Excerpted from Birth as an American Rite of Passage

Fasting

Description and Official Rationale

Food and most drinks are routinely withheld from laboring women in most hospitals. Food digestion sometimes slows a little during unmedicated labor; narcotic analgesics cause considerable slowing of digestion. The rationale behind the practice of not permitting women in labor to eat is that, should they need a general anesthetic, the danger of inhaling undigested stomach contents if they vomit while anesthetized is greatly reduced. Aspiration of solid food can cause choking, and aspiration of acidic gastric juices can lead to a number of complications, including pulmonary edema and partial lung collapse, part of a rare and potentially lethal complication known as Mendelson's syndrome. According to Williams, "Vomiting with aspiration of gastric contents is a constant threat and often a major cause of serious maternal morbidity and mortality [in obstetric anesthesia]" (Cunningham et al. 1989:327). Stating that such dangers were "described by Mendelson in 1946" (1989:331), they cite as evidence a 1972 survey by Crawford that identified inhalation of gastric contents as associated with at least half of all maternal deaths.

Physiological Effects

The commonly held belief in the dangers of gastric aspiration is not based on fact but on anecdote and "hype" (McKay and Mahan 1988b:224). This medical myth continues to deprive hundreds of thousands of laboring women in this country of the nourishment their bodies need. The truth is that aspiration itself is extremely rare, and when it does occur it very seldom causes death. Mendelson's original 1946 article reported several cases of aspiration and the subsequent development of aspiration pneumonia, but no deaths. The cumulative results of more recent studies show that aspiration, far from being the leading cause of maternal death, is a minor and rare cause, accounting at the most for 2% of maternal deaths (Baggish and Hooper 1974), or 1 in every 200,000 laboring women (Scott 1978). And, as Moir (1979) pointed out, even this small risk of gastric inhalation under general anesthesia can be avoided, under all but the most dramatic of circumstances, by the use of regional anesthesia.

Ironically, insisting that women fast during labor may actually, should they inhale their vomitus, increase their risk of pulmonary edema, because the gastric juices left in the stomach after hours of fasting are far more acidic than usual; highly acidic fluids in the lungs are more toxic to lung tissue.2 Moreover, the supine position necessitated by the administration of anesthesia increases the risk of gastric inhalation and likelihood of aspiration (Pedersen and Finster 1979). The risk of aspiration increases further when medical personnel apply yet another fairly common intervention: pushing on the abdomen (fundal pressure) to speed up the birth (Kruse and Gibbs 1978).

Starving laboring women may also result in ketosis--a condition of weakened muscle cells and alterations in the blood chemistry which results from too-rapid depletion of the laboring woman's stores of glycogen, which then causes her to start using her fat stores as a form of energy; ketones are the by-products of this process; their unchecked buildup in the bloodstream causes the uterus to contract less efficiently and labor to slow down. When this happens, the usual hospital response is to speed up labor with the synthetic hormone pitocin, which entails its own set of risks, as we will see below.

Would an athlete run a 24-hour marathon without food or drink? Both the athlete and the laboring woman need quick energy from food to maintain their increased cardiac output. Both take more time than usual to digest solid foods but can use oral fluids to keep blood glucose levels up. Hazle has suggested that women in early labor should be encouraged to eat meals similar to the pregame meals of athletic competitors: "high in carbohydrates for quick energy, and fluids for hydration, and low in fats for digestive ease" (1986:174). Such foods, as well as electrolyte-replenishing fruit juices and fluids (such as Recharge, Third Wind, 3 and Gatorade) can be used during active labor (Hazle recommends at least 4 oz. per hour) as long as narcotic analgesia (which slows digestion dramatically) is avoided.

Such evidence and suggestions seem to confront laboring women with a choice: to eat and drink during labor to keep up their strength but stay away from digestion-slowing analgesics, or to utilize pain- relievers, accept the lessening of endurance that comes with fasting during extreme physical exertion, and rely on synthetic labor stimulation should a resultant slowing of labor occur. Such a choice, however, is in practice not usually the woman's to make, as standard policies in most hospitals prohibit her from eating or drinking anything more sustaining than ice chips, tea, or lollipops.

