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Monday, May 7, 2012

I can has cheezburger? Rethinking the "nothing by mouth" rule

I can has cheezburger (in labor)?
For decades it's been common hospital practice to restrict women from eating or drinking during labor. The ubiquitous cup of ice chips has probably been featured in every movie and sitcom featuring birth, but do we really know why - or even when - this "rule" came about?

In 1946, Dr. Curtis Mendelson studied the medical records of over 44,000 women and found that 66 of them experienced pulmonary aspiration - the process of taking food, fluids or secretions into the lungs, essentially. Forty of those women aspirated liquids; only five aspirated food. Only two of the women died.

One of the risk factors for aspiration is anesthesia - which causes the normal protective reflexes such as swallowing or coughing to be diminished. Therefore, Mendelson surmised that because that danger is there, common practice should simply be to cut off all food and fluids to a laboring woman, just in case. Another risk factor is the lithotomy position, the manner in which probably every laboring woman during Mendelson's stint in obstetrics gave birth.

In Dr. Mendelson's day, general anesthesia was widely used in childbirth, even in vaginal deliveries. Therefore there was greater risk - but as you can see from his study of the 44,000 women, the risk even then was still quite low. Today, few women receive general anesthesia during birth - somewhere between 3 to 13 percent of women undergo it for a cesarean section - and it's much safer and used with greater knowledge and skill today than 65 years ago. So why do we still follow this outdated rule?

Studies have recently shown that prohibiting food and drink in labor serves little if any benefit. What it can do is practically starve the laboring woman, especially if her labor is a long one, during a time when her body needs crucial energy. Maternal exhaustion can be a factor in many long labors that end in cesarean.

In other countries, such as the UK and The Netherlands, many care providers leave the decision to eat and drink up to the mother. A majority of hospitals in both countries do allow the woman to drink, and about a third allow both fluids and food. In US hospitals, it's more commonplace to be restricted to just ice chips, although things are changing - slowly.

The common alternative to the "nothing by mouth" rule is to administer fluids intravenously, which has it's own set of disadvantages. Being hooked up to an IV pole can severely curtail movement, which limits your ability to cope with pain and probably means you'll want an epidural if you're confined to bed. Although it's possible to just trek around the hospital hallways with your IV pole in tow, I think in my childbirth experiences I've only ever seen one woman do it. Some that I talked to said they basically weren't allowed to walk the hallways at all. Excess fluids can pose problems, including fluid overload. It can also impact what is perceived to be newborn weight loss if a mother has received lots of IV fluids, which might hamper breastfeeding relationships if care providers fail to take this into account.

Some studies show no difference in outcomes between the groups who were allowed to eat and drink freely and those who weren't. Other studies show that it shortens labor and reduces the need for Pitocin. And still other studies found that among those who drank large amounts of fluid, they actually experienced failure to progress more frequently (no word on whether they were allowed to empty their bladders, though, which can make a difference in some women).

Other concerns that some obstetricians have is that eating and drinking can cause nausea, even though at least one study showed that none of the participants experienced nausea (all women drank fluids and 85 percent of them ate food). It's also common for women to experience nausea and vomiting anyway because of transition, which is a totally normal process of labor.

While many women might not want to eat anything, the choice should still be left up to them. I personally made sure to eat something simple - a piece of bread with butter on it and a glass of orange juice - before leaving the house to head to the hospital. In my VBAC labor, I drank bottled water but didn't feel hungry, even though I gave birth close to lunchtime. I ate the same thing prior to my last birth, which ended in cesarean, and the anesthesiologist was excessively worried about the lone piece of bread I ingested over an hour before. It wasn't a problem, but ironically I had a bad reaction to the Reglan they gave me for nausea. We have to ask ourselves: what about risks among the general non-pregnant population? Should we make everyone eat nothing for six to eight hours prior to getting in their car simply because they might get into an accident and need surgery? Of course not!

It will be interesting to see if more OB's, hospitals and even patients get on board with this idea - and realize the notion of limiting oral intake for every woman, regardless of risk, is more outdated obstetrics than "modern."

More reading:
Should we eat or drink in labor? - by Robin Elise Weiss, LCCE
Mendelson's Syndrome
Oral Intake During Labor: A Review of the Evidence


Deena Blumenfeld RYT, RPYT, LCCE said...

Thank you for writing this! I teach my childbirth ed. students they should eat and drink as they see fit. Honestly, most birth professionals I know, understand that no food by mouth is bunk... but it's hospital policy, so they are stuck with it. We are hard pressed to find the OBs and nurses to fight this openly.

Enjoy Birth said...

I had a doctor tell a mom she can't have a cheeseburger while in labor - it will kill her. It was so absurd that I blogged about it and refuted why she most certainly would live.

I may be a bit biased because I ate a hamburger during my last birth and lived to tell the tale.

Thanks for reassuring women that it is safe to eat during birth and it should be their choice if they want to or not.