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.

“Nothing by mouth?” — not so fast!

Often when women are in labor, they are forbidden by the hospital from eating or drinking anything — perhaps they may be allowed to suck on ice chips or a popsicle or something like that, but everything else is forbidden. (Not every hospital is like that; and some hospitals have “official policies against it” but nurses may say “you’re not supposed to eat, but of course if I don’t see it, I can’t stop you”).

This arcane policy goes back to the days when women were routinely knocked out for birth, and of course before any planned surgery (in this case, the only “surgery” planned was the routine episiotomy — and, yes, the cutting of vaginas is technically a surgery) or any other procedure in which a person is given general anesthesia, it is accepted practice to prevent the patient from eating or drinking, to minimize nausea and vomiting while unconscious, and particularly the danger of breathing in the vomit, which may result in serious complications or even death. Of course, it is also standard practice to put a breathing tube down a person’s throat when s/he’s put under so as to eliminate even this small risk — especially since the stomach is never completely empty, and inhaling straight gastric juice is not good for you either!

But, even as routine “knock ’em out & drag ’em out” births went the way of the dodo, the practice of “nothing by mouth” (npo, non per os) remained. The technical reasoning for this was that some women may require general anesthesia during or after birth (emergency C-section, hysterectomy, etc.), so it was considered safer to keep all women from eating and drinking anything. Of course, the actual likelihood of these things happening (especially with local anesthesia and epidurals being much more common than general anesthesia), as opposed to risks and downsides from women and babies starving for hours is usually not discussed — interventions are easily begun but terribly difficult to stop.

Hypothetically, had the practice of food restriction never begun and become engrained and entrenched in American birth, do you think it would be started today? Food for thought. Why or why not? And furthermore, do you think that before it became widespread, it would be subjected to rigorous study before being implemented? I would like to think that, no, it would not even get started; but that if somebody had the “bright idea” to start it, that it would be subjected to studies before it became widespread. (Hey, I can hope, can’t I? Obstetrics is supposed to be evidence-based medicine, after all!)

But now, like so many things, something that is normal and natural (eating when hungry, drinking when thirsty) is forced to defend itself, and to prove that it is either beneficial or at least not harmful. At least they’re studying it! This is not the first study to look at maternal eating and drinking during labor, but it is the most recent one. 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.”

If you don’t want to eat or drink during labor, then that’s fine — I didn’t in my first labor, and threw up every time the midwife made me drink apple juice. (Being a first-time mom, she figured I’d take a long time to labor, so she wanted to make sure I didn’t dehydrate or get too weak or otherwise have a problem and end up having to transfer to the hospital.) And if you choose to eat or drink, make sure that whatever you consume will also come back up easily — in other words, no orange juice, because it’s nasty when vomited back up! If you’re trying to figure out what you should eat or drink in labor, pretend you’ve got a stomach virus and choose accordingly — nothing greasy or heavy — that sort of thing.

Oh, and print out a copy of pertinent documents to take with you to the hospital, so that if they pull the “it’s not safe for you to eat or drink while you’re in labor,” you can say, “Oh, yeah? Who says? — Not according to this!” 🙂


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It might have happened — what then?

Women are often told not to eat when they’re in labor. In fact, I heard one story in which a woman was having some early labor, and called the hospital to see if it was “real labor” or not, and while they didn’t say that it was or wasn’t, they told her that if she thought she was in labor not to eat. It was Thanksgiving Day. She had looked forward to the sumptuous spread all year, and she had to spend the day smelling the delicious food being prepared, but was not allowed to eat a bite. Why?

The rationale is that you might need general anesthesia at some point (for an emergency C-section and/or hysterectomy), and you might vomit the contents of your stomach when you’re unconscious, and it might be inhaled, and it might cause aspiration pneumonia or even death. The risk is slight, but real. A relative of a friend died because of this several years ago, when she had a tonsillectomy. They have anesthesia procedures that when followed properly almost entirely eliminate this possibility, but doctors are human too so there is always a tiny possibility that something could go wrong.

