Informed Consent Involves More Than Saying "It Could Be Dangerous"
Wednesday, November 3, 2010 at 5:29PM
By Jill—Unnecesarean
Someone claiming to be an anesthesiologist left a comment on an old post about routinely denying all laboring women food in hospitals. I replied and Kathy, who subscribes to comments, jumped in with some insights and questions.
The thread is a bit of train wreck, so I’ve pasted it for you below. Spinal Doc’s replies have it all—all of the classic defensiveness associated with the old I KNOW WHAT I KNOW AND I DON’T NEED TO TELL YOU WHY I KNOW IT AND YOU JUST NEED TO TRUST ME BECAUSE I WENT TO MEDICAL SCHOOL drill that so many of us discuss here.
You will see the following:
Don’t you care about your baby?
We are just concerned about your safety.
YOU try living with the burden of a dead patient!
We are not all bad people
Trust me, there is Real Danger ™
Plus:
Comparison of the risk of a procedure to a terrorist attack
Claiming that ending the routine denial of food during labor will open the door for obese pregnant women to “gorge on anything they want.” (see Spinal Doc’s last comment)
Evading questions
This mirrors my experience with medical prenatal care and birth, except the CNM and doctor were nice and not hiding under the internet’s veil of semi-anonymity. As I’ve written before, I was told I needed a cesarean at about 38 weeks because I had a suspected macrosomic (big) baby and would be likely to experience shoulder dystocia. In a series of conversations that were not at all hostile, I had my requests for an idea of the likelihood that it would occur met with increasingly dramatic descriptions of shoulder dystocia, the Zavanelli maneuver, broken collarbones, proctoepisiotomies and, of course, death and permanent injury.
While I sympathized with the stress they personally experienced when encountering birth emergencies, I simply wanted some numbers and a more compelling reason to preempt vaginal birth with a planned cesarean than, “I’ve seen shoulder dystocia and it’s really bad. You don’t want that.” I left these appointments with a polite smile, and at one of them, I scheduled a cesarean knowing that there was about a 5 percent chance I would actually keep the appointment. Instead, I showed up a week earlier in labor, refused a cesarean and gave birth normally.
Patients deserve better than this. I do not expect care providers to remember every figure and percentage they’ve ever read off the top of their heads, but I would trust them to look it up and get back to me, even in the time-sensitive window of pregnancy. Spinal Doc’s attempt at a compelling argument was to ask “Have you seen a mother die after aspirating stomach contents during a stat c-section leaving a grieving husband with three motherless children?” and, in spite of apparent access to the internet, Spinal Doc refused to use it to find evidence that support her claims. I am very sorry that she has had a rough time emotionally because a patient aspirated and died, but making non-evidence based procedures, treatments and surgeries routine simply because a care provider doesn’t want to personally experience the death of a patient again is an extreme measure.
The name of the commenter appears under the comment.
Do any of you worry about your children? Have you denied them privileges because you have contemplated the potential risks? Yes food is wonderful! Have you seen a mother die after aspirating stomach contents during a stat c-section leaving a grieving husband with three motherless children? You are all so obtuse. Health care providers are concerned for your safety. We have weighed the risks. When a midwife can’t get the child out and the patient needs a c-section and has a full stomach they are in real danger of aspirating! You can quote statistics until the cows come home, try living with the burden of a dead mom whose silver bullet was a $1.99 Happy Meal!
October 26, 2010 | Spinal Doc
As a “spinal doc,” I hardly see how you speak on behalf of all health care providers. If you want to come back with a real argument and not a screamy, juvenile internet rant, go for it.
Since you’ve weighed the risks, why don’t you tell everyone what the actual risk is of aspiration under general during an emergency c-section? Percentages, please. Don’t forget to cite.
October 26, 2010 | Jill—Unnecesarean
I don’t know if you are angry or passionate. Lots of doc bashing goes on here. We’re not all bad people. While it is true the trends for aspiration have gone down, it is not because the risk of aspiration is less, it is because more C-sections are done under regional anesthesia (spinal/epidural) and the patients can maintain their own airways. In the event of a true emergency, requiring general anesthesia, the risk is very real. It takes 25ml of clear stomach fluid at a pH of 2.5 to cause an aspiration pneumonitis. Add to this a relaxed lower esophageal sphincture (under general anesthesia), rotation and upward displacement of the stomach from the gravid uterus, lying supine with a stomach full of pneumotoxic food and you have the makings of a disaster. The risk of maternal death is 16.7 times greater under general anesthesia, and a majority of those are related to airway management/failed intubation/ pulmonary aspiration. As ansthesiologists our primary concern is moms safety. What is wrong with being safe? The risk is 1:450-1:700
October 27, 2010 | Spinal Doc
That’s much better. I’m surmising from your first few sentences that you feel defensive and that’s why you left the original comment.
