- Y'all, a mere moments before I turned this camera on,
Lumi the Light Fetus
fell off of the wall. (light thumping)
I legitimately thought my roof was falling in. (laughing)
I wish that the camera had been on.
Like I am still shaking.
Ah. (laughing)
Sorry, Lumi the Light Fetus.
If you're having a baby in a US hospital,
most of the time, you are told you're not allowed
to eat anything.
Where does this practice originate?
Well, it's a little old.
Like do you remember when we still gave chloroform
to people who were in labor
to decrease their pain?
Neither do I.
That's because it was the 1940s
when that stopped happening
and the 1940s when this one emerged.
In this video, we're gonna talk a little bit
about where that practice came from
and the data that it's based on.
Then we're going to decide if we think
that it makes sense.
And I'll give you a hint, I do not think it makes sense.
US anesthesiologists, do not come at me
unless it is with data.
Thank you.
(upbeat music)
As always, this video's meant to be educational
and should not be taken as individual medical advice.
Please talk to your doctor or midwife
before making decisions for yourself.
In 1946, a guy names Curtis Mendelson published a paper
that was looking at some pregnancy complications.
And in that paper,
he identified a risk of something called aspiration
of one in 667, approximately, pregnancies.
That is a risk of 0.15%.
Aspiration is where you inhale stomach contents
into the lungs.
That can be extremely dangerous.
It can kill you.
It often doesn't kill you, but it certainly can.
Now, aspiration as a whole is thought to be increased
in pregnancy for a few reasons,
one of those being that you have an increase in pressure
that pushes up on your stomach,
which allows any contents of the stomach
to come up more easily.
Another reason being that, in pregnancy,
your gastric emptying,
how fast your body digests the food in your stomach,
is slower, so you have a higher chance
of having undigested food in your stomach.
The risk of aspiration comes along mainly
when we're talking about needing to do a Cesarean delivery
or some kind of surgery on someone who is pregnant
under a general anesthetic.
Most C-sections and surgeries that are done in pregnancy
are done with a neuraxial anesthesia,
so a spinal or an epidural.
But sometimes they don't work or we can't use them
and you have to be put completely to sleep
with a breathing tube, which is a general anesthetic.
The risk of aspiration comes with that part
of this discussion.
So, already it's a pretty low percentage of pregnancies.
In that original study from 1946,
anesthetic techniques were primitive compared to today,
to say the least, and we have advanced that significantly.
So, the risk of aspiration related to general anesthetic
has drastically decreased over time.
Despite that, the NPO recommendation,
which you would think is written down on stone,
Biblically inscribed by Jesus himself
based on how strongly Twitter anesthesiologists
have clung to this,
despite not being able to even discuss
the actual data or risk with me when I ask them to,
was based on two deaths from aspiration
in 40,000 pregnancies in 1946.
For those following who like the numbers,
the risk of dying from obstetric aspiration in 1946,
when it was magnitudes more common to die from pregnancy
and also anesthetic techniques made it easier
to aspirate, was .0045%.
I don't know if you're into statistics,
but that is very low.
Okay, so, that's where the recommendation comes from.
And it's probably clear, you can already tell
how I feel about this,
but we're gonna go through the data
because I can support the reason I feel this way.
We've established that the touted risk here is aspiration.
And while pregnancy does convey
a theoretically increased risk of aspiration,
I say touted because the risk of a low-risk laboring patient
aspirating in pregnancy is all but nonexistent.
The risk of aspiration in all pregnancies,
including low- and high-risk, in modern times
is actually quite difficult to tease out
when you look at the data.
Risk of death from aspiration in modern times
is quite difficult to assess,
particularly in low-risk patients,
because you'll be hard-pressed to even find a case report
on someone dying from obstetric aspiration
who did not have a serious risk factor
for having that happen.
I mean, you're hard-pressed to find one
even on someone who did, but I digress.
We do have data coming out of the UK
which says that the risk of death from aspiration
is probably around one in six million.
One in six million,
a number which interestingly did not change
before and after
they stopped this NPO practice 16 years ago.
Yes, you heard that right.
UK has not been doing this for 16 years.
We also do not do this here in Aotearoa, New Zealand,
where I currently work.
I think it is worth noting that the developed nations
who have better maternal and neonatal outcomes than us
stopped doing this a long time ago.
I don't even know what the number needed
to treat for this would be.
Number needed to treat is a phrase we use in statistics.
If you take a group of people,
how many people do you have to treat
with an intervention to forego one complication
that you're trying to avoid?
It has to be in the many, many thousands.
Typically, we consider a number needed to treat
like over one in 100 to be questionable,
but one in thousands is,
would not be considered something
that like the FDA would approve if you were trying
to get a medication out there, for instance.
Interestingly, the American Society of Anesthesiology
recommends against full NPO status in labor,
saying that they think it's okay for you
to have clear liquids, which is a relatively recent change,
but that they still stand by
that you should not be allowed
to eat in the process of labor.
A statement that they recommend based on exactly no data,
according to their own published recommendation.
They actually state in that publication,
there is insufficient, (laughing)
I can't even say it without laughing,
there is insufficient data to support the consumption
of solid food in labor,
which is a wild stance to take, in my opinion,
when no data to support the fact
that it actually improves the outcome
you're trying to avoid.
In any other circumstance,
then the answer to that would be, "All right, cool,
since we don't have that data,
we'll let the patient make an informed decision
and choose for themselves," right?
Like, since when did, "Oh, we don't have any data.
We're just going to tell you what you have to do,"
become the default?
