Information Sheet: Non Per Os
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Information Sheet: Non Per Os

Info Sheet: NPO non per os nil by mouthRestricting food and drink is still a common practice in many hospital settings.  Here is our presentation of the information so you can make an informed decision for your labor:

Definition:  Non Per Os or Nil By Mouth
From Wikipedia [1]:
Nil per os (alternatively nihil/non/nulla per os) (NPO) is a medical instruction meaning to withhold oral food and fluids from a patient for various reasons. It is a Latin phrase which translates as "nothing through the mouth". In the United Kingdom, it is translated as nil by mouth (NBM).

Typical reasons for NPO instructions are the prevention of aspiration pneumonia, e.g. in those who will undergo general anesthetic, or those with weak swallowing musculature, or in case of gastrointestinal bleeding, gastrointestinal blockage, or acute pancreatitis. Alcohol overdoses that result in vomiting or severe external bleeding also warrants NPO instructions for a period.

When patients are placed on NPO orders prior to surgical general anesthesia, physicians would usually add the exception that patients are allowed a very small drink of water to take with their usual medication. This is the only exception to a patient's pre-surgery NPO status. Otherwise, if a patient accidentally ingested some food or water, the surgery would usually be canceled or postponed for at least 8 hours.”

*History
Why was it adopted in labor?  What was it supposed to treat? 
Restricting food and drink was supposed to prevent Mendelson’s Syndrome.  It is a condition…it is a theory that there is an increased risk of the stomach contents entering the lungs…here is a little history from About.com [2]:
“In 1946 Dr. Curtis Mendelson hypothesized that the cause of pneumonia following general anesthesia was aspiration of the stomach contents, due to delayed gastric emptying in labor. He noted that food could be vomited 24-48 hours after being eaten. Dr. Mendelson experimented on rabbits to examine the effects of content in their lungs. Aspiration (taking the particles into your lungs) of undigested food could cause obstruction, but not aspiration pneumonia, and no deaths were due to aspiration of fluids with a neutral pH. The rabbits only died when they aspirated materials containing hydrochloric acid. He said by forbidding food and drink in labor you could reduce stomach volume, thereby decreasing the risk of maternal problems from acid aspiration while under general anesthesia. We also found that there were two factors that increased the risk of maternal problems:


    • A volume of an aspirate of 25+ mm
    • A pH of 2.5 higher (biggest problem)

However, in the 40's and 50's general anesthesia was used much more often for labor and delivery. For example, most forceps were done under general anesthesia. Gases were given with a face mask, often opaque, which hampered the anesthesiologist's view of the airway. Dr. Robert Parker, in 1950, largely blamed aspiration on poor anesthetic technique and poor quality of the practitioners.


Has it been effective: as in, has the incidence decreased or has a problem been solved as a result of the intervention/procedure/test?
From About.com [2]
“The risks of aspiration are only a problem when general anesthesia is used (3.5-13% of cesareans), and the technique has improved. Anesthesiologists now have more quality control.

So the two solutions that have been the most popular have been the IV and antacids before a cesarean surgery.

IV fluids are not always reasonable solution to hydration problems, as they have problems of their own: over load, closer monitoring of intake and output, hyperinsulinism in infants after 25 g of glucose, and the salt free solutions can result in serious hyponatraemia in mom and baby. And the antacids are usually given in the quantity of 30 mm, a volume known to increase the risks of aspiration pneumonia.

We also know that restricting food in labor can cause problems of its own. Besides the stress factors, restricting intake during labor can cause dehydration and ketosis.”

*Pros and Cons
Pros:
Theoretically: if you have an empty stomach, you are easier to treat.  In reality: very hard to justify one.  The idea of an “empty stomach” is a fallacy, and anesthetic techniques and training are vastly improved since the initial hypothesis about the link between aspiration and pneumonia in the 1950’s.  You have to evaluate how you feel about this statement:  “Labor is not an illness to be treated – it is a natural event that needs to be supported.”

Cons:
  • Stress factors caused by denial of food and water
  • Dehydration
  • Ketosis
  • Longer labor: women who are allowed to eat and drink to comfort in labor have shorter labor (by an average of 90 minutes)
  • May need augmentation with Pitocin
  • May require more pain medications
  • In one study, babies had lower apgar scores than of those in the control group. [2]

Most telling is this practice guideline published by the anesthesiologist in 2007.  The folks doing the anesthesia are saying it is safe for low-risk mothers to eat and drink in labor, even with anesthesia, and go so far as to make recommendations about the type of foods that can be eater:

From the Practice Guidelines from An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia [3]
II. Aspiration Prevention
Clear Liquids.
There is insufficient published evidence to draw conclusions about the relationship between fasting times for clear liquids and the risk of emesis/reflux or pulmonary aspiration during labor. The consultants and ASA members both agree that oral intake of clear liquids during labor improves maternal comfort and satisfaction. Although the ASA members are equivocal, the consultants agree that oral intake of clear liquids during labor does not increase maternal complications.

Recommendations.
The oral intake of modest amounts of clear liquids may be allowed for uncomplicated laboring patients. The uncomplicated patient undergoing elective cesarean delivery may have modest amounts of clear liquids up to 2 h before induction of anesthesia. Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, black coffee, and sports drinks. The volume of liquid ingested is less important than the presence of particulate matter in the liquid ingested. However, patients with additional risk factors for aspiration (e.g., morbid obesity, diabetes, difficult airway) or patients at increased risk for operative delivery (e.g., nonreassuring fetal heart rate pattern) may have further restrictions of oral intake, determined on a case-by-case basis.

*Links 
Resources with other options to explore if you want to negotiate for unrestricted eating and drinking in labor – maybe you will “compromise” and get “clear fluids”.  These are more studies and articles that demonstrates that eating and drinking in labor is a sound evidence-based practice:

1.) Singata M, Tranmer J, Gyte GML. Restricting oral fluid and food intake during labour. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD003930. DOI: 10.1002/14651858.CD003930.pub3.
http://summaries.cochrane.org/CD003930/eating-and-drinking-in-labour

2.) Health Behavior News Service, part of the Center for Advancing Health (2013, August 22). Restricting food and fluids during labor is unwarranted, study suggests. ScienceDaily. Retrieved September 10, 2013, from http://www.sciencedaily.com/releases/2013/08/130822141954.htm

3.) Wiley-Blackwell (2010, January 22). Eating and drinking during labor: Let women decide, review suggests. ScienceDaily. Retrieved September 10, 2013, from http://www.sciencedaily.com/releases/2010/01/100119213043.htm

4.) Summary of these three articles in our blog post “Can I Eat and Drink in Labor?”

Did you eat and/or drink during your labor?  Did you worry about it?  What was your thought process? 

References:
[1] http://en.wikipedia.org/wiki/Nil_per_os

[2] http://pregnancy.about.com/cs/laborbasics/a/eatinginlabor.htm

[3] http://journals.lww.com/anesthesiology/toc/2007/04000
Anesthesiology:
April 2007 - Volume 106 - Issue 4 - pp 843-863
doi: 10.1097/01.anes.0000264744.63275.10

Disclaimer: 
The material included on this site is for informational purposes only.  It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation.  Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided.  This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.
Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson









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