Most of your comment was explaining how aspiration under general can occur. Here are the stats you have shared:
1. Maternal death 16.7 times higher under general, most of which are due to airway management/failed intubation/ pulmonary aspiration. (Source unknown)
2. The risk of something is 1:450 - 1:700. (Risk of what exactly?)
If a pregnant woman wants to know why she can’t eat anything during labor and that’s what you give her in terms of informed consent, you’ve really told her nothing.
1. What are the odds that a cesarean will be performed under general? (# and percent of all births)
2. How many maternal deaths have occurred in the last decade (or last few decades) that can be directly attributed to aspiration under general?
You state that aspiration trends are down. Down from what? There’s a 1974 study (Baggish) that found that 2% of maternal deaths in the U.S. occurred as a result of aspiration. If it’s down from that, which you attribute to regional anesthesia for cesareans, it sounds like the chance is almost nil for a pregnant woman checking into a hospital for labor.
You might also consider the 2010 study, Restricting oral fluid and food intake during labour, in the Cochrane Database.
(http://www2.cochrane.org/reviews/en/ab003930.html)
We identified five studies (3130 women). All studies looked at women in active labour and at low risk of potentially requiring a general anaesthetic. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.
When comparing any restriction of fluids and food versus women given some nutrition in labour, the meta-analysis was dominated by one study undertaken in a highly medicalised environment. There were no statistically significant differences identified in: caesarean section (average risk ratio (RR) 0.89, 95% confidence interval (CI) 0.63 to 1.25, five studies, 3103 women), operative vaginal births (average RR 0.98, 95% CI 0.88 to 1.10, five studies, 3103 women) and Apgar scores less than seven at five minutes (average RR 1.43, 95% CI 0.77 to 2.68, three studies, 2574 infants), nor in any of the other outcomes assessed. Women’s views were not assessed. The pooled data were insufficient to assess the incidence of Mendelson’s syndrome, an extremely rare outcome. Other comparisons showed similar findings, except one study did report a significant increase in caesarean sections for women taking carbohydrate drinks in labour compared with water only, but these results should be interpreted with caution as the sample size was small.
I would love to hear your case for why NPO should be routine for all laboring women. It’s going to have to be a lot better than “As ansthesiologists our primary concern is moms safety. What is wrong with being safe?”
October 28, 2010 | Jill—Unnecesarean
@Spinal Doc,
A “friend of a friend” died after aspiration from GA, so I know the risk is real; however, this woman died not from an unexpected C-section, but from a planned surgery (tonsillectomy, I think), for which she was properly prepared with no food for X hours before, and whatever other precautions would have been taken 15-20 years ago. Apparently, the risk of aspiration with GA can’t be reduced to zero.
You said, “It takes 25ml of clear stomach fluid at a pH of 2.5 to cause an aspiration pneumonitis.” How long should a person go without food, in order to have a stomach with less than 25ml in it? Also, would the use of antacids help to reduce the level of acidity (that is, increase the pH level), so that even if stomach contents were aspirated, there would be less danger to the woman? Is there a direct correlation of how much “stomach contents” would need to be inhaled, in proportion to the level of acidity? That is, if the stomach contained food of a basic nature which increased the pH level to greater than 2.5, would the patient need to inhale more than 25ml of stomach contents, in order to cause aspiration pneumonitis?
I’m going to assume, based on Jill’s final question preceding your latest post and the rate you cite, that “the actual risk is of aspiration under general during an emergency c-section” is 1:450-1:700 First, before I forget, “risk of aspiration” does not equal “death,” does it? That is, not all people who aspirate stomach contents under GA die, do they? So, it looks like out of 450-700 women who have a C/s under general anesthesia, 1 may aspirate — do I have that right? And then, of that number, even fewer will die. I’m not sure what the rate of “GA for C/s” is — either you or Jill may have that number — but let’s say it is 5% of all C/s occur under GA, which I think rather high. Out of 4 million births, with a 34% C/s rate total, and 5% of that under GA, that’s 68,000. If 1/450-700 of these 68,000 will aspirate their stomach contents, that works out to 97-151 women (out of 4,000,000 births, or 0.00002425-0.00003775). So, depending on the risk of death due to aspiration, the risk of death will be even lower.
In looking for “risk of death due to aspiration of stomach contents under general anesthesia,” I found this article written by an OB/GYN which said, “The actual incidence of aspiration during birth is 7 per 10 million births,” which is less than a one in a million; and if the risk of death due to aspiration is even less than the incidence of aspiration, we’re talking about a very rare possibility indeed.