According to this article, the likelihood of a first-time mom giving birth vaginally having a hysterectomy is 1 in 30,000, but the risk increases dramatically if you’ve had a prior C-section. Emergency hysterectomies are usually performed for uncontrolled bleeding after birth, if other measures to stop the bleeding have failed. Obviously, it’s rare. Up to 30% of U.S. women now give birth via abdominal surgery, but C-sections under general anesthesia are rare, because even most unplanned C-sections are not true emergencies, and there is time to place or strengthen epidural anesthesia. So, the likelihood of you needing general anesthesia is very slight. Also, according to Henci Goer’s The Thinking Woman’s Guide to a Better Birth, p. 77, studies show that “no time interval since the last oral intake guarantees a stomach volume below [25 ml — the “threshold of risk”] in a pregnant woman. In fact, no time interval guarantees a volume of less than 100 ml.”

Now on to the “what if.”

When I had my first baby, my water broke before I had any contractions. There was no warning that labor was going to start that day, as opposed to a week before. Although I was very tired of being pregnant, there was no way to know when labor would begin–it was just “business as usual.” So, that night we ordered in Chinese, and I ate my fill. About an hour or so later, my water broke.

The umbilical cord, of course, did not prolapse, and I went on to have a normal and completely unmedicated birth, but what if it had? What if I had needed an emergency C-section? My stomach was extremely full — what then? Simple — the anesthesiologist would just need to follow modern standard anesthesia techniques, stick a tube down my throat to maintain my airway so that even if I vomited, I could not inhale it.

Anesthesiologists have to deal with this all the time. Do you think that every person who needs emergency surgery — victims of heart attacks, strokes, car wrecks, skiing accidents, etc. — has an empty stomach?

When there is a scheduled surgery under general anesthesia, it makes sense to try to minimize the risk by fasting for a few hours beforehand, even as slight as the risk already is. But for a 1/30,000 chance that you might need general anesthesia? And since a lot of C-sections are done because mothers are just too exhausted to go on, quite possibly because they haven’t eaten in several hours and their energy stores are depleted, doesn’t it make more sense to let women eat in labor if they wish so that they can withstand the hard work of bringing forth their babies?

And if you don’t believe me…

…then check out this article by a former L&D nurse. (Be sure to click “next” which is on the left-hand side of the screen to read the next page of the article.)

She talks about (among other things) why you can’t eat or drink in labor; the downsides of epidurals; why doctors are so quick to call for a C-section; that doctors aren’t trained to attend vaginal breech births; that (in fact) doctors aren’t trained to do a lot of things any more, because they are trained to rely on machines and medicine; giving medicine via IV without the woman’s knowledge or consent; the use of Cytotec; and hospital-acquired infections.

Doctors trying to figure out what midwives have known for millenia

I save a lot of stories and websites on my computer bookmarks or “favorites,” and just the other day, I came across this link to an article in a British newspaper entitled, “Cramp blamed for Caesarean boom.” It says that doctors have found higher-than-normal levels of lactic acid in the wombs of women who have had a C-section. Interesting. In doing some more research on lactic acid, I’ve discovered that there are conflicting theories. The old idea (which this newspaper and/or doctor hold to) is that lactic acid is a waste by-product of muscles working too hard with not enough oxygen–this stemming from experiments a scientist did about a century ago and just handed down as unassailable truth. Newer theories and newer research does not back up the idea that lactic acid causes muscle cramps, although it is noted that high levels of lactic acid are indicative of muscle cramps and fatigue. But whether it’s a “cause and effect” question, or that excess lactic acid is simply a marker of muscle fatigue is unknown. More research is needed, but what is known is that intense activity causes lactic acid to accumulate.

In the article, it mentioned that lactic acid build-up is well-known among athletes, so I dug further and found this article on Muscle Cramps/Spasms: Nutritional Causes, Prevention, and Therapies. Again, very interesting. Although it deals primarily with athletes, and training for things like long-distance running and biking, as well as weight-lifting, it made me wonder if some of the things could apply to labor. Since labor typically takes many hours, perhaps even more than 24 hours in some cases (I’ve even heard of labors taking several days), it would definitely qualify as an athletic event. This article makes me wonder how much of the pain of labor, and the length of labor, and labor dysfunction and dystocia, can actually be traced to nutritional deficiency (since it implicates low calcium or vitamin E intake in some causes of cramps and lactic acid build-up).

