlantic region, with over 2,400 deliveries a year, all women were kept fasting during labor

    This outdated practice can lead to:

    • Increased stress
    • Increased labor pain
    • Dissatisfaction with the labor experience

    Current evidence and guidelines support providing clear liquids to laboring women at low risk of an operative delivery and pulmonary aspiration 1- 3

     Objectives

    • Create and implement an evidence-based policy for oral carbohydrate-based liquid nutrition in laboring women at low risk of an operative delivery
    • Develop an evidence-based tool for use by the obstetrical providers to assess risk of an operative delivery
    • Increase the availability of a liquid based nutrition for women at low risk of an operative delivery

    Methods

    • Population: all women admitted for labor during the implementation period at a large community
    • Based upon an evidence search, a tool was developed to assess risk of operative delivery (Figure 1)
    • Women at low risk were ordered a carbohydrate-based clear liquid diet
    • Women at high risk were kept NPO with Ice Chips
      • Education was provided for the staff prior to implementation
      • Anesthesia and Obstetrical staff at weekly department meeting
      • Nursing staff during change of shift huddles over two weeks
      • Staff were given verbal and email reminders on use of the assessment tool, policy, and diet orders
    • Patient charts were reviewed to record the frequency of high/low risk patients, diet orders and high risk characteristics
      • Analyzed using descriptive statistics (Table 1, Figure 2)
    • A Not Human Research Determination by the facility Institutional Review Board was obtained prior to implementation

     

    Figure 1Table 1 Figure 2

     

    Discussion

    • Due to this practice change 98 women were identified as low risk and allowed to have clear liquids during their labor
      • Consistent with the literature, there were no reported complications
    • Identified barriers to compliance:
      • Additional step of adding the clear liquid diet order
      • Disagreement with the high risk characteristics in the assessment tool (maternal age, gestational HTN)
    • Recommendations for continued success:
      • Add the clear liquid diet order to the admission order set
      • Include the assessment tool in the electronic medical record
      • Adjust the operative delivery assessment tool
      • Remove maternal age, gestational HTN, and Illicit drug/alcohol use from the high risk category

     

    Conclusions

    • The project was successful in implementing a policy and assessment tool for carbohydrate-based liquid nutrition in labor
    • According to the literature, allowing women carbohydrate-based clear liquids in labor can decrease stress, labor pain, and increase satisfaction with the birth experience
      • Next Steps: assessment of these quality indicators
    • Recommendations for future QI projects include:
      • Assessment of satisfaction, impact on vaginal versus cesarean delivery rates, and impact on workload for the nursing staff

     

    References

    1. American College of Nurse-Midwives. (2016). Providing Oral Nutrition to Women in Journal of Midwifery & Women’s Health, 61(4), 528–534.
    2. American College of Obstetricians and Gynecologists. (2009). ACOG Committee Opinion No. 441: Oral intake during labo, (Reaffirmed 2017). Obstetrics and Gynecology, 114(3), 714-714.
    3. The American Society of Anesthesiologists. (2016), Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology, 124(2), 270-300 .

     

    Acknowledgements

    • Debbie Kisner, PhD, RN, CNOR, NEA-BC, Chief Nursing Officer, Vice President Patient Care Services, MedStar Franklin Square Medical Center
    • Lynn Petty, MA, RN, NE-BC, Clinical Administrator Women’s and Children’s Service Line. MedStar Franklin Square Medical Center
    • Jennifer K Stephenson, DNP, RN, PDS-EBP and Research, MedStar Franklin Square Medical Center

     

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