But is there nothing that can be done to reduce even further this slight risk? You said above that one of the problems with aspiration was the supine positioning of the woman. Would it be possible to raise the head of the bed (I know that surgical tables do not allow this, but hypothetically speaking…) so that the woman wouldn’t be supine, and therefore it would be less likely for the stomach contents to be pushed all the way up a sloping (as opposed to horizontal) esophagus? Would it be possible to have something covering the opening of the esophagus, so that if anything were to come up out of the stomach, it would be stopped at the top of the esophagus, and thus not allowed to go into the lungs? The article above cited also seemed to speak favorably of having a little liquid in the stomach — liquid so that it clears out quickly, but *something* which reduces the acidity of the stomach — so that if the stomach contents are inhaled, the acidity level will be less, and therefore less likely to cause a problem if inhaled into the lungs.
On that note, I remember reading a comment several months ago from a woman who had some medical problem which caused her to occasionally regurgitate the contents of her stomach, and occasionally she inhaled them [sorry I can’t be more explicit, but this is what I remember]. She said that of all the times she inhaled food as compared to plain gastric juices, she had a much easier recovery; but the times when she inhaled gastric juices after a period of fasting (like, sleeping overnight), she would usually end up in the hospital with aspiration pneumonia. I thought that interesting, to say the least.
October 28, 2010 | Kathy
Chadwick, HS: Obstetric Anesthesia Closed Claims Update II. ASA Newsletter 63(6):12-15, 1999.
(here is some info)
C-SECTIONS AT A GLANCE
A government-sponsored study of 230,000 births between 2002 and 2007 found that the C-section delivery rate was 30.5%.
- so 1 in 3 women have a c-section
October 28, 2010 | Spinal Doc
Thank you Kathy! You must consider that your computations are based on a majority of patients who where kept NPO. It is unethical to deisign a study in which women were fed a full meal and the placed under General anesthesia for a C-section. You may find true numbers from other countries or data from the 50’s and 60’s when GA was the norm. This is interesting: Michael Rothschild, a former business professor at the University of Wisconsin, worked out a couple of plausible scenarios. For example, he figured that if terrorists were to destroy entirely one of America’s 40,000 shopping malls per week, your chances of being there at the wrong time would be about one in one million or more. If this played out, would you go shopping?
October 28, 2010 | Spinal Doc
Regarding the C/s rate of 30% vs 34% — the latest annual figures are closer to 33%, but I added an extra percentage point because 1) the C/s rate has increased every year for the past several years, 2) the reported C/s rate may be lower than the actual rate, and 3) the higher the C/s rate, particularly with GA, the greater the likelihood for any single rare negative thing to happen. If you’re wanting to argue that 100% of all laboring women should be kept NPO on the basis that a percentage of a percentage of a percentage of a percentage may die, then the higher the # of any of those percentages, the better it is for your argument. If you want to use 30%, that’s fine by me — it would reduce the # of C/s under GA to 60,000, instead of 68,000 (again, assuming a GA rate of 5% of the total C/s #). I could use 50%, since many hospitals have that C/s rate, but that would still be 133-222 women who would experience aspiration due to GA in a C/s, out of 4,000,000 births; but the likelihood is that with an increase of overall C/s rate, the incidence of GA for C/s would decrease, as more and more women would be given C/s before an actual emergency requiring GA presented itself. Put it this way — if 100% of women had non-emergency C/s as opposed to vaginal births, there would be almost 0 C/s done under GA [some women would still request or need GA, due to known allergy to the medication of an epidural, epidural not working, etc.]. As more hospitals and doctors do C/s prior to an emergent need, they will undoubtedly perform routine C/s under epidural anesthesia that had labor continued would have become emergent C/s under GA. So, if with a 15% C/s rate, 5% of those surgeries would be under GA, I daresay that at 30%, the rate of GA C/s would be less, though perhaps not half the rate; and at 50% C/s rate, the rate of GA C/s would be even less. But, I still don’t know what the average rate of GA C/s is at 30%, or indeed any rate — I’m hypothesizing here. Oh, there would also be a small percentage of women who would need emergency postpartum surgery that would not need C/s but would have GA (D&Cs and emergency hysterectomies and such)
You said that my numbers are taken from rates when people are kept NPO — so the 1:450 and 1:700 you cited are from those statistics? It’s true that the rate of aspiration due to GA has gone down since the 50s and 60s when most women were given GA for normal vaginal births, but have there been no improvements in anesthesia technique in that time? Surely the rate would be better now than then! Yes, knowing that a full meal before GA increases the risk of aspiration, it would not be wise to knowingly eat a large meal soon before surgery; but I bet that the fact that you *might* end up in a car wreck minutes after leaving a restaurant and end up needing emergency surgery under GA, does not inhibit you from eating your fill while at the restaurant, just because you *might* need surgery. So, there is a difference between a known and guaranteed surgery, and a mere *possibility* of a surgery, yes?