This article was also interesting in that it says that lactic acid is made by breaking down glucose, and is used as fuel by the muscles; and when athletes train in brief intense spurts before their competitions, they increase their ability to burn lactic acid as fuel. Braxton Hicks contractions, anyone?

And then there is this article, which has the following quote:

Lactic acid does not cause that dreaded burning sensation during intense exercise. Lactic acid is formed from the breakdown of glucose, our body’s main source of carbohydrate. When made, it’s split into a lactate ion (lactate) and a hydrogen ion. The hydrogen ion is the bad guy–the acid in lactic acid that interferes with electrical signals in nerve and muscle tissue. When the rate of lactic acid entry into the blood exceeds our ability to control it effectively, then those pesky hydrogen ions begin to lower the pH of muscle. This invariably interferes with how the muscles contract and thus our ability to perform. [emphasis added]

So this makes me think that glucose is burned as the first muscle fuel, and lactic acid is secondary. The more efficient your muscles are at burning lactic acid the better, because if too much lactic acid builds up then it lowers the pH of muscle, and causes problems with contractions. Or perhaps this hypothesis is wrong, and that high levels of lactic acid simply indicate that your muscles can’t use it quickly enough, so it’s running out of fuel. Your uterus is a muscle, and it needs to be able to efficiently contract in order for your cervix to dilate, and then to push your baby out.

This leads me to an article in the current Runner’s World magazine (March 2008), about world-record holder Paula Radcliffe. This article talks about her pregnancy, baby and birth as part of a larger discussion of the British runner’s life and running career. As a birth junkie, the birth part is what I’m most interested in. She was induced because she was more than a week overdueno reason other than she went past a magic date on a calendar. Although she ended up having a vaginal birth, inductions are much more likely to fail (and then necessitate a C-section) in first-time moms. She did, however, have an extremely long and painful labor, which is also pretty typical of inducing a first-time mom–in her case, 24 hours of Pitocin-induced contractions, which most women will say is harder than normal labor. Here is a quote from the magazine article:

There were the 14 hours sitting immobile and cross-legged, under orders not to get up; there was the raging thirst she wasn’t permitted to quench because they told her she might eventually need a cesarean and therefore could have nil by mouth, as doctors say. (‘They said, “Imagine that this is a marathon and so you can’t have anything to drink!” I said, “Actually, in a marathon you can start drinking at five kilometers.” They said, “You can wet a flannel, and we’ll squeeze it into your mouth.”‘)

[As an aside, just from the scanty information provided in this article, the following things in Ms. Radcliffe’s labor went against the World Health Organization’s “Safe Motherhood” guidelines: Of “Practices which are Demonstrably Useful and Should be Encouraged,” she did not have #4. Offering oral fluids during labour and delivery, or #15. Freedom in position and movement throughout labour; of “Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue,” she had #3. Fundal pressure during labour; of “Practices which are Frequently Used Inappropriately,” she had #1.Restriction of food and fluids during labour, #3. Pain control by epidural analgesia, #7. Oxytocin augmentation, and #12. Operative delivery (vacuum assistance). While I do not blame her for getting an epidural (after many, many long hours of Pitocin-induced contractions, without being able to move from the bed), that probably made vacuum assistance necessary. “[T]hings culminated in a wild finale with two nurses pushing on her belly and a suction device on Isla’s head and the doctor bracing one foot against the delivery table in order to yank full strength.”]

In Henci Goer’s book, The Thinking Woman’s Guide to a Better Birth, she discusses IVs in labor (usually a glucose solution) being used instead of the woman being allowed to eat and drink as she wishes. On page 77 she says, “IVs are problematic by nature. Hunger and thirst and our natural responses to them invoke complex balances in both mother and unborn child. These balances are disrupted when they are bypassed by dumping huge amounts of fluids, often over a short period of time, directly into the bloodstream.” Then on page 79 is this, “Dehydration and starvation are associated with longer labors, increased use of oxytocin (trade name: Pitocin or “Pit”) to stimulate stronger contractions, and instrumental delivery. In addition, during pregnancy, starvation causes a faster, sharper drop-off in blood sugar levels and an earlier switch to metabolizing body fat. Vigorous exercise–in this case, labor–accelerates this process.” Then on page 80 is the following, “Glucose-containing IV fluids, also called ‘dextrose’ IVs, can raise maternal and fetal blood glucose levels to diabetic levels (hyperglycemia). Hyperglycemia in the baby increases the production of lactic acid, a metabolic by-product when there is insufficient oxygen.”

