ORIGINAL RESEARCH

Food management during childbirth under woman's perception

Laura Maria Tenório Ribeiro Pinto^I; Maria Cristina Soares Figueiredo Trezza^II; Amuzza Aylla Pereira dos Santos^III; Géssyca Cavalcante de Melo^IV; Jovânia Marques de Oliveira Silva^V; Larissa Lages Ferrer de Oliveira^VI

^I Obstetric Nurse. Master student from the Universidade Federal de Alagoas. Maceió, Alagoas, Brazil. E-mail: lauraatenorio@gmail.com
^II Post-PhD in Nursing, Universidade Federal do Rio de Janeiro. Professor, School of Nursing and Pharmacy, Universidade Federal de Alagoas. Maceió, Alagoas, Brazil. E-mail: trezzacris@gmail.com
^III PhD in Health Sciences. Professor, School of Nursing and Pharmacy, Universidade Federal de Alagoas. Brasil. E-mail: amuzzasantos@bol.com.br
^IV Master in Nursing by the Graduate Program in Nursing, Universidade Federal de Alagoas. Maceió, Alagoas, Brazil. E-mail: gessycamelo@hotmail.com
^V PhD in Nursing, Universidade Federal da Bahia. Professor, School of Nursing and Pharmacy, Universidade Federal de Alagoas. Brazil. E-mail: jovaniasilva@gmail.com
^VI Obstetric Nurse. Master student, Universidade Federal de Alagoas. Maceió, Alagoas, Brazil. E-mail: larissalagesf@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.14205

ABSTRACT

Objective: to analyze women's dietary experiences during childbirth. Method: this descriptive and qualitative study was carried out with 40 puerperal women who were in the Rooming In of three maternity hospitals in Maceió, Brazil. Data were collected through semi-structured and audio-taped interviews. Results: the data showed that fasting during labor and delivery still appears as a hospital routine. On the other hand, women who experienced the fasting understood that gettimg feeded at this moment would provide them good condition during labor. Conclusion: to appreciate women's beliefs is inherent in midwifery care, since they are the ones that experience the whole process. Thus, it is possible that the childbirth becomes a more natural and physiological proccess, where the woman is the protagonist.

Keywords: Food; diet; labor; natural childbirth.

INTRODUCTION

Over the years, the World Health Organization (WHO) has been in constant development to build a new paradigm of care to women's health in the puerperal-pregnancy cycle. In this way, it has been sought a comprehensive obstetric care permeated by a quality assistance, based on assistance practices grounded on scientific evidence, on women's right to choose and on the minimization of interventions at this moment^1,2.

In Brazil, the Ministry of Health (MoH) has corroborated this same orientation through the development of public policies on women's health, prioritizing a comprehensive care and the retrieval of the physiology of childbirth and humanized care in this context³. For this purpose, the Program for the Humanization of Labor and Birth (PHPN in Portuguese) was created in the 2000s, as well as the financing and encouragement of professional qualification in this area through the implementation of the Stork Network^1,4.

In 2014, the Brazilian MoH launched the Booklet for the Humanization of Labor and Birth, which emphasizes that better maternal and perinatal outcomes occur when labor flows as a physiological and natural process, and that interventions during labor should only be applied when complications that justify these interventions arise⁵.

In this sense, by correlating unnecessary interventionism and the humanization of women's care during labor, we step into the object of this study, revealing that the provision of food to the woman refers to a behavior that follows the precepts of the humanization of care during labor and birth. Humanization is understood as a quality service based on professionals' recognition of the aspects that women value and express through their verbal, corporal, cultural and social language. Thus, childbirth should be a moment of women's exercise of autonomy^4,5 .

Restricting the intake of solid and liquid food during labor is a common routine in current hospital care. It is supported by the fear of vomiting and by the intent to prevent the risk of gastric aspiration. However, this risk is related to the use of general anesthesia in childbirth, which is very little used today, and, according to obstetric evidence, food restriction is a hospital routine to be discontinued among women with low-risk gestation⁵.

