Eating and drinking during labor

As I've mentioned previously, I'm a former Ironman triathlete, and I draw a lot of parallels between my Ironman experience and my labor experiences.

Ironman is lengthy (I completed mine in just over 13 hours; participants have up to 17 hours to finish) and physically intense. This can lead to the dreaded "bonk," which is sudden and extreme fatigue that occurs after exercise depletes the body's glycogen stores. Obviously, fatigue is not a good thing in the middle of a long race, so Ironman participants and other endurance athletes eat/drink throughout the race to replenish those glycogen stores. Not a five-course meal or anything crazy like that, just light snacks (fruit, pretzels, energy gels, etc.) and plenty of liquids (water, electrolyte drinks e.g. Gatorade, etc.)

Labor also tends to be lengthy and physically intense, so it makes sense to me that laboring women should be fed and hydrated much like Ironman participants, with light snacks and plenty of liquids.

So why do many hospitals restrict laboring women to only clear liquids or, in some cases, only ice chips?

The roots of this restriction lie in a landmark 1946 paper by an OB named Curtis Lester Mendelson, entitled "The aspiration of stomach contents into the lungs during obstetric anesthesia." I can't find the full text online, but this recent paper has what appears to be a pretty decent summary:

Nitrous oxide and ether anaesthesia administered by face mask for operative delivery was complicated by aspiration in 66 women from 44 016 maternities (0.15%) between 1932 and 1945. The only two deaths were from airway obstruction by solid, undigested food in two of five women who aspirated [vomited and then inhaled] solid material. In those who aspirated liquid, a syndrome of dyspnoea, cyanosis and tachycardia was observed. Recovery after 24–36 h was universal—in an era that predated respiratory intensive therapy by decades.

Prevention of "Mendelson's syndrome" via NPO (from the Latin nil per os, or nothing by mouth) after midnight of the day of a planned surgery became a key component of anesthesiology. After all, if you have nothing in your stomach when you're anesthetized, you have nothing to aspirate, right?

Well, not exactly: Turns out that the emptying of solids and liquids from the stomach is not as straightforward as you might think. For example, multiple studies have shown that your stomach contents are smaller if you drink clear liquids 2-4 hours prior to a procedure, versus fasting for 4 hours. As a result, the American Society of Anesthesiologists no longer recommends NPO after midnight prior to surgical procedures. Instead, they recommend fasting from solids for 6 hours prior to the procedure, but continuing intake of clear liquids up to 2 hours prior.

Even if you didn't follow those fasting guidelines, read the quote above again: In Mendelson's original study, only 0.15% of women aspirated at all, and only two out of over forty four thousand women (0.004%) died as a result of aspiration. And this was 70-odd years ago, when (as noted in the quote) respiratory intensive therapy didn't exist, not to mention numerous advances in anesthesiology that we enjoy today. Today's risk is almost certainly lower.

Finally, this should be obvious, but laboring women are not surgery patients. (With the obvious exception of scheduled c-sections, which are rightly subjected to the same restrictions as any other planned surgical procedure.) Despite all the consternation about the USA's high c-section rate, the fact remains that 2 out of 3 pregnant women will deliver their babies vaginally. And approximately 95% of those who do deliver via c-section will do so under regional anesthesia (spinal or epidural), which carries a much lower risk of aspiration than general anesthesia, like that used in Mendelson's study.

In other words, the risk of a woman going into labor planning a vaginal delivery and ending up with a c-section under general anesthesia leading to death via aspiration are miniscule. (One study theorized that it might happen in approximately 7 in 10 million births.) The risk of that same woman having a fairly lengthy delivery and needing something besides ice chips to avoid the labor version of "bonking?" Much, much, much, much higher.

So why the continued insistence on restricting food and drink? Well, old habits die hard: Even for planned surgical procedures, many hospitals still do not adhere to the updated ASA guidelines. See, for example, this study, this study, this study...

Also, women in labor (regardless of pain medications used, or not used) often vomit, which can obviously be unpleasant with a full stomach. Still, this is purely a comfort issue, not a safety issue, so it hardly seems right to tell a woman who wants to eat that she can't. Some providers recommend not eating anything that you wouldn't want to vomit back up, which is excellent advice. But that determination should ultimately be left to the patient, not the hospital. It's also worth pointing out that studies (such as this one and this one) have shown that women who eat during labor are no more likely to vomit than women who don't.

Finally, to be fair, I should also point out that those studies don't show any significant benefit to eating/drinking during labor. In fact, the first one found that women who eat tend to have longer labors -- although presumably, they're more comfortable because they're not starving! There is no significant difference in intervention rates or adverse birth outcomes. Again, I think this backs up the idea that the laboring woman is best positioned to decide whether or not she wants to eat. Blanket hospital policies should be reserved for safety issues. This isn't one.

OK, I'll step off my soapbox now. Here are my own experiences with eating/drinking during labor.

With Littles
When I went over my birth plan with Dr. K, I specifically brought up eating/drinking during labor. She said she had no problem with it, but warned me that the nurses might not be as accommodating.

The topic came up again when I got scheduled for my induction. Inductions can take a long time and I wanted to make sure that I wouldn't starve during the process. Dr. K encouraged me to eat a good dinner before coming in to start Cervidil at night. She also told me that the hospital would bring me breakfast in the morning. I chose to skip the bacon and eggs, and just eat cereal.

Once active labor got underway, my nurse informed me that I couldn't eat or drink anymore. I knew I could either sneak some snacks (I had brought some from home) or get Dr. K to tell the nurse it was OK for me to eat, but I wasn't hungry by that point anyway, so I chose not to push it. Since I was allowed clear liquids, I drank a lot of cranberry juice to keep my energy levels up. It worked out fine.

With Noob
When I asked F about eating/drinking during labor, I got a similar response to what Dr. K had said: She had no issue with it, but the nurses might. I talked it over with M at one of our prenatal visits, and she confirmed that I'd have no problems sneaking in some light snacks, but: "You probably won't be able to eat Chick-fil-A while in transition." :) This became a running joke between us, but in all seriousness, it was one of the things that made me start leaning towards homebirth. Even a great hospital is still a hospital. You simply don't have the same freedoms that you do at home. And while I was pretty certain that I wouldn't want Chick-fil-A while in transition, it made me wonder what things I might actually want that wouldn't be possible in a hospital.

In contrast, C, like most homebirth midwives, actively encourages eating during labor. I had some fruit for breakfast on the morning of Noob's birth, and then when C arrived, she had me eat a light snack (apples and peanut butter). I also drank water freely throughout. As it turns out, my labor wasn't long enough to need anything else. And anyway, it was a Sunday, so Chick-fil-A was closed :)

With Q
I ate a normal dinner the night that I went into labor. Since active labor ended up spanning a time (roughly 10 PM to 1 AM) when I don't usually eat anyway, and since it went so quickly, I didn't end up eating anything while laboring, or even immediately afterwards. I ate a normal breakfast the next morning -- my husband's homemade breakfast tacos, yum! Much better than hospital food, or Chick-fil-A!

And in case you're curious: I've had some mild nausea with all of my labors (much more with Littles than with the other two), but no vomiting.