Now, let’s talk about the assumption of what a woman eats while in labor. My first pregnancy, I went into labor less than an hour after eating a large supper — my water broke, followed by the onset of contractions about half an hour later. The whole labor, up until about half-way through pushing (about 9 hours, minus 20 minutes), I wanted absolutely nothing to eat or drink, and in fact threw up my meal a few hours after labor started. My midwife kept making me drink apple juice (first-time moms usually have long labors, and she didn’t want me to get dehydrated or tired out — not having a crystal ball, we neither of us knew that my labor would be so short), but every time she did, within the next ctx or two, I would throw up all that I had drunk. Finally, about half-way through pushing, I felt shaky as if my blood sugar were low, so I requested and received (and greatly benefited from!) a few sips of apple juice.
My second labor, the ctx were irregular and widely spaced apart, so even though I was in labor for 24 hours, I did not know and accept that I was in labor until my water broke, about an hour before the baby was born. I ate if I was hungry, and drank if I was thirsty, but could not tell you what type nor quantity of food/liquid I had. If I had been deprived of food for 24 hours, I can tell you that I would *not* have been happy, although the first labor, I preferred *not* eating/drinking at all.
So, assuming that 100% of women would eat in labor, if “allowed” to do so might be false. Some might only want a little sip of something here and there; I doubt that very many women would want anything substantial while dealing with contractions, but would naturally gravitate towards things that are light and easily digestible. But again, we are still dealing with a very small percentage of women who *might* be adversely affected; and I think that’s something that women should be able to choose for themselves, rather than having forced on them, no matter how well-meaning the intention. Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience. — C. S. Lewis :-)
Instead of doing a study of feeding women who know they will be having surgery under GA (which is, as you said, unethical), what we could do instead is look at the rates of maternal death, aspiration, and GA in countries that allow and those that do not allow eating while in labor. Of course, you’d have to be careful to compare like with like — it would do no good to compare developed and under-developed countries. It would likely need to be a large, country-wide study, since we are talking about such a minute risk.
In regards to your question about the mall — yes, I think I would go shopping just the same. [Although this is a bigger hypothetical for me than you know, since it’s been some years since I’ve set foot in a mall!] Here is the reason why — I think the risk of my particular shopping mall being destroyed is quite low, because it is rather small and obscure. When the Muslim terrorists attacked us on 9/11, they did not target my county courthouse, although they technically could have; they attacked the WTC and the Pentagon. My local courthouse, like my closest mall, has a much lower risk of being attacked than a high-profile building or mall such as Wrigley Field or the Empire State Building or the White House, or one of these other big and/or important and/or patriotic places. In a similar way, I believe my risk of ever needing an emergency C/s under GA to be somewhat less than the average woman, for a number of reasons.
Now that I’ve answered your questions, I hope you will answer mine from the previous post — 1) how long does a person have to fast in order to get less than 25ml of stomach contents; 2) is there an inverse relationship between how much “stomach contents” one would have to inhale in order to get aspiration sickness, and the pH level of the stomach acid? 3) could giving antacids prior to surgery (which I think I’ve heard of doing), lower the risk of aspiration sickness and death due to aspiration sickness, by lowering the pH balance and thus reducing the risk of stomach acid destroying delicate lung tissue? 4) out of curiosity, is it hypothetically possible to reduce a person’s risk of aspiration by raising the head of the bed so that he is less likely to inhale stomach acid, or is there some medical reason (other than, “Well, that’s just the way we’ve always done it” or “that’s just the way surgical tables are made”) for a person to be supine during a surgery like a C/s?
I could probably get the answer to the first 3 questions by much searching, but I figure you would probably have learned this in the course of your education, or could easily get it by searching medical journals; and the 4th question is a hypothetical, relying on your wisdom, knowledge and judgment of the situation.
October 28, 2010 | Kathy
SpinalDoc, am I just not asking my questions specifically enough? Let’s try again:
Most of your comment was explaining how aspiration under general can occur. Here are the stats you have shared:
1. Maternal death 16.7 times higher under general, most of which are due to airway management/failed intubation/ pulmonary aspiration. (Source unknown)
2. The risk of something is 1:450 - 1:700. (Risk of what exactly?)
If a pregnant woman wants to know why she can’t eat anything during labor and that’s what you give her in terms of informed consent, you’ve really told her nothing.
1. What are the odds that a cesarean will be performed under general? (# and percent of all births) [The national cesarean rate is not the answer to how many cesareans are performed under general, nor how the percentage of all births that will be performed under general!]
2. How many maternal deaths have occurred in the last decade (or last few decades) that can be directly attributed to aspiration under general?
Answering these questions for a patient would mean that you can truly offer that patient the chance to give informed consent about NPO. If not, you’re telling her that it could happen and, umm, it’s a lot like being scared of terrorists, sweetheart.
I have an article that applies to you perfectly. The Folly of 1 Percent. Only in this case, it would be The Folly of 0.0000007, making even less of a case.