Studies based on obstetrical evidence have put into practice the assistance to laboring women proposed by WHO. These studies were transformed into a guideline, in which food restriction emerges as a hospital routine to be discontinued. In agreement with this same proposal, we propose, in this scope, the accomplishment of further evidence-based research that consider women's subjectivity and opinion about feeding during the childbirth⁵.

From this perspective, the present research had as guiding question: what are women's eating experiences during childbirth? For this purpose, the objective set was to analyze the eating experiences of women during labor.

LITERATURE REVIEW

The debate over the provision of food to laboring women has persisted since the 1940s, when Dr. Curtis Mendelson proposed restricting the intake of solid and liquid foods during labor and delivery and the administration of hot antacid before cesarean surgery with the purpose of reducing the stomach volume, minimizing the risk of aspiration of gastric contents, in the case of a general anesthesia was necessary⁶.

Since then, the practice of feeding laboring women has been considered clinically unacceptable, and the politics of nothing by mouth has been introduced in obstetric units as a way to reduce this risk by using fasting as a measure⁷.

In recent years, the feeding behavior of laboring women has been outlined in a different way from what was proposed decades ago, in which fasting was the guiding practice of food management during labor. Thus, there has been the insertion of care practices that consider the provision of clear liquids and soft and/or light diets to the laboring women, in order to guarantee maternal-fetal well-being⁵.

According to a systematic review indexed in Cochrane, the food management of 3,130 low-risk laboring women was analyzed, and there were no significant differences between women who had food intake restricted and those to whom it was not restricted. It concluded that food restriction during labor is not justified. At the same time, it demonstrates the need for studies that contemplate the evaluation of women's opinions on this subject^8,9.

In fact, studies have found that most of these women wish to eat and drink at this time, especially during the initial phase, and claim that a decrease in that desire naturally occurs with the progression of labor. Thus, although some studies have reported that food increases the incidence of nausea and vomiting, women themselves consider the significance of these symptoms in relation to the foods they desire and those offered to them by the health team. It is noteworthy that women themselves are able to adjust their oral intake to meet both their needs and their preferences at childbirth. This regulation of women's own diet decreases stress levels and promotes a feeling of self-control and greater satisfaction^8-10.

These studies reveal that there is a need for analysis and reflection on the importance of reviewing childbirth as a natural process with the provision of care based on scientific evidence. Moreover, the excessive modernization and technology available for childbirth has caused that professionals have lost the confidence in themselves, placing it blindly in science¹⁰.

In this sense, professionals' positions regarding food intake during labor are controversial; therefore, further research are necessary in this field to support wise decision-making.

METHODOLOGY

This is a descriptive study with a qualitative approach, carried out in the rooming-in of three low-risk maternity hospitals in the municipality of Maceió/AL. A total of 40 postpartum women who had undergone natural childbirth participated in the study. Inclusion criteria were being over 18 years old, voluntarily accepting to participate in the research and being physically and emotionally able to answer the questions of the data collection instrument. Exclusion criteria were being a puerperal woman who had experienced natural childbirth with fetal death.

The scenarios were randomly referred to by the letters A, B and C and the puerperal women were characterized according to the chronological order of the interviews, being identified by the variations of the letters A (A1 to A10), B (B1 to B10) and C C1 to C20), in order to maintain the anonymity of institutions and preserve the identity of the interviewees.

Data collection was guided by a semi-structured form elaborated according to the practices based on obstetrical evidence and contained questions that allowed the characterization of the subjects as well as subjective questions about the eating experiences of women during natural labor. Information on the professionals' behavior related to women's food management were collected directly in the medical records, as a form of certification of some questions of the research form.