So how does this all work together? Here is my summary: Lactic acid is indicative of muscle fatigue (even if it’s not a cause or effect). To analogize, glucose is cash in your pocket that your muscles “spend” in order to work; lactic acid is “money in the bank.” Your body automatically converts glucose to lactic acid, so dumping too much glucose in your system at once (such as with an IV) can be counter-productive because the glucose is too-quickly converted into lactic acid (the “cash” is automatically deposited into your “savings account”); while the body’s normal digestive system allows you to take in a large amount of food and slowly converts it into “cash.” If you run out of glucose (easily expendable cash), then you must do the harder work of getting energy from lactic acid (taking a trip to the bank, waiting in line….). If you run out of cash at the grocery store, it doesn’t matter if you have a million bucks in a money market account–you still can’t buy your groceries because you have no cash in your pocket. Your body can increase the efficiency at which it burns lactic acid, but this takes time and training, neither of which is available in labor. (It’s possible that Braxton Hicks contractions leading up to labor are making the muscle of the uterus become more efficient at burning lactic acid–but this is just my hypothesis.) If your body is not very efficient at “spending” lactic acid, then the overload of lactic acid may make your uterus contract less efficiently–either due to the overload itself, or the fact that your muscles can’t efficiently “spend” the lactic acid, so you’re standing in line at the bank too long, trying to “liquidate your assets,” as it were. Marathon runners (or any athletes, for that matter) speak of hitting “the wall” when they simply can’t go any further. One of the articles I read says that the body has only so much possible reserves of calories to spend, and loading up on carbs before the event can help you overcome “the wall”; but food and drink during competition are necessary, too. As the world-record holder Paula Radcliffe said, “You get to drink at the 5-K mark!” Expert runners can complete a marathon in a few hours, average runners take several hours to complete. Volunteers line the race path with food and drink for the runners to have if they need it. This “quick energy” is enough to keep them going. When women are forbidden to eat or drink during labor, it seems like there is a time when the uterus hits “the wall” and simply can’t keep working under such adverse conditions. (Could you walk, run, or bike for hours without anything to eat or drink? Would that even be considered healthy? Is fasting a good thing for your baby?) Glucose IVs can help, but they can be “too much of a good thing” in a lot of ways, including the too-quick conversion of glucose (which your body is best at burning) into lactic acid (which your uterus is not as used to using). Artificial stimulation of the uterus through Pitocin can force it to contract and may prevent a C-section from being necessary, but this is not always the case.

A better way to avoid uterus fatigue is what midwives have always known and what women have always done (prior to about a century ago, when they started going into hospitals)–eat if you’re hungry, and drink if you’re thirsty.

Safe Motherhood, pt. 4

The following is taken from the World Health Organization’s report on Safe Motherhood, Care in Normal Birth: a practical guide. There are a couple of introductory pages and about fifteen pages of references, and the remainder of the 57 pages of this pdf file are devoted to a discussion of the typical practices in birth around the world, finally dividing them into one of four categories: 1) practices which are demonstrably useful; 2) practices which are clearly harmful; 3) practices for which insufficient evidence exists; and 4) practices which are frequently used inappropriately. They arrived at these conclusions from studying birth practices around the world (from the high-tech U.S. to the impoverished third-world countries), citing a plethora of published research along the way. This document is pretty “meaty” or “heavy” reading, but quite understandable. Some of the practices (like using sterile instruments) are obviously always done in the U.S., but other countries need to improve on them. I would encourage you to read the full document, especially to see how they arrive at some of the following conclusions (the numbers at the end of each point correspond to the discussion sections in the document, and they are in chronological order–pregnancy, first stage of labor, second stage of labor, etc.). This discussion is for normal labor with normal women; there are things that could make a woman high-risk during pregnancy, or things that happen during labor that would change the “risk category”. But this is for most of the women in the world. (I will put italicized explanatory notes on some of these; and I will emphasize certain words from the original in bold.) This is part four.

