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The very first time that I was at a small, local hospital that didn't allow laboring patients to eat or drink anything (ice chips only), my client's lips turned blue during pushing. She pushed for hours, exhausted. Why are people who are working so hard asked to forgo SIPS OF WATER??? And what is the difference between sips of water and ice chips? Isn't someone in labor burning the caloric equivalent of a marathon runner? Watching my client, hungry and exhausted, filled me with righteous rage. And so I went home and researched...
I want to be clear that this blog post is not meant to be or give medical advice, since that is never what doulas do. Instead, I work hard to help people access full informed consent: knowing the benefits and risks so that they can make a decision that is right for them. In order to fully understand why you might be asked not to eat or drink anything in labor, you'll need to know the history and context of that order.
History
Since that fateful blue-lipped birth, I've learned that the "nothing by mouth," or NPO, orders that exist today come from the 1940s when Twilight Sleep was a common practice used in childbirth for white people (Black folks were regularly denied pain medication). During that time, white people giving birth were given drugs that sedated them and made them forget their experience. People were routinely tied to the bed, and many babies were born using forceps. NPO came about when birth was a very different experience medically.
If people were given anesthesia, they were often given chloroform. In addition, the way that people's airways were protected during anesthesia for surgery was also not as advanced as it is now more than 80 years later. All of these factors led to a much higher risk of aspiration.
Aspiration: when the contents of the stomach enter the airways and eventually the lungs.
"Mendelson Syndrome"
In the 1930s and 1940s, Dr. Curtis Lester Mendelson conducted a study of 44,000 OB patients and found 66 cases of aspiration and 2 cases resulting in death. He then renamed aspiration after himself, like all men of a certain age working in obstetrics, and made a list of recommendations. Even though more than 80 years have passed, many of his recommendations are still in place today. Some recommendations, like never eating and drinking in labor, may merit some updates in light of new technology.
What is the risk of aspiration today? We have helpful data from the UK, where the recommendation changed to encourage drinking freely and a light meal in labor in 2007. The rate of mortality for birth went down in the years following the policy change (though there is no definitive evidence the two are related). From 2013-15, one person died of aspiration-related complications out of 2.3 million people who gave birth. The protocol for someone with a full stomach was not followed in that case.
Context
Understanding the hierarchy of decision making is a key to understanding how these policies play out in U.S. hospitals. Recently, I was at a hospital that prohibits patients from eating and drinking anything in labor during, including water. My client was about 24 hours into a multi-day induction. The nurse stopped me on my way to refill my client's water bottle.
I said in disbelief, "Wait, y'all don't still follow that out-of-date policy, do you?"
"I know, I know. What can you do? It's the policy?"
"Wait, so they really can't even have sips of water? That feels so inhumane to me."
In a whisper, "I know! If I'm being honest, I totally ate and drank during my own labor. I had my husband go buy me a chicken sandwich! I was starving. I just didn't tell anyone because I didn't want them to get in trouble."
I call this the "don't ask, don't tell" eating and drinking policy, which is the most common policy I see after clear liquids being allowed (broth, tea, jello, popsicles, etc). The hospital midwives and nurses know that NPO can actually hold up labor progress, and that it is brutal to tell someone that they can't eat during labor, but unfortunately, they don't outrank the people making the policy: anesthesia.
American Society of Anesthesiologists
Interestingly, the American Society of Anesthesiologists came out with press release in 2015 saying that they believe that a change in practice "makes sense" and that "aspiration today is almost nonexistent, especially in healthy patients." They note that calorie needs in labor are analogous to those of a marathon runner. They also note what I see as a doula, too: most people lose their appetite during very active labor. The letter does note that there are some circumstances when the ASA believes that risks of aspiration outweigh risk of withholding nutrition:
Pre-eclampsia and eclampsia, serious medical conditions
Use of opioids to manage labor pain because it slows digestion (aka epidural)
Obesity; don't get me started on the medical community's bias against fat people...