In accordance with the legislation regulating the conduct of research involving human beings, included in Resolution 466 of December 12, 2012 of the National Health Council¹¹, the present study was only started after the project was approved by the Research Ethics Committee of the Universidade Federal de Alagoas, under process number 30773714.7.0000.5013. The study was carried out from March to November 2014.

The interviews were recorded and the analysis of the information began with transcriptions of the subjects' speeches in full, complemented with the information obtained in the records, data organization, pre-analysis, reading of the produced texts, categorization and analysis of qualitative data¹². Three thematic categories emerged from the analysis of the speeches: the woman's food intake before hospitalization; food intake during hospitalization and the first food intake after childbirth.

RESULTS AND DISCUSSION

The woman's food intake before hospitalization

At the beginning of the development of civilizations, the care of women during childbirth was carried out in their homes by midwives, who were considered as reliable persons by the pregnant woman or who had recognized experience in the community. Childbirth was considered a natural and physiological phenomenon, in which the female instinct would guide this process and the midwife would help in the development thereof^10,13.

In this sense, the present study revealed how the influences of the socio-cultural practices is linked to the way women had conducted their food intake at home when they supposed to be in labor.

These women reported that they had not eaten before leaving home due to the advice of people close to them (mother, sister, friends and neighbors), or because they had been on a journey for a long time in search of a maternity hospital, or because they felt that food intake would bring problems to the delivery process. Such conditions can be seen in the testimonials:

Some women had fasted due to the pilgrimage experienced in search of a maternity hospital:

And others because they thought that food intake would cause problems for childbirth:

Coupled with the assumption that labor is near, these women are advised to take various measures during this time. In this context, socio-cultural practices regarding food management at delivery directs the woman's posture on the best way to proceed with it through the assumption that they can prevent the occurrence of any risk at birth.

It is known that people's behaviors are dictated by their own culture, which arises from the social interaction from birth, especially with family members. That is, the interaction between people produces the meanings (beliefs and cultural values) that coordinate the way of acting of each one and of society^5,14.

Food intake during hospitalization

When the woman notices the onset of the signs and symptoms that precede delivery, she quickly seeks maternity for the birth of her baby. This decision is justified by the global change in the place of delivery that has passed into the hospital scenario. This change has begun in the mid-nineteenth century, fostered by the relationship between technology and safety.

Thus, women have come to believe in a practice of institutionalized, interventionist and medicalized childbirth care, which has been the only one considered safe^14,15. Thus, the establishment of a new model of childbirth care, valued in routine, standardized and interventional obstetrical practices has emerged.

Due to the numerous activities that professionals must perform during hospital admission, they often end up addressing these women merely through technical procedures centered on the development of childbirth¹⁵ .

In this sense, it was noticed that the food supply to women during hospitalization cannot be insignificant, since when these women perceive that childbirth is close, many of them stay a long time without feeding in their homes.

Among the women interviewed, some were not offered food during labor, while others were fed. Thus, fasting or food restriction continues to be proposed by professionals. However, this practice may be considered as an outdated practice, as scientific obstetric evidence shows that there is no justification for the application of fasting to laboring women at normal risk^5,8,9. It was also found that some women received food offers during childbirth, demonstrating that there has been already a change in the assistance related to food management by some professionals.

Corroborating with these data, the researchers confirmed in the medical records the behavior adopted towards feeding during childbirth. The indication of fasting by the professionals stood out, who preserved the null diet during labor. It was also noticed that feeding was left in the background during the care, because professionals had not recorded data on this issue in the medical records. On the other hand, some have adopted the obstetric evidence referring to food management, not restricting food.

In this context, women who had not received food during childbirth justified the fact of not eating until the birth of their babies mainly by the recommendation of health professionals. Some reported not feeling hungry, but some others decided not to eat in order not to defecate during childbirth, which is demonstrated in the following statements:

It is noteworthy that, with the institutionalization of childbirth, the professionals have seized the woman's body and used the routine obstetric practice of total food restriction, based mainly on the justification of the probable evolution of a normal delivery to a cesarean surgery. Family and individual beliefs about not eating during labor are still present during hospitalization and can be a determining factor for the development of labor.