Pointing out that "studies of the nutritional needs of laboring women are virtually nonexistent," McKay and Mahan suggest:

Labor is very hard work--perhaps the most prolonged and intense physical exertion that many women ever undertake. We would do well to pay attention to the rapidly emerging field of exercise physiology for new ideas about oral nutrients we might use to maximize the natural progress of labor. Improvement of the mother's nutrition and strength, if done correctly, may have salutory effects on fetal outcome. -1988a:219

After reviewing all recorded cases of actual maternal deaths from aspiration, these authors suggest that the standard NPO policy actually serves to displace preventive efforts onto the mother and to distract clinicians from focusing on the true causes of the few cases of maternal aspiration that do occur: inadequate equipment, faulty practitioner training or technique, and hospital understaffing.

Women's Responses

I went into labor just after dawn. I called my OB, and he said not to eat, so I skipped breakfast and went on in to the hospital. By that evening, when things were getting really intense, I was so weak from hunger I thought I would die...it wasn't till I had the epidural that I started to feel like I could make it.
-Charla Lovett

In the responses of individual women to the obstetrical procedures thus far analyzed, we can begin to detect the gradual process of the conceptual fusion of the laboring woman's beliefs with the technocratic model. This process, from beginning to end, will be analyzed in detail for a number of individual women in Chapter 5. Here I will only pause occasionally to point out this process of cognitive transformation as it occurs or is subverted by the women whose responses are included here.

Suzanne Sampson's response to the wheelchair, for example, was that she suddenly began to feel that maybe she was not "in control any more"; Susan Smith's response to being separated from her husband was to become "confused" and to begin to "lose control." In these responses we can detect the beginnings of the cognitive disorientation that is a prerequisite for the reconstruction of their individual belief systems in conformity with the technocratic model.

Further examples of this process at work are provided by Charla Lovett's response to fasting (above) and by Elizabeth Fisher's response to lying down ("I felt defeated. And it seems to me now that my lying down tacitly permitted the Demerol, or maybe entailed it. And the Demerol entailed the pitocin, and the pitocin entailed the Cesarean...). As these two women indicate, birth rituals often function like "cranking gears": as they work to map the technocratic model onto the laboring woman's perceptions of her birth experience, they also set in motion a physiological chain of events that will make this model appear to be true, and their intensified performance to be both appropriate and necessary. By the time I interviewed Elizabeth and Charla some months after their births, they had become consciously aware of this cranking gear process, and pointed out how one procedure had inevitably led to another in their labor and birth experiences.

Ritual Purposes

According to Feeley-Harnik, "persons undergoing rites of passage are usually prohibited from eating those highly valued foods that would identify them as full members of society" (1981:4). In rites of pregnancy and birth across cultures, food tabus serve the purpose of marking and intensifying the liminal status of the pregnant woman. The pseudo-foods (ice chips and lollipops have no nutritional value) allowed in the hospital are often fed to the laboring woman by her partner as if she herself were a baby, a symbolic process that can heighten her own sense of weakness and dependence.

In a recent article in Birth, Broach and Newton (1988) address the question of why laboring women are still prohibited from eating and drinking in labor in spite of mounting evidence that such prohibitions are medically contraindicated. Pointing out that this custom started in the 1940s when general anesthesia was widely used for childbirth and the danger from aspiration was therefore high, they posit that its continuance is the result of "culture lag"--that is, of "culturally patterned behavior [that] continues to be practiced long after the reasons for doing so have disappeared" (1988:84).

On the contrary, I would suggest that this custom forms an integral part of the technocratic tapestry of birth in the United States, continuing as routine procedure not because of culture lag but because it serves so well to legitimate and further necessitate the technocratic interventions we investigate here as transformative rituals. To deny a laboring woman access to her own choice of food and drink in the hospital is to confirm her initiatory status and consequent loss of autonomy, to increase the chances that she will require interventions, and to tell her that only the institution can provide the nourishment she needs--a message that is most forcefully conveyed by the "IV."

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