Tuesday, January 26, 2010

Labor Anesthesia With A Full Stomach

The New York Times highlighted a provocative research paper that advocates more leniency of NPO status in women undergoing labor. The paper is published in The Cochrane Review and is a meta-analysis of 11 studies looking at the rate of birth complications and likelihood of Caesarean sections as related to NPO status. The analysis shows no difference in APGAR scores, need for C-sections, or pain scores between women who were allowed to eat and those who were kept NPO. Thus the authors recommend that women should no longer be kept NPO during child delivery.

I say that's a bunch of hogwash. The official opinion from the American Society of Anesthesiology is not mentioned until at the very end of the article. Dr. Craig Palmer, Chairman of the Committee on Obstetrical Anesthesia said of the study, "From an anesthesiologist’s perspective, they missed the boat on this one. They looked at the impact on the progression of labor, but to be honest, that’s not an issue for anesthesiologists. Our primary concern is patient safety."

From my own personal experience most women who undergo C-sections have extreme nausea and vomiting during the procedure, especially when the uterus is brought out of the abdomen and hard pressure is placed on the dome to push out the baby. It is ugly enough when bilious emesis spews forth. I couldn't imagine the complications if the patient had a full stomach. The authors also fail to take into account well documented changes in gastric physiology of women with term pregnancies, including delayed gastric emptying, higher acidic content, and decreased lower esophageal sphincter pressure.

The news article mentions one OB/GYN who compares labor and delivery to driving a car. She says people can have accidents anytime, requiring emergency surgery. But we don't keep people NPO before getting into their cars. I'd counter that the argument is naive. Up to 25% of pregnancies now end with C-sections. If 25% of all vehicular trips end in accidents requiring surgery, then yes people should be NPO before getting into their cars. The authors also say that with improved techniques, the risk of aspiration with general anesthesia during labor is extremely low. Well that is a totally circular argument. The reason labor anesthesia is so safe nowadays is precisely because of rules advocated by anesthesiologists, including keeping patients NPO, that lowers the complication rates for the patients and their OB docs.

So this article is misinformative at best, dangerous at worst. The article leads with a mention of the low likelihood of gastric aspiration during labor anesthesia but that is not what the study is about. Now patients will be clamoring for their doctors to change their diet orders in Labor and Delivery when in fact the study does not compare the risk of aspiration in full stomach vs. NPO laboring patients. And frankly, a real randomized double blinded study like that will never be performed. If any women would like to volunteer to be in the full stomach branch of that study, be my guest. As long as they sign wavers absolving all legal responsibility of their doctors when they wretch up that oatmeal and bacon they had for breakfast and aspirate into their lungs.

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