In this context, food restriction often leads to the use of intravenous infusions. The prescriptions of the women interviewed included the use of 5% glucose serum or 5% glucose solution with oxytocin.

The biochemical effects of intravenous glucose solutions during labor were evaluated in several controlled studies, which demonstrated that the use of these solutions may result in an increase in blood glucose levels of the baby and also a decrease in pH in the umbilical artery blood due to excessive production of insulin in the fetus when women receive more than 25g of glucose intravenously during labor, which can lead to hypoglycemia and elevated levels of lactate in the baby, in addition to restricting women's movements^5,8.

These possible risks of intravenous infusions could be avoided by the simpler and more natural way of allowing women to eat and drink during childbirth, placing them as the protagonist of that moment. However, the interventionist and medicalized model prevents labor from occurring as a physiological process, and intravenous catheterization becomes commonplace^5,8,9.

The provision of food during childbirth should be encouraged in the care, aiming to reduce interventions at that time and promote comfort, in addition to considering the preferences of women, which favors their autonomy in the course of the labor process^16,17.

The first food intake after childbirth

After giving birth, women stay hospitalized as expected, and the studied cycle of food management ends when they receive their first feeding after childbirth. The hospital food routine caught the researchers' attention as, according to the data on the times in which the meals are served in each maternity hospital, some women had been fed only at the time established by the institution, while others received food of the hospital routine. The following statements represent how this experience reflected for women:

Considering these data, the woman's opinion about the importance of the feeding behavior during childbirth was a decisive target in the course of this study - to evaluate this moment under the eyes of those who are experiencing it.

For women who find it important, feeding provides the energy they need to withstand contractions and use strength to expel their children during labor and to ensure a good body condition after giving birth, avoiding dizziness, weakness and fainting. Here are the reports:

Of those who reported not being important to feed themselves, the justifications revealed several aspects, one of them was the fear that the delivery would progress to a cesarean as informed by the professional who attended her:

Reports of nausea have been understood as negative events in childbirth, being the feeding its cause and, therefore, should not be desired:

The influence of sociocultural values built through the interaction with relatives and close friends determined the relevance of feeding during childbirth:

Pain at birth was also considered:

In this way, several recommendations emerged about the types of foods they would like to have eaten and those they would indicate to other women during childbirth. Among them, it was highlighted the indication of feeding with juices, fruits and liquids:

The predominant recommendation made by women was feeding with juices, fruit and soup, corroborating with the indication of Brazilian MoH, which encourages the ingestion of light foods and/or fluids³. However, others have recommended the consumption of a reinforced diet, composed of foods that guarantee energy during childbirth. There have also been reports that a woman should eat what she is used to or whatever she wants. There were still those who reported that, at that moment, anything offered was good, or even those that indicated fasting.

Women consider that feeding is essential for the proper development of childbirth, because it will bring strength and energy for that moment, and consequently, it will bring benefits both for the laboring women and for the birth of their children. Thus, the physiology of childbirth should be incorporated into the principles of care with the aim of democratizing the relationships between professionals and patients, sharing of knowledge and valuing multiplicity, diversity and singularities, thus providing women's autonomy during childbirth^18,19.

CONCLUSION

Food management of women during childbirth has been approached superficially, with fasting being the most recommended practice for laboring women in the present moment, linked to the routine use of intravenous infusions. Such conducts are not recommended by obstetrical evidence. At the same time, women value the act of receiving food at this time, relating it to the good development of childbirth.

Health professionals need to update their knowledge regarding the most appropriate food management to laboring women, avoiding basing their behavior on childbirth care in customs and routines. At the same time, information on this subject should be provided since the contact with the pregnant women in prenatal care with the purpose of overcoming empirical practices, providing these women with better obstetric care and a more natural and physiological way of experiencing childbirth.

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