October 28, 2010 | Jill—Unnecesarean
The Chadwick “article” cited answered a question that I didn’t even ask. Here is an excerpt from your article on closed claims:
Lessons Learned
The most recent analysis of the obstetric anesthesia-related liability files reveals similar results to those of our earlier reports. Liability risk in obstetric anesthesia differs considerably from that in nonobstetric practice. Complications involving the respiratory system account for the largest proportion of damaging events in both groups and problems with difficult intubation and pulmonary aspiration are disproportionately represented in the obstetric files. These findings corroborate most anesthesiologists’ belief that the pregnant patient’s airway demands additional attention and care. As for regional anesthesia-related claims, local anesthetic toxicity remains a concern, although the number of such claims appear to be declining. Nerve damage also constitutes a relatively large percentage of claims, although, as with newborn brain injury cases, the relation to anesthesia care is often in doubt.
The most surprising difference between obstetric and nonobstetric claims is the large proportion of claims for relatively minor injuries in the obstetric files. While reducing major adverse anesthetic outcomes in obstetrics is important, attention must be paid to limiting liability risk associated with less severe outcomes like headache, pain during anesthesia and emotional distress. To some extent, the large proportion of relatively minor injuries in the obstetric files may be due to a greater incidence of such problems in these patients. However, detailed review of these files suggests that in many cases, patients were unhappy with the care provided and felt mistreated. Clearly, factors other than major injury are important in motivating a patient to bring a claim.
Therefore, anesthesiologists should attempt to conduct themselves in a manner such that patients will not be motivated to bring a suit for an unexpected outcome. Measures should include establishing and maintaining good patient rapport. Anesthesiologists should become involved in the prenatal education process. A careful preanesthetic evaluation is very important and should occur as early in labor as possible. Special care should be taken to provide patients with realistic expectations of common minor and potential major risks associated with anesthetic procedures. This discussion should be clearly documented in the medical record.
With this citation, you’ve told me that at least part of your concern with ditching routine NPO is legal. Is that in the patient’s interest or your own?
Also, one of the “lessons learned” is that you should take special care to “provide patients with realistic expectations.” A scenario of terrorists attacking U.S. malls does not do this.
October 28, 2010 | Jill—Unnecesarean
I was simply making an analogy with the mall scenario. The ASA NPO guidelines state that clear liquids (water, black coffee, Jello, apple juice) may be consumed in moderation up to 2 hours prior to elective surgery. There is a buffer on this (about 90minutes for 25 ml) But many factors can influence Gastric emptying time (Obesity, Diabetes, Opiod based pain medicine, Progesterone, Solid food). Some foods are far more toxic (for example the oil from peanuts is fatally toxic to the lung). The primary c/s rate is about 25%. So, 1in 4 primies will get sectioned (probably from failure to wait). The Obesity epidemic mirrors the c/s rate map on your web site. Obese women are more likely to be c/s. They probably received some form of narcotic (stadol demerol) for pain, or have an epidural with fentanyl in it. GDM is high in obese pregnant women, so we must consider diabetes. Lord knows their progesterone levels are high. Hey, here is a brilliant concept, lets now let them gorge on anything they want! You can’t go without food for 1/2 day? People fast all the time. Pregnant women fast. Clear liquids, fine. Large meals while laboring, sell crazy somewhere else. Legal ramifications? Why don’t you ask Courtroom Mama. Unless your into same sex marriage, I’m not your “sweetheart”.
October 30, 2010 | spinal doc
You’re simply evading questions and your comment is disorganized (and mostly nonsensical). Maybe next time you can support your claims with evidence. If your hospital only lets women labor for half a day before sectioning them, that’s a problem, as labors often last much longer than 12 hours, Spinal Doc. If you’re having trouble separating “eating” from gorging,” that’s another problem.
Re. the sweetheart comment, that was not directed at you. Read the sentence again and you’ll see that it was something condescending to say to a patient (“it’s a lot like being scared of terrorists, sweetheart.”), just as it’s condescending to tell someone that they should just trust that you know what you’re doing in recommending NPO when you can’t tell them why with actual numbers.
October 30, 2010 | Jill—Unnecesarean
Ok, so some foods are more toxic than others — might be beneficial then to write up a list of the “top ten” worst and best foods to consume in labor, instead of just saying, “DON’T EAT ANYTHING!!! NO MATTER HOW LONG YOUR LABOR IS!!! NO MATTER HOW HUNGRY YOU ARE!!! (Because a small percentage of 30% of all laboring women may have a C/s under GA, and a small percentage of them may aspirate on their stomach contents, and a small percentage of *that* percentage may die or have severe negative sequelae.)”