Unfortunately, in 2022 they went back on their statement and resumed recommending an NPO policy. Most of the research cited in this "update" is from before 2015. There is a notable exception from 2022 that concludes people in labor digest slower than people not in labor; something that I believe was already common knowledge based on my own non-medical training. In that statement, they recommend that solid foods are avoided in case of the need for an emergent cesarean procedure. They state that clear liquids should be encouraged.
My frustration is that my clients can handle a nuanced conversation about the risks and benefits of choosing to eat a certain amount at a certain time in labor, but they are not able to have those conversations with the anesthesia team because you usually don't meet them unless you are requesting an epidural or are in need of an emergency surgery. They aren't part of your team until the moment that you need them. And the moment they step in the room, they are almost always the highest ranking medical professional on your care team. They have a lot of power and influence with very little direct face time.
Yet, if a nurse gets caught telling a patient they can eat or drink, they get in trouble. So, they don't ask and they hope you don't tell them. Unfortunately, just like the old military policy, this one isn't so helpful either. Not asking prevents people having a nuanced conversation with their nurses or providers about the most beneficial foods in labor and how to strategize about when / how much to eat. It prevents a real conversation about how much risk is involved, and that in itself is a minefield: sometimes providers don't reveal that they are worried your at a higher risk for an emergency cesarean, they just tell you not to eat or drink. One helpful question to ask, is:
Is this your recommendation for everyone? Or is there something about my circumstances specifically that makes you believe NPO is the safest option?
Out of Hospital Midwives
I also think it is helpful to know that, at least in my experience, birth center and home birth midwives don't really care what clients eat. In fact, at one home birth I was scolded for offering my client water instead of a drink with sugar in it. In part, this is because anyone giving birth at home or a birth center is categorized as "low-risk." Many hospital midwives feel the same way, but are bound by the policies.
As I mentioned before, the UK encourages people to drink freely and eat a light meal in labor. I always encourage my clients to look at other countries to see how their policies are similar or different from the US.
So How Do You Decide What to Do?
I highly recommend doing your own research first. Which you are! Good work! I recommend clicking through the additional reading linked at the bottom of this article to get a good sense of multiple opinions. Then take some clear action steps:
Take a childbirth class so that you have the information you need to make nuanced and informed decisions for yourself
Hire a doula who can help you navigate all of the information plus your own personal desires
I can sneak you Sprite when you ask me to, but I can't change the hospitals policies. Don't hire a doula thinking that they can help you eat and drink at will in a place with strict NPO policies. We're good, but we aren't that good!
Talk to your labor support team to help clarify what your desires are and get on the same page
NPO / nothing by mouth
Ice chips only
Water and ice only
Clear liquids: electrolyte drinks, some juices, broth, jello, popsicles, etc
Drinks and a light meal
Unrestricted
Choose a place to give birth and a provide that matches with your desires
if you want to eat and drink in labor, don't go to a hospital that enforces strict policies; you won't meet your nurse until the day of so there is no way to know if you'll get someone who is very strict or someone who will follow a "don't ask, don't tell" policy
I've witnessed a person attempting a VBAC begging for water. The nurse told her that if she "needs to feel the sensation of water" that she could swish and spit. Don't go to those places unless you are prepared to abide completely by their rules.
Do some self-reflection: are you more of a people pleaser? A rule follower?
Are you willing to eat a big meal at home and then forgo food for hours or days?
Have a conversation with your provider
Bring the research and evidence that supports your thinking with you
Ask open ended questions about the hospital policy
Remember that there is no one right answer. Everyone has different risk factors in their pregnancy and different a different amount of comfort with risk ("risk profile"). No one can tell you what the right choice is. You will need to figure that out on your own. I have had many clients say, "I'm sure it will all be fine," and then feel very unsatisfied with their options at their birthing time. Please do make sure you have a clear plan for yourself, even if that plan ends up changing.
Additional Reading & Sources
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