“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?

Why can’t I eat or drink in labor?

(Part 2 of “Why, why, why?”)

Let’s take being denied food and water as a prime example of asking why something must be done, since most hospitals today have that as their protocol. You may actually be already expecting it, and have never thought to question it. But now, ask yourself, “Why should I not get to eat or drink during labor? Why do I only get hard candy or ice chips?” Do you know? Really?

The real answer is that back half a century ago, most women were anesthetized during birth, many under general anesthesia, and anesthesia techniques were not as good as they are today, and many patients–not just pregnant women, but all people undergoing anesthesia for surgery–vomited and (being unconscious) inhaled the vomit. Many of them got sick, and some even died. Modern anesthesia techniques eliminate that possibility; so unless you have an incompetent anesthesiologist, this will not be a problem. Even if it were still a problem, the likelihood of you actually needing general anesthesia is very slim. Even if you need an “emergency C-section,” in most cases, it will be in reality an “unplanned C-section”–there will actually be plenty of time to place an epidural, which will allow you to remain conscious during the procedure. If you are awake, trust me, you will not inhale your vomit.

But you’re in the hospital, and you ask the nurse for some food because you’re hungry and it’s suppertime. “Oh, no,” she says, “you can’t eat in labor.” At this point you can say, “okay,” or you can say, “why?” She will probably say that it is hospital protocol, routine, or procedure, and hope you shut up. Do you say, “okay” or “why?” See–you may think you have been given an answer, but “this is what we always do” does not answer why you can’t eat. You are not a three year old child who cannot understand the reasonings of an adult. Many times, you will find that hospital answers to such questionings are basically the equivalent of “because I said so.” You deserve better. You are an intelligent adult, and should understand the logic behind the request, before just mutely submitting to it. So, in answer to your question, the nurse may say, “Well, you may vomit if you eat.” You can say, “I’ll take my chances–I’m really hungry!” She may still resist–and remember, most women just blindly follow hospital protocol, so this is a learning experience for her, too. She may speak of the danger of vomiting; but as I’ve already shown, the real danger is so miniscule as to be nonexistent. Think of it this way–there is a greater possibility of a driver getting into a wreck and needing emergency surgery under general anesthesia right after he finished his lunch (so a very full stomach), than of you needing the same. Yet there are obviously protocols in existence to minimize the risks of aspiration in those cases, so why should you be any different?

One further question–how do you think your doctor would react if you told him at your next prenatal appointment that you had worked outside all day without eating or drinking anything but a little hard candy and some ice chips? Your body is working very hard–hey, it’s called “labor” for a reason!–and needs fuel to continue. So ask your doctor or nurse why you should fast and become dehydrated at the end of your pregnancy, if it is dangerous during pregnancy. What athlete would compete in an endurance event without proper nutrition and hydration? Labor may last longer than a marathon, and you’re supposed to complete it without food or water?