Food - The Illogic of "Nothing By Mouth"

In the 1940s, back in the days when general anesthetics were administered through opaque face masks, doctors began forbidding food to patients undergoing surgery because they realized that vomiting and inhaling food particles into the lungs (aspiration) was a grave and often fatal complication of surgery.  Since laboring women during this time were usually heavily drugged and often had general anesthesia even for vaginal births, doctors extended the policy to childbirth.  On no grounds whatever, and despite knowing that clear liquids empty rapidly from the stomach, the ban included drinking too.  Thus, "nothing by mouth," or NPO for the Latin non per os, became standard practice before surgery and during labor.

Today, changes in anesthetic and obstetric practice have made aspiration a vanishingly rare event.  Less than 2 per 1,000,000 pregnant women in the United States between 19988 and 1990 died of any anesthesia-related-complication--not just aspiration--during delivery.   Better training of anesthesiologists and the modern anesthetic practice of intubation, putting a tube down the throat to protect the airway, are largely responsible for the improvement.  The virtual disappearance of general anesthesia for vaginal birth and its replacement with epidural and spinal (regional) anesthesia for most C-sections has also contributed.  Nonetheless, NPO in labor remains the norm at many hospitals because many doctors erroneously believe that eating and drinking in labor is risky and that IV fluids are a risk-free replacement for oral intake.

The Illogic of "Nothing By Mouth"
 To begin with, eating and drinking in labor are safe.  In three large U.S. studies totalling seventy-eight thousand women in labor who ate and drank freely, there was not one case of aspiration.  The anesthesia-related maternal mortality rate in England and Wales, where oral intake in labor is usual, is indentical to the rate in the United States, where it is not.  Nor is aspiration a problem in other countries that permit eating and drinking inlabor, such as Japan and the Netherlands.

The real problem is the occasional incompetent anesthesiologist.  Experts agree that poor technique is the major cause of airway-related anesthesia deaths, including aspiration.  Doris Haire, long-time childbirth activist and writer on maternity care issues, says, "I have searched back through twenty years of the medical literature, and there is not a single documented case of aspiration in an individual [not just pregnant women] who was properly anesthetized by today's standards of anesthesia."

Secondly, medical research does not support NPO or routine IV policies.  The authors of A Guide to Effective Care in Pregnancy and Childbirth, the bible of evidence-based obstetric care, place both under "Forms of Care Unlikely to Be Beneficial."

Why, then, the strenuous objections to oral intake and the insistence on routine IVs?  What we have, once again, is an obstetric belief system that defines childbirth as a medical-surgical event.  Eating and drinking do not fit this model.

(Additional information in the book.)

Pros and Cons of Forbidding Food and Drink in Labor
Pros: None.  Some caregivers tell women that what goes down in labor will only come back up, so there is no use in attempting oral intake, but this is not true.  Few women allowed to eat and drink as they wish will vomit.
Cons: Hunger and especially thirst causes considerable discomfort.  Midwives observe that dehydration may cause fever.  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.  This is a problem when women fast in labor because metabolizing fat produces keytones. In animals studies, keytones have been shown to cross into fetal circulation, making the fetal blood more acidic (acidosis). Acidosis is a symptom of fetal distress.  Also, undiluted stomach acid poses a severe hazard to lung tissue should it be aspirated.