I’m glad to see that you admit that most C/s are unnecessary and due to “failure to wait” — I hope you’ll be able to work in your hospital to bring down the rate of unnecesareans, although I can see that might be difficult not being an OB. However, there have been a few studies in different hospitals that showed that if doctors waited for labor progression for an extra 2 hours (instead of calling for a section after just an hour or two of “stalled labor”), that there was no increase in problems for either mother or baby, and instead it increased the rate of vaginal birth, which are better for mother and baby (barring complications). Perhaps asking OBs what they think of those studies, and why or why not they don’t alter their practice style in the light of that evidence would get them to think about it (not confrontational, but just, “Hey, I was online and I saw this study about…”).
Certainly if doctors are routinely sectioning women after “half a day” of labor (the time stated as being easy for a laboring woman to fast), then they are performing a great number of unnecesareans. This undoubtedly increases the chance of aspiration, in addition to the other problems with C/s, if the more C/s that are done, the more that are done under general, as some women will not be able for one reason or another to have an epidural, and, as stated above, even following NPO protocol does not guarantee that a person under GA will have no aspiration. I wonder what the rate of unnecesareans has to be, in order to make the rate of C/s (even following NPO protocol in labor) more dangerous for aspiration, than allowing all women to eat light foods in labor if hungry. There has to be some sort of curve or slope, in which the rate of aspiration due to unnecesarean even when 100% of women are NPO is equal to or greater than the rate of aspiration due to only necessary C/s when all woman are allowed to eat (within sensible recommendations) but the C/s rate is low.
October 30, 2010 | Kathy
Photo credit: Etsy
Reader Comments (43)
Now that is something special to behold.
Heehee I'm almost sure I'm the frequent asperator mentioned in this as I did talk about that in a previous post. It's well remembered but slightly off. I asperate stomach acid aproximately once every other month or so, used to be every month but it's gotten a little better recently. It is WAY worse when my stomach is empty. I usually have an 'asperation attack' when there is atleast some food in my stomach as I intentionally eat small amounts to keep it that way when I'm having a bad acid reflux day. But while I was heavily pregnant I asperated pure stomach acid before I had eaten in the morning. It was horrible. Worst it had ever been and I almost called 911 I was afraid my breathing wouldn't start again. (My lungs always freeze after the inhalation and its something of a struggle to start that initial cough to start clearing my lungs, once I start I have a coughing fit that can last for 30 minutes or more. Usually it's just a momentary spasm, but this time it was a good 30-45 seconds before I could make myself breath to start coughing.) It was terrifying and I had a long 30 seconds to wonder how I could call 911 when I couldn't draw breath to talk. However, in all my cases of asperation I've never gotten pnemonia, it just causes an asmatic like attack for several hours, sometimes my lips and fingernail beds turn blueish, and then my breathing is depressed for about 3 days. Also it tends to spike my pulse, like really spike, it's been over 200 bpm right after an attack before. Anyway, I told the professionals before both my births that I absolutely WOULD NOT be fasting, plus I took gavascon (the only antiacid that actually works). No one was bothered by my insistance to not have an empty stomach and one nice OB (not one in the practice I was seeing one I contacted via the internet) assured me that they do give a dose of industrial strength antiacid to mothers before c-sections, which made me feel a lot more comfortable. Still, I am completely at a loss to explain, given my own experience, why any doctor would risk asperation of pure stomach acid (since even an empty stomach can have more than 25ml of acid in it) when they could risk a much less sever asperation of diluted stomach acid if they did have to deal with an asperation. Okay...that was longwinded.
I want to buy you and Kathy a Happy Meal (tm). Gorge while you can, y'all. Thank you for being sane and expressing it.
Brilliant, thank you!
Seriously, would you tell a person about to run a marathon to skip a couple meals beforehand? No, that's just stupid. And in this case not eating and getting worn out by this strenuous activity (giving birth) won't just mean you collapse from exhaustion, it probably increases your chances of needing a c-section, right? It's a self-fulfilling prophecy.
Plus the doc's argument is basically that she(?) doesn't want women to eat because she doesn't want to deal with the guilt if something goes wrong, not for the health and happiness of the patient. If the health of the patient was a priority here, we'd be finding ways to keep a woman nourished and comfortable without putting her at higher risk of injury or death, not this, basically telling women to "suck it up" and calling the women who question their authority irresponsible and heartless.
That was fun. It's weird that docs are coming online now to desperately cling to their ideals that have no basis in research. I guess it's less scarey than seeing it firsthand though. No, after seeing both, it's definately scarier in person, online it's just kind of sad. I always enjoy the example of the grieving husband and the motherless child. What about the woman who was denied food, had the pit turned up, experienced exhaustion, was sent away for a c-section, bled out, died and left a grieving husband and motherless child? What about that family? I guess they aren't as sad because this guy says so.
The main point here isn't to say that everyone should eat during labor or that there's something wrong with you if you feel safer not eating during labor or that there aren't certain circumstances in which a woman might work out a plan with her midwife or doctor to avoid food.
This conversation gives me deja vu.
It's dangerous.
Well, what are the odds that it will occur.
Look, I've seen it happen and it's awful.
