Belly Up

* bellies * birth * babies * breastfeeding *

Friday, June 17, 2011

Eat, Drink and Be Merry

For years women have been told not to drink or eat while they are in labor.  The main reason for this forced fasting was to lower mom's risk of aspirating the contents of her stomach if general anesthesia was required during the delivery.  While the food and drink restriction may then seem logical, the restriction didn't necessarily actually avoid the problem.  When the stomach is empty, the contents actually increase in acidity which then may increase the risk of aspiration and furthermore, withholding food specifically during labor does not insure that the stomach is empty as the hormones of labor slow digestion.  As soon as the body recognizes labor, it slows the digestive process to ensure that there is a reserve of energy in mom's stomach.  Unless a woman routinely avoids eating during the last weeks of pregnancy (as if!), an empty stomach cannot be assured.  It can however be assured that withholding food can result in dehydration and ketosis...both unpleasant for mom and baby during labor and both are much more common than the use of general anesthesia during labor, which is rare. 

This may not be the best choice!
Luckily the American College of Obstetricians and Gynecologists, fondly known as ACOG, recently (circa 2009) decided to reverse its policy on withholding beverages for laboring women.  This is good news except the new recommendations have not made their way into common practice in many hospitals around this country.  Women are still being routinely denied the opportunity to drink even water during labor, never mind something crazy like a cup of tea or juice and the reason still being given is the risk of aspiration.  Other moms are simply told that eating or drinking will make them throw up.

Vomiting does happen to some laboring women, usually regardless if she has eaten or not. As previously mentioned, when a woman eats as desired in the early hours of labor, that food will barely start to digest and instead it will stay in her stomach and will provide the energy needed by both mom and baby throughout labor.  Then during transition, those fun last 3 centimeters of dilation, glucose levels will decrease to protect the baby's brain from excessive lactic acid while the baby's head is compressed during its journey through the pelvis.  High levels of lactic acid in the uterus may also cause contractions to be less effective over time. So the reason some moms vomit in the late stages of labor may just be that her body seems to determine how much nutrition it needs and then effectively gets rid of the extra.  That's where the vomit comes in...or out so to speak.

So where do IV fluids fit into the equation?  IV fluids are helpful if mom is suffering from dehydration or if she needs other medication during labor (ie pitocin or an epidural).  Of course if mom is unable to drink due to hospital policy then mom is indeed at risk of dealing with dehydration and may then need IV fluids, but IV fluids are not the same as food and drink.  For one they don't taste good or quench a dry mouth, but more importantly the use of IVs carry risk.  Having an IV decreases mobility and can be uncomfortable.  The biggest problem with IV fluids is the increased risk of fluid overload for both mom and baby and if the fluids used also contain glucose the baby's blood chemistry changes with increased insulin production which can cause problems immediately after birth.  Another concern is the risk of infection that is present anytime something is placed under the skin.  Bottom line, IV fluids do not provide a source of energy for a laboring mother and do not do a better job of hydrating during normal labor than allowing mom to just drink when she is thirsty.

I think the Cochrane Report from 2010 sums it up best,
Since the evidence shows no benefits or harms, there is no justification for the restriction of fluids and food in labour for women at low risk of complications. No studies looked specifically at women at increased risk of complications, hence there is no evidence to support restrictions in this group of women. 
So I say eat, drink and be merry during your labor!

Friday, June 10, 2011

Your Pelvis is Cooler than Elvis

Elvis's pelvis looks pretty wide here!
Today we are going to show the pelvis a little love.  Afterall, our pelvis is what we sit on, it holds our bodies in a upright position and also allows a woman to hold and grow a baby in her womb and then, when the time is right, it opens to allow that baby down and out.

I think many of us picture our pelvis as a fixed and immobile structure but that is not the case.  It is true that in non-pregnant women (and men) the pelvis is locked, but every pelvis is made up of 4 distinct bones that are held together by connective tissue, cartilage and ligaments.  The cool thing is that in a pregnant woman, as the pregnancy progresses and especially during the end of pregnancy and labor, the hormone relaxin is released and works to turn those connections into stretchy soft rubber bands (the midwife Gloria Lemay describes them as being like bubble gum) that allow the pelvis to loosen and to expand so a baby can pass through.

You may have come across a few medical terms for a pelvis: adequate, inadequate (or contracted) or even proven.  The term "adequate pelvis" is hardly a ringing endorsement for the powerful pelvis, but contracted is obviously worse and proven seems to hold the pelvis's ability in an attitude of guilty of inadequacy until proven innocent.  However, judging the size and ability of a pelvis prior to spontaneous labor is about as helpful as deciding the turtle neck part of a turtle neck shirt is too small to fit over your head before you try to put it on.  If a careprovider tells a mom that her pelvis is small, this is a huge red flag that he is setting her up for failure.  Probably not on purpose, but it means he may not appreciate the way the pelvis works during labor.  He certainly has not taken into account the bubble gum features of the pelvis.
 Relaxin is not the only thing that opens the pelvis.  The position one's body is in makes a difference as well. Squatting is said to increase pelvic dimensions by 30%.  That's a lot!   You can experience this simply by standing, placing your hands on the area just below your hips then move into a squat.  You can feel that your hands are now further apart than they when you were simply standing.  This same thing happens when walking, lunging, walking up stairs etc.  A baby's head also opens the pelvis, just as the example of the turtle neck demonstrates something that is pliable will make way for something being pushed through it.

Don't disrespect the pelvis...this position makes it smaller!
Conversely, as the pelvis is not fixed and is movable, there are also some things that can make it smaller too...which is of course the opposite of what one wants in labor.  Things like laying on one's back or in a supine position blocks the tailbone and sacrum from moving backwards and out of the way of the baby's descention and also decreases pelvic capacity.  Since the supine or semi-sit position is popular for hospital birth based on the convenience it extends to the careprovider, often the very way moms give birth lessens their ability to...give birth.  That's pretty disrespectful to the pelvis (and laboring women).

Induction also interferes with the pelvis's amazing ability to open.  Relaxin, that hormone that helps cartilage turn to bubble gum, is released in large quantities in the last days of pregnancy and during spontaneous labor.  When labor is induced, the body has not had a chance to finish its production of relaxin.  During an induced labor, depending on the circumstances, the body may not get the chemical signals that generally get it to start pumping out this and other labor hormones and therefore the pelvis is not able to reach its full potential.  Add in the other limitations, including the aforementioned pelvic closing positioning, that come with an induction and you can see why many times baby simply seems stuck in the pelvis.  The pelvis just didn't have the tools to do what it was designed to do.

Allowing the pelvis and the baby to work together in birth produces the best outcomes.  So when it comes time to have a baby, think bubble gum thoughts and make like Elvis....swing and tilt that baby out!