6.4Practices which are Frequently Used Inappropriately

[This section deals with practices which may be beneficial, but it depends on the situation. As with section 3, I strongly recommend that you read the supporting documentation, to understand the reasoning of the authors, as well as how it affects you.]

1.Restriction of food and fluids during labour (2.3). [Most hospitals have this as a strict policy. See my post for more on that, as well as read the WHO document.]

2.Pain control by systemic agents (2.6). [“Systemic” means that it affects the whole body, and includes drugs such as Demerol (pethidine is what the WHO document calls it, which is British, not American), Phenergan (promethazine), and Valium (diazepam). Many women have reported that receiving these drugs only “takes the edge off of pain” while some say that it didn’t affect their level of pain at all–it only made them so drowsy that they couldn’t do anything (even speak), even though they were still in pain.]

3.Pain control by epidural analgesia (2.6). [The authors point out that there are no randomized trials that compare epidural to no pharmacological pain relief–only between different types of epidurals and between epidural and other pharmacological pain relief. Therefore, it is impossible to know for sure what differences an epidural makes vs. “natural” pain relief methods such as emotional support, laboring in water, massage, etc. They also question whether a labor that uses an epidural can be considered “normal.” They also note that first-stage labor tends to take longer; more women require being augmented with oxytocin, and require “assistance” with vacuum or forceps; and that if given in early labor, a C-section is more likely.]

4.Electronic fetal monitoring (2.7). [The authors note that EFM has a high “false-positive” rate (meaning that the machine wrongly signals a problem with the baby), which leads to unnecessary interventions, especially in a group of low-risk women, although high-risk women can benefit from this. The authors end this discussion by noting that often people in the room pay more attention to the monitor than to the mom, and that nurses may not even come into the room, and only monitor the mother from a central location.]

5.Wearing masks and sterile gowns during labour attendance (2.8). [While the WHO document places great emphasis on the cleanliness of the birth attendant, it notes that masks and gowns are “useless” for protecting women from infection. However, if the woman has a disease such as HIV, or Hepatitis B or C, then the masks and gowns can protect the birth attendants from contact with contaminated blood.]

6. Repeated or frequent vaginal examinations especially by more than one caregiver (3.3). [“The number of vaginal examinations should be limited to the strictly necessary; during the first stage of labour usually once every 4 hours is enough.”]

7. Oxytocin augmentation (3.5). [Other of my “Safe Motherhood” posts also refer to this; but here is a quote from the document, “Oxytocin augmentation is a major intervention and should only be implemented on a valid indication.”

8. Routinely moving the labouring woman to a different room at the onset of the second stage (4.2). [Many hospitals in the U.S. now have L&D or LDR or LDRP rooms, which stand for labor, delivery, recovery, and postpartum. Previously–and perhaps still in some hospitals–women would labor in one room, be moved to a delivery room for the birth, then to another room for the immediate postpartum (recovery), and then to a final room for the remainder of her hospital stay. They may still be moved from one room to another, but most of the time, the only time women are moved to a different room during labor is for a C-section in an operating room. Some high-risk women (or if they are known to be carrying a high-risk baby, or a baby with special needs), may give birth in a different room that has all the bells and whistles because of the much higher possibility of actually needing the machines and things. Many women speak of a great deal of shame with being transported on a hospital gurney in a flimsy hospital gown down the halls filled with strangers able to see who-knows-what while they’re either pushing or being told not to push.]

9. Bladder catheterization (4.3). [Most women will be able to go to the bathroom by themselves; and catheterization may lead to infection, or be “difficult and even traumatic” if the baby’s head is firmly engaged in the mother’s pelvis.]