That's like obstetric paternalism.
That's what it is. (laughing)
The reason these numbers are so small
is because if you look at low-risk people
who are in labor,
the actual chances of them needing
a Cesarean delivery under a general anesthetic
are really low on their own.
And then, in addition to that,
the risk of them aspirating because of it
is extremely low as well.
Both an ACOG editorial and the previously mentioned
American Society of Anesthesiology documentation cite
a article that says 7% of in-hospital cardiac arrests
during obstetric hospitalization are related to aspiration.
And they use that as evidence that they think
that this should be the policy still.
You know, we've forgotten in the course of that
that we don't have any information that says
eating and drinking in labor
actually increases your risk of aspiration.
Again, I will state that the policy came
from Mendelson's original paper,
which half the aspirations were food and half were not,
and we're advocating that you can drink but not eat.
This is, (laughing) it's not, this is...
I'm just confused, okay?
I'm just, I'm confused.
It's confusing.
Regardless of that,
the risk of cardiac arrest
during an obstetric hospitalization is incredibly low.
Like that hardly ever happens.
And I'm not saying that it doesn't matter when it does.
Obviously, I've been a part of a cardiac arrest,
meaning somebody's heart stops
while they are admitted for an obstetric reason,
and it's horrible and awful.
But I don't think that the incredible rareness
of that and then 7% of that incredibly rare event
being related to aspiration,
something we don't even know if we reduce the risk of
by preventing people who are low-risk from eating in labor,
justifies these blanket policies.
I hope this is making sense.
I mean, we can approach this like sensically, right?
If I have a patient who is low-risk
for needing a C-section in general
and who is incredibly low-risk for needing a C-section
under a general anesthetic,
and they come in and they say like,
"I just wanna eat a little bit while I'm in labor.
You know, this has been a long labor
and I just want something to eat,"
we shouldn't just go,
"Yeah, actually, one time in 1946,
they published this paper that said two people died
after aspirating food.
So nobody's eating or drinking in labor.
Oh yeah, also, a lotta people aspirated
that didn't have food in their stomach,
but sorry." (laughing)
Just, I don't understand.
I very much appreciate the guidance from RANZCOG on this,
which acknowledges the small risk of aspiration
but also acknowledges the lack of data.
Their recommendation is that people who are in labor
should have light meals or drink access,
and it should be guided by the patient.
And I think that's a reasonable thing to do, right?
Like, if you have something that is one in six million
risk of killing you, like,
if you're against that, then like,
we can't even get in a car when we're pregnant, right?
Because you're much more likely to die in a car accident.
And I would argue that we know that not getting in a car
reduces your risk of dying in a car accident,
but we don't know that not eating during labor
reduces your risk of dying from aspiration.
So, I actually (laughing) think it would be more reasonable
to say nobody can get in a car while pregnant,
which is a stupid thing to say. (laughing)
Now, I haven't even addressed the potential risk
of not having any nutrition during labor.
There are some good research studies on this topic,
but they're equally inconclusive,
so I don't think that it's worth making this any longer
by going through all of that.
Some of the people that I talked with
about this on Twitter said something to the effect of like,
"Oh, we're supposed to do no harm, and it could do harm."
Well, I don't think we have a lot of evidence
that it could do harm.
I mean, I guess if we're gonna
theoretically accept that as fact, we can.
But we also don't have evidence
that withholding food from somebody who says they wanna eat
is not harmful, right?
I mean, that could,
come on, this just goes back to a paternalistic attitude of,
people who are pregnant need
to have decisions made for them,
even about things that are incredibly rare,
because you don't have the agency
to make those decisions yourself.
That is the culture of a lot of medicine in the US,
especially in regards to pregnancy.
I mean, we talked about this with COVID vaccines,
when employers were refusing to give vaccinations
to their pregnant employees
because there was no data on it.
Like yeah, there's not much data on any of it.
Shouldn't it be my choice if I wanna protect myself?
Like, no, you're pregnant,
you can't make decisions for yourself.
(playful music)
This is all, to me, wrapped up in this whole thing
of not respecting the autonomy of people once they are noted
to be pregnant.
And that is a much larger issue
that I think these things lay the foundation for.
If we really want people who are pregnant in the US
to be treated with agency and autonomy,
we have to start viewing these little decisions
as things they are capable of making.
And I think it's worth noting that most developed nations
around the world have foregone this practice
decades, more than a decade ago.
And they have better outcomes than us.
I think it's important.
I know some of you are gonna think this is a stupid video
that's not important, but it's important to me.
It's important to me.
I think this is important.
It doesn't have to be important to you,
but it's important to me.
And notably, if some of the arguments
on the Twitter discussion were like,
"Well, nobody wants to eat and drink in labor anyway
'cause they're just gonna throw up,"
okay, well, then tell them, "You might throw up.
So if you don't want to throw up the food,
then don't eat it."
Like, okay?
The argument that, "Oh, people wouldn't do it anyway,"
is stupid, because if they're not gonna do it anyway,
then you don't need a policy about it.
And if you have a policy about it,
you probably think that they may want something to eat
on hour 22 of waiting for their baby to exit their uterus
with sufficient force that they have to provide.
Obstetrics needs more giving patients who are pregnant
the information they need and allowing them
to make decisions that are best for them,
especially when it comes to things
which present an incredibly low risk
and are places where we could make change
to be a more patient-centered model of care
in obstetrics in the US.
If you're new here and you wanna subscribe,
I would love to have you.
I'll see you next Monday.