How often does it happen and how likely is it that it will happen to me?
Just trust me.
I've seen some really bad car accidents. Since my plans to travel to a hospital or birth center include driving in car, perhaps the hospital should pay to have laboring women transported in helicopters to their destination to avoid the risk of a car accident. How likely is it that a car accident will happen? You don't need to worry about that. Just get in the helicopter.
Claiming that ending the routine denial of food during labor will open the door for obese pregnant women to “gorge on anything they want.” (see Spinal Doc’s last comment)
When is the fatty bashing going to cease? I am so tired of care providers playing the fat card. Do they have any idea how desperate and petty they sound when, like schoolyard bullies, they blame a woman's size for any problem, even the ones that exist only as hypotheticals?
what is this I don't even
I *heart* Kathy for many, many internet postings, this one included.
Greek-American father of 4 children, last one home-born, i animate expectant father groups at Eutokia (Greek Association for Natural Childbirth). I greatly favor natural childbirth at home, which i know is SAFER than hospital, yet think that today most women would have to expand their hearts and minds before they can create a good birth, especially a good home birth. Some of that heart-and-mind expansion will inevitably have to be "against" the prison walls of the obstetrics industry, but the real expansion will have to be inner, to expand the expectant mother's confidence in herself and her own incredible age-old natural power. That is why i have joined forces with Eutokia, to educate, animate and support the largest possible number of women and men in the heart-and-mind expansion that will empower them to have good births.
I agree that women should have better access to full statistics and proper in depth research and risks of this kind of thing. If a woman is instructed not to eat during labour then yes she deserves the right to know exactly why. However I do honestly believe Spinal Doc is just doing his/her job and honestly believes it is safer in many situations to not eat during labour. I can't believe people are attacking or criticising spinal doc just because they are thinking of the safety of mothers. We should be thankful for all our medical professionals and what they do everyday to ensure our babies are born healthy and safe. I know I am. My spinal docs were both lifesavers in ensuring my 2 c sections were safe and that I could feel no pain. I wish I could comment on the post so I could say thankyou to spinal doc and support what they are saying, which is just informing us of possible risks from eating in labour. YES there should be better information for any woman who wants it but NO we should not be attacking any medical professional for having ours and our babies safety on their priority list.
So my labor lasted for 22 hours. I ate lightly until about 5 pm... really lightly But from 7 pm -5 am all I was allowed to eat was 1 thing of Jello. It was the orange jello even... I am so not a fan of jello. I was exhausted. I would have loved some simple carbs or a granola bar. Something that would have given me actual energy not just a sugar spike. I ended up throwing up the jello in transition anyway.. so there was really nothing to aspirate if I did have to go under GA... although I already had an Epidural so I couldn't feel from my boobs down anyway. Oh I finally ate around 7 am when my daughter was away from me.. Worst pancakes ever. Point... As a Laboring mother I would have loved something to eat..
Melanie- Not all Dr.s have their patients best intentions in mind.
Although I haven't seen any instances where doctors could benefit from different things e.g c sections over natural births, I REALLY can't see how they could benefit from telling us not to eat during labour. They have absolutely nothing to gain from that therefore in this instance they must be thinking solely of our safety.
Ok I somehow missed out on reading the last couple of comments when I read the post before, now that I have I have just seen the last post by Spinal Doc and I have to admit that was quite rude and offensive, especially to larger women and thats not called for. I do agree with Kathy in her last comment, the whole not eating rule should be subject to each particular woman, longer labours will def need some food to keep up energy etc..It is a good idea to have a list for labouring women of foods that are more dangerous and those that are not so at least some women can have some food. There shouldn't just be one rule for all women and all labour, thats not right.
I was simply going to say that I wish I were either you or Kathy, but the happy meal TM (git 'em while ya still can!) made me laugh.
Also, Monkey Mama, that disorder? situation? sounds awfully terrifying, and I'm so sorry you go through it so often.
Anyway, that WAS fun, thank you!