10. Encouraging the woman to push when full dilatation or nearly full dilatation of the cervix has been diagnosed, before the woman feels the urge to bear down herself (4.3). [The authors point out that a woman may be fully dilated for some time before she feels the urge to push; if she happens to have a vaginal exam during this time, it is unknown how long she was fully dilated. Further, there are no trials of normal labor; but a trial of women with an epidural shows that “delayed pushing did not show any hazardous effect on fetal or neonatal outcome. In the early pushing group, significantly more forceps deliveries occurred.” And they further point out that most midwives do not ask the women to push until they feel like it, which shortens the bearing down time and is easier on the women.]

11. Rigid adherence to a stipulated duration of the second stage of labour, such as 1 hour, if maternal and fetal conditions are good and if there is progress of labour (4.5). [The authors cite various studies which show no improvement of fetal/neonatal outcomes by arbitrarily stopping the woman from pushing, and using forceps, vacuum, or C-section to accomplish the birth of the baby.]

12. Operative delivery (4.5). [The authors note an increase in operative delivery world-wide, and wonder if convenience, financial gain, or fear of malpractice lawsuits are driving this increased interference in birth, which is many times unnecessary.]

13. Liberal or routine use of episiotomy (4.7). [You must know what your caregiver’s philosophy of episiotomy is! And “only when I think it’s necessary” is not an informative answer–how often does s/he find it to be necessary is the information you’re seeking. Here is the summarizing information from the WHO guidelines: “In conclusion, there is no reliable evidence that liberal or routine use of episiotomy has a beneficial effect, but there is clear evidence that it may cause harm. In a thusfar normal delivery there may at times be a valid indication for an episiotomy, but a restricted use of this intervention is recommended. The percentage of episiotomies attained in the English trial (10%) without harm to the mother or the infant (Sleep et all 1984) would be a good goal to pursue.”]

14. Manual exploration of the uterus after delivery (5.7). [Used routinely, there is no evidence of benefit; only if a piece of the placenta is known or suspected to be missing is this of any benefit.]

Safe Motherhood, pt. 2

The following is taken from the World Health Organization’s report on Safe Motherhood, Care in Normal Birth: a practical guide. There are a couple of introductory pages and about fifteen pages of references, and the remainder of the 57 pages of this pdf file are devoted to a discussion of the typical practices in birth around the world, finally dividing them into one of four categories: 1) practices which are demonstrably useful; 2) practices which are clearly harmful; 3) practices for which insufficient evidence exists; and 4) practices which are frequently used inappropriately. They arrived at these conclusions from studying birth practices around the world (from the high-tech U.S. to the impoverished third-world countries), citing a plethora of published research along the way. This document is pretty “meaty” or “heavy” reading, but quite understandable. Some of the practices (like using sterile instruments) are obviously always done in the U.S., but other countries need to improve on them. I would encourage you to read the full document, especially to see how they arrive at some of the following conclusions (the numbers at the end of each point correspond to the discussion sections in the document, and they are in chronological order–pregnancy, first stage of labor, second stage of labor, etc.). This discussion is for normal labor with normal women; there are things that could make a woman high-risk during pregnancy, or things that happen during labor that would change the “risk category”. But this is for most of the women in the world. (I will put italicized explanatory notes on some of these; and I will emphasize certain words from the original in bold.) This is part two.

6.2 Practices which are Clearly Harmful or Ineffective and Should be Eliminated

[Several of these practices are common in U.S. hospitals, so if you’re one of the 99% of women who are planning a hospital birth, it would be beneficial to discuss these with your doctor or midwife now, to see if you are going to be subjected to a practice which is “clearly harmful or ineffective.”]

1. Routine use of enema (2.2). [This used to be standard in U.S. hospitals, and some still do it.]

2. Routine use of pubic shaving (2.2). [This used to be standard in U.S. hospitals, and some still do it.]

3. Routine intravenous infusion in labour (2.3). [Since getting an IV is standard in U.S. hospitals today, I strongly encourage you to read the corresponding section in the full WHO document.]

4. Routine prophylactic insertion of intravenous cannula (2.3). [This may also be called a “Heplock”; it’s essentially an IV inserted into your hand, but not set up to a bag of fluids with the IV pole. It is capped off so germs can’t enter your bloodstream, but allows a quick access to a vein should an emergency arise. Most hospitals require either this or the full IV. The WHO document says that this “invites unnecessary interventions.”]

