No Justification for NPO

The Cochrane Collaboration recently issued its finding on the topic of NPO or “nothing by mouth” [non per os], saying that restricting a woman in labor from eating if she’s hungry and drinking if she’s thirsty is not evidence-based. It also coincides with the recommendations made by the World Health Organization’s guidelines for Safe Motherhood, which I wrote about in this post almost a year ago:

The World Health Organization (see pp. 13-14 for the specific discussion on this) says that while a few women who are at high risk for the potential of general anesthesia may need to restrict food and drink in anticipation of such surgery, that restriction should not be extended to all women, since labor “requires enormous amounts of energy. As the length of labour and delivery cannot be predicted, the sources of energy need to be replenished in order to ensure fetal and maternal well-being.” They conclude the section by saying, “The correct approach seems to be not to interfere with the women’s wish for food and drink during labour and delivery, because in normal childbirth there should be a valid reason to interfere with the natural process. However, there are so many die-hard fears and routines all over the world that each needs to be dealt with in a different way.”

Glad to see that obstetrics is finally catching up to what midwives have known all along. 🙂 Once this becomes ingrained, and routine starvation of women in labor is a distant memory, I’m sure Dr. Amy will point to that along with other hallmarks of “modern obstetrics” as being “midwives only doing what doctors are doing, so they shouldn’t claim any credit for the idea.” 😉

The sad thing to me, though, is that the current and modern practice of NPO is based on a study from 1940, as if nothing had changed in obstetrics or medicine since that time, which would render NPO obsolete, along with routine pubic shaves, enemas, etc., etc. Sheridan at EnjoyBirth wrote a post along these lines several months ago, titled, “Death by Cheeseburger?” which breaks it down this way:

So, while aspiration is a very, very, very small risk***

for Jane Doe, it could happen

If she needs an emergency cesarean

with general anesthesia

and if her anesthesiologist doesn’t intubate well

and she vomits

she may aspirate some vomit

which could cause complications

one of them potentially being death.

…So about 10 in 100,000 moms die due to childbirth in the US.  (I found stats ranging from 9.3 to 11, but to make the math easier, I chose 10.)  Which is the same as 100 in 1 million moms.  So the only statistic I found that could be aspiration related said 6%.  SO –

6 in 1 million moms, who die due to birth related causes, could be due to aspiration.

Which equals 0.000006% chance of dying from aspiration.  Which numerically speaking is a very, very, very small risk.

The post was written because an obstetrician told a patient that aspiration was “the #1 cause of death during birth” is aspiration. Not hardly.

[Update: a 2006 study reported that little is known about eating and drinking in labor, saying, “Only one study evaluated the probable risk of maternal aspiration mortality, which is approximately 7 in 10 million births.”]

Some doctors will almost certainly still try to use this study to justify NPO, I suppose based on the lack of a recommendation to require eating, or that the measured results (which did not include maternal satisfaction, btw) were no different whether the women were assigned to eating or starving, so, “since it doesn’t make any difference,” why not continue restricting food and beverages? Um, sorry, BZZZZ wrong answer! It is the intervention which requires justification, not what is otherwise natural (eating when hungry, drinking when thirsty). You first have to prove that intervention is better than not intervening — that there is overriding benefit from the intervention. And if anyone disagrees with these results, then what they need to help fund a large, well-designed study that is somehow better than the studies already done, to prove a benefit to NPO, not just “a lack of harm.” Until there is proof that NPO is beneficial, or that eating and drinking as desired is harmful, then doctors have no evidence to restrict food or beverages from laboring women.


9 Responses

  1. I’m always very confused by this, why would a woman follow this order? It has to be the easiest one to ignore without being called on it by the doctor/nurse. (nurse leaves room, laboring woman turns to husband ‘I’m thristy, would you get me a drink?’, husband hands wife ‘his’ drink, woman drinks to satisfaction, doctor/nurse none the wiser…same thing with food) I’m truly puzzled by it, what do women think the hospital is going to do? Stick a endoscope down their throats to check for food/drink and pump their stomach in the middle of labor? I’ve asked people before, what if the woman just ignores this? and never gotten an answer. This seems so simple, they can’t keep you from eating/drinking, so why bother listening/obeying if you disagree? (although obviously I think its stupid that they continue to tell you not to eat/drink)

    • I know — it always puzzles me a bit too. Part of the problem, I think, is the whole “authority” complex — doctor and/or nurses say it’s forbidden, and we want to be good, obedient and compliant, so we follow orders. Or they don’t want to make waves, or risk having the nurse turn into Attila the Hun or something. Or they think that there is a real risk or danger (as opposed to 0.000006%), and they want to “be safe.” And if husbands buy into that (and most guys *are* protective of their wives, and want to do their part to keep them safe), then they will step into protector-role and remind their hungry or thirsty wives that it’s not good/allowed/safe for them to have anything. *And* a guy would look like a lout if he eats in front of his starving wife who is not allowed food, so he would likely raise a few eyebrows for bringing food into the room “just for him.”