Thanks, everyone who liked my comments -- that warms my heart. :-)
Jespren - yes, that must have been you; I remembered the general idea, but messed up the particulars. Thanks for setting the record straight. ;-)
Had the conversation on that post continued, I was going to add to my last comment the reasoning behind why there should be a list of "definite no-nos" to eat, assuming that peanuts (as an example) really are that toxic to the lungs. Some women may eat during labor, or have eaten prior to labor, despite NPO orders. What if a woman eats a Snickers bar ("packed with peanuts" as the slogan goes), when she could have had something without peanuts just as easily, had she only known? [I'm also curious as to what makes peanuts particularly bad, if a person is not allergic to them; and just how dangerous it is to eat peanuts in general, based on the off-chance that they might "go the wrong way" and get into the lungs. I think I'll risk it and not give up eating peanuts, but comments like that set off my curiosity. Of course, as they say, "Curiosity kills the Kat," so I'd better be careful, eh? ;-)]
Melanie, first, here's the link to the old post, for easy reference (Jill also had it in the opening paragraph of this post). Secondly, I don't doubt that most doctors do have their patients' best interest at heart, at least partially because most of the time, what's best for the patient is also best for the doctor. Yet, there can be times when the interests of the one are different from those of the other. For instance, doctors are human, and I can easily understand why a doctor, who attends a birth at midnight, would want to speed up the 3rd stage by manually removing the placenta, 1 minute after the baby is born, even if it is not evidence-based, and the mother and child may in fact have received benefits from a physiologic management of 3rd stage (that is, to wait for the placenta to naturally release from the uterus, and for the mother to push it out). The doctor very likely has to drive home, sleep a few hours, and then in the morning get up and see a full roster of patients; so if he can cut short 3rd stage from half an hour to 1 minute, he gains extra sleep which he, as a human, certainly needs. If he can do this without harming either mother or baby, which he believes to be the case, not seeing any danger in pulling the placenta out one minute after birth, then why not? [True case; and although there were no known negative outcomes from what he did that time, other than that he had to manually explore the uterus to make sure all the pieces of placenta were out (not a pleasant experience for the mother, even with an epidural), there could have been.]
But in this particular instance, doctors are mostly following tradition when they keep patients NPO (non per os, nothing by mouth) during labor. In the last century, as birth moved to the hospitals, more and more women were routinely given general anesthesia during all births, vaginal or C/s. Doctors discovered that many people given GA for surgery were dying of aspiration, and that by keeping patients from eating, they lowered the risk. So, the idea is not without merit. However, women are now *not* routinely given GA during *any* birth -- even most C/s are performed under epidural anesthesia -- yet the tradition of NPO for all laboring women has remained, regardless of how unlikely it is for women to be given GA. Much like enemas, pubic shaves, and 100% episiotomy rates were standard, but are now known to be more harm than good, even so this tradition of "NPO for all laboring women" should be made to stand trial to see if it really is better. It certainly is not physiologically normal for hungry people to be denied food, particularly while working; but rather, it is normal for people who are hungry to eat. It is the *intervention* or the "unnatural" thing (whether NPO, episiotomy, pubic shaves, immediate cord clamping, lithotomy position during birth, etc.) which should be made to prove itself better, rather than the natural thing being made to prove itself. If it definitely is better, then the thing should be used ...or at least, the mother should have the benefits and risks explained to her, and she should be allowed to make the choice between the physiological norm and the intervention, judging whether the minuscule risk of death by aspiration should she be one of the few women who needs general anesthesia in the course of birth is of enough benefit to keep her from eating if she is hungry.
"It is the *intervention* or the "unnatural" thing (whether NPO, episiotomy, pubic shaves, immediate cord clamping, lithotomy position during birth, etc.) which should be made to prove itself better, rather than the natural thing being made to prove itself. If it definitely is better, then the thing should be used ...or at least, the mother should have the benefits and risks explained to her, and she should be allowed to make the choice between the physiological norm and the intervention.."
Yes, this. It applies to all things birth-related. Physiologic birth unless there is a real reason to intervene and mom is fully and objectively informed.
Loving this post! That was an amazing discussion.
Oh Melanie, do you really think that doctors are always right? They are human, and human beings are subject to prejudice and being misinformed. Getting a medical degree doesn't change that.
The sad fact for Spinal Doc was that she could not answer your questions with any actual studies to back up her viewpoint....because there aren't any. I for one would be glad to see more studies done, even if they proved Spinal Doc right, because that's important information to know. But in the meantime, all the handwaving and I SEE DEAD PATIENTS stories are not answers, but *attempts to evade answers.*
The fact that this discussion keeps happening says to me that obstetrics (and maybe other fields as well) has a long way to go in making sure its standard practices are based on evidence, not habit and custom.
Of course there are risks to eating during labor. Sure, very, very tiny risks. I think to make this decision properly one must do a risk-benefit analysis: is there a BENEFIT to eating in labor? Are there risks to NOT eating during labor?
I would answer, Yes. The risk of going without food during labor is that the woman will be tired out, sapped of energy, and unable to manage her labor as effectively. She might not have the energy to walk around, even if that's what she needs to do. And her pushing may be much less effective. For long labors, as well as the early stages of any labor, I think it's beneficial to have at least a little something light to eat. This isn't just a matter of "a fat woman wanting a Big Mac." This is a matter of a woman undergoing one of the hardest exertions of her life, and being able to do a better job if she isn't being starved on top of that.
Generally, I think a woman's instincts are good guide here. If she doesn't feel like eating, it might be because her labor is going quickly and she won't need to. But if she's starving, give her something to eat! I sure wanted something besides apple juice in my labor, though I did throw up the apple juice in transition, so no worries about me having anything in my stomach anyway!