5. Routine use of the supine position during labour (3.2, 4.6). [In case you are unfamiliar with the term, “supine” simply means lying down on your back. (As an interesting aside, the dictionary includes this definition for the word: “failing to act: utterly passive or inactive, especially in a situation where a vigorous reaction is called for.”) Since most U.S. hospitals require you to lie down in the bed for most or all of your labor, I strongly encourage you to read these sections of the WHO document–3.2 covers first-stage labor (dilation), while 4.6 covers second-stage labor (pushing). And here is a link for some alternative labor and birth positions.]

6. Rectal examination (3.3). [Used as an alternative to vaginal exam in some countries, in an attempt to avoid vaginal/uterine infection.]

7. Use of X-ray pelvimetry (3.4). [The use of X-rays to determine if a woman’s pelvis is “adequate” to give birth. The practice of “pelvimetry”–attempting to measure a pelvis to see if the woman’s body grew a baby too big for her to birth–infuriates me more than just about anything else, because it instills in women fear and mistrust of their own bodies. Plus, it’s notoriously inaccurate! In cases of women who had childhood diseases that stunted their growth, and specifically the growth of their pelvis, then perhaps pelvimetry is useful; but most normal, healthy, American women will be able to birth their own babies, thank you very much. And using X-rays increases the risk of childhood leukemia.]

8. Administration of oxytocics at any time before delivery in such a way that their effect cannot be controlled (3.5). [Again, from the WHO document, ” This (giving oxytocin/Pitocin/”Pit” only in “facilities where there is immediate access to a C-section should the need arise”) is a reasonable precaution, given the unpredictable nature of artificially managed labour.”]

9. Routine use of lithotomy position with or without stirrups during labour (4.6). [“Lithotomy” is lying on your back, with your legs open and knees flexed. It is for the doctor’s benefit only, so he doesn’t have to assume any awkward position while he’s working. The fact that you’re doing all of the work in an extremely unnatural and awkward position doesn’t seem to matter. This is another of my pet peeves, can you tell?]

10. Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour (4.4). [Otherwise known as what you see on all the birthing shows–“Okay, here’s the contraction, hold your breath and PUSH, 1….2…..3……..8….9….10. Take a quick breath, OK, AGAIN……. AGAIN!!!”–also called “purple pushing” because most moms get blue in the face from the lack of oxygen. Imagine what it’s doing to the baby. Typically, they try to get the mom to push three sustained times each contraction; all this while holding her breath, and taking a quick breath between each loooooong push. Pregnant or not, I would suggest as an interesting and informative exercise to assume the lithotomy position on your couch, and hold your breath (don’t worry about pushing) while somebody is in your face yelling at you to push while counting slowly to ten….three times in a row. I just did it and feel out of breath, dizzy, and light-headed, and that was just for one “contraction”; now multiply that experience by doing that every few minutes for an hour. You can try a variety of positions–even just right now, sitting at your computer desk, hold your breath like that and see how you feel.]

11. Massaging and stretching the perineum during the second stage of labour (4.7). [Many midwives and doctors will massage the lower vagina and surrounding tissues to attempt to keep the woman from tearing. While there is evidence to suggest that perineal massage done in the latter part of pregnancy will reduce the incidence of tearing during birth, massage done while the woman is pushing does not seem to help.]

12. Use of oral tablets of ergometrine in the third stage of labour to prevent or control haemorrhage (5.2, 5.4). [Not usually done in U.S. hospitals.]

13. Routine use of parenteral ergometrine in the third stage of labour (5.2). [Not usually done in U.S. hospitals.]

14. Routine lavage of the uterus after delivery (5.7). [Not usually done in U.S. hospitals.]

15. Routine revision (manual exploration) of the uterus after delivery (5.7). [May be standard in some hospitals. According to the 2002 “Listening to Mothers Survey” by the Maternity Center Association, 58% of all women had a “gloved hand inserted into their uterus after birth.” While this is beneficial if part of the placenta is missing, and this is how doctors will check to make sure a C-section scar didn’t give way during labor, the WHO report states, “There is not the slightest evidence that such a policy is useful; on the contrary, it can cause infection or mechanical trauma or even shock.”]