      There are some nurses who have a “don’t ask, don’t tell” attitude, or even hint that the women should eat if they’re hungry — saying things like, “It’s hospital policy for you not to eat anything… but what I don’t see, I can’t stop” {wink-wink}. And it’s not uncommon in birth-junkie type sources to give tips on how to appear compliant with NPO while still having sustenance: freeze juice in cubes and pretend it’s ice, making sure the cup has a lid on it so the nurse is none the wiser, packing food like granola bars in your luggage, etc. Still, it’s irritating to have to sneak around like a child, especially as we know now that there is no evidence for it.

  2. To be honest, I didn’t want to eat during either of my labors. But what killed me during my first labor in the hospital was NO WATER. Ice chips, pfft. I was so thirsty after laboring for 46 hours that all I could think about was having a big mug of ice cold water at the end. I wasn’t even thinking about my baby. How sad is that? And when I did get my big mug of water, I gulped it down so fast that the nurse CHASTISED ME. Why, I have no idea, but I told her, “I haven’t had anything to drink for TWO DAYS.” (so leave me the hell alone!)

    We’d never expect a marathon runner to complete a race without water. Labor is just as much hard work.

    • Sad. 😦

      I didn’t want anything during my first labor, but am sure I ate something during my second — I just don’t remember anything in particular. I was “waiting for *real* labor to start,” during the course of that 24 hours, so I’m sure I ate fairly “normally,” but it didn’t register as “eating during labor.”

  3. Funny, I don’t see aspiration even listed in the causes of maternal mortality on the WHO 2005 report:

    Severe bleeding (haemorrhage) 25%
    Infections 15%
    Eclampsia 12%
    Obstructed labour 8%
    Unsafe abortion 13%
    Indirect causes 20%
    Other direct causes 8%

    Detail on direct and indirect causes:

    Maternal deaths due to indirect causes represent 20% of the global total. They are caused by diseases (pre-existing or concurrent) that are not complications
    of pregnancy, but complicate pregnancy or are aggravated by it. These include malaria, anaemia, HIV/AIDS and cardiovascular disease. Their role in maternal mortality varies from country to country, according to the epidemiological context and the health system’s effectiveness in responding (10).

    The lion’s share of maternal deaths is attributable to direct causes. Direct maternal deaths follow complications of pregnancy and childbirth, or are caused by any interventions, omissions, incorrect treatment or events that result from these complications, including complications from (unsafe) abortion.

    • “Global” maternal mortality causes are going to be quite different from causes of maternal mortality in developed countries — 99% of all maternal deaths occur in “developing” countries, mostly in sub-Saharan Africa and poor countries in Asia. Aspiration is only going to be a problem for women who are under general anesthesia — if a country or area doesn’t have the facilities for emergency surgery, they’re not going to be at risk at all for aspiration… but they will be at risk of death from diseases or other causes. Few or no women in America are going to die of malaria, infections, eclampsia, or obstructed labor, because we have ample and easy access to safe C-sections, clean water, antibiotics, etc. In America, we have to worry about maternal mortality from reasons of obesity and other “diseases of luxury” (if you will).

    • AYC,

      Here is a Joint Commission document which states, “According to a study by the CDC of pregnancy-related mortality in the U.S. between 1991 and 1997, (5) the leading causes of maternal death are: hemorrhage, hypertensive disorder, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing chronic conditions (such as cardiovascular disease).” This demonstrates the difference that exists between the causes of maternal mortality in developed and developing countries. But aspiration didn’t make this list, either. And I updated the post above with a link to an abstract that noted that one study estimated the risk of maternal death due to aspiration to be 7 in 10,000,000 births.

  4. I know that if baby is not showing much variation during a NST they encourage drinkng, it wakes the baby up. I would think that some decels/limited variability on the strip can occur with NPO. Somethng about that ice cold drink rouses baby as does any food.

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