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Interviewer: Eating and drinking during labor. Is this a thing that women should be concerned about? We'll find out next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: We're talking today with Debra Penney. She is a Certified Midwife from the College of Nursing at the University of Utah. A topic of concern for women going into labor is whether I can eat and drink, because for the longest time anesthesiologists have said that women shouldn't be eating and drinking because of the risk of aspiration.

Debra: Traditionally when the anesthesiologist comes into the room, perhaps, to give an epidural to a woman, they routinely ask the woman to only have ice chips, and this is really hard for women because they're doing a lot of work in labor, and sometimes they need the glucose or the sugar that's in a drink or sometimes some light food to eat, and they feel really restricted a lot, and mentally it's just not good. They want to eat and drink in labor because they're doing a lot of hard work.

Interviewer: It can be a long time too.

Debra: It can be a long time for their body to have to keep working. So when we look at the evidence for the risk of aspiration, which would be like inhaling something, perhaps vomit in labor, that's not a big concern as it used to be because of many reasons. One is they're less likely to even be intubated for labor because they had an epidural, and a lot of times a C-section can be done under a spinal and they can use that same epidural to do a spinal so they don't need to be intubated during labor. So there's even less intubation going on and that decreases the risk of aspiration.

Interviewer: And so with all these new evidence that say it might be okay for a woman to eat and drink during labor, if there is an increase, are women still being in aspiration or is it just fine?

Debra: So it's really hard to track aspiration. It can be lethal if it happens. Most often it happens with general anesthesia and intubation, but it can happen to anyone who vomits anytime. We know that some women are at risk for aspiration. Women who are obese. Women who have GERD, or they have gastric reflux anyway. Women who have been given IV narcotics for pain relief because the intestines just aren't moving in a normal fashion, and so they're at risk, so it would really be good to know what risks exist for women and to discern that rather than just saying every woman should not eat or drink in labor. And of course drinking clear liquids is going to be your least likely problem if you aspirate, because the lungs can clear that out easier.

Interviewer: So it seems to me like it's actually a pretty safe thing for women to eat and drink in labor. You agree with that?

Debra: If they're low risk during their pregnancy, they don't have any medical problems, and they're also progressing normally in labor, there shouldn't be any reason to restrict, at least clear liquids if not food for them because their chance of aspirating is less than getting hit by lightning. Evidence has shown that this fear of aspiration is not as universal as we thought it was, and women should be allowed to at least drink in labor, if not eat.

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Interviewer: Giving birth in water - is it something that you should consider? That's coming next on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthy life. You're listening to The Scope.

Interviewer: It's a trend. It's like one of those popular things that expectant moms-to-be are just doing. It's giving birth in the water. We're talking today with Debra Penney. She is a certified nurse-midwife in the College of Nursing at the University of Utah. Is it, first of all, safe?

Debra: Yes. Actually, for low-risk women who have no medical problems who are expecting a normal progress in birth, it's very safe and it's very comfortable. It can relieve a lot of pain in labor as well.

Interviewer: Is that why a lot of women choose to give birth in the water, then, as opposed to the traditional way?

Debra: Yeah, many women find it very relaxing and pain relieving to be in the water during birth. It's warm water, it's clean, it's filtered as hours progress, and they find it very good to be buoyant and in the warm water.

Interviewer: Is this something that's done at home or is it also something you can do at a hospital?

Debra: Not every hospital offers this. Here at the University of Utah we are offering it, and yes, they can do it in the hospital. It's often done at home for home births as well.

Interviewer: And so I guess if it's safe, if it's comfortable for the mom, my next question is, what is the difference between giving birth in the water versus the traditional way? Is there a difference in why a mom would choose to give birth in the water instead?

Debra: Well, as midwives we like to give mothers choices, and we like to really consider the safety of those choices as well. So for the low-risk women we do some additional laboratory tests like hepatitis C for the mother because that can be transmitted in the water, and so if she's negative with that we can go ahead and anticipate a normal birth with her in the water. So the midwife traditionally can bring the baby to the surface at birth within five seconds. There's actually a protocol for safety, both for mom and baby with a water birth.

Interviewer: Are there any side effects or risk?

Debra: There's very few risks. If she's got a lot of meconium that shows up telling us the baby is stressed, we'll get her out. If for some reason labor doesn't progress, we'll get her out. And we always give women the choice to self-select when it comes time to push, and a lot of these women do get out to push the baby out and/or the placenta after the birth. But of all of the water births that have been done around the world, there's not a huge chance for infection or any of the other normal risks you would think of.

Interviewer: So it sounds like it's a pretty safe, natural process to give birth in the water. If it is a choice given to moms, then, is there a deciding factor, like, "Oh, I should be giving birth in the water versus in a hospital in the traditional way?"

Debra: It's really up to the woman, and some women come in wanting that straight from the beginning and we have not offered it until now. Some women just choose to labor in water and to get out when they're ready. So it's really up to the woman as far as what she wants, and having only one tub at the University will limit some of their choices. But it is sort of a trend these days.

Interviewer: So it's not really a "this is better than this" sort of a thing?

Debra: No, it's definitely not necessarily better. It's just a choice.

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Interviewer: Eating the placenta, should you or should you not? That's what we will be discussing next on The Scope

Announcer: Medical news and research from University of Utah physicians, and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: We are in the studio today with Debra Penney. She is a nurse-midwife from the College of Nursing at the University of Utah. Debra, one of the popular things to do now after labor is to eat your placenta. That sounds kind of odd, kind of weird, kind of gross all at once, but from a medical standpoint is that an actual common thing that mothers do after a birth?

Debra: They've looked at the statistics and it's I guess about 3% of women choose to have their placenta processed by boiling and drying, and then they have it encapsulated. So it's kind of an easy way to ingest it. Very few people eat it raw.

Interviewer: So it's like a pill.

Debra: Yeah. After it's processed they ingest it and there's really no [inaudible 00:00:57] or frequency that's common, but you can find this on the internet.

Interviewer: Why do they do it? What's all the hype about?

Debra: Well, it's interesting. I think they read on the internet that it has specific benefits like decreased fatigue, better breast milk, less chance of depression, but none of these factors are verified by any kind of research. So they read this on the internet and they think it's true, and they thought, "Well, yeah," you know, "And I see other animals eating their placenta like herbivores, like horses and cows, so it must be something we should be doing, too," although historically there's very little evidence.

Interviewer: I have read that, again on the internet, the Chinese also eat the placenta after birth and they've had great results. Is it even treating the same symptoms? Is it even for the same illness?

Debra: Chinese medicine has used the placenta, but not for any of the factors that I've just mentioned. They've used it in other potions for other things, but not specifically for anything related to birth or after birth, and that's really only evidence we have of people really eating the placenta. They may have been a tribe of Indians in Mexico that had a ritual of eating it, but overall in the human race, eating the placenta is not a common thing that's even known to anthropologists.

Interviewer: So a straightforward question would be, is it even recommended to eat the placenta?

Debra: Well, we don't recommend it because there's not enough research to even verify any of the claimed benefits of better breast milk, decreased fatigue, and less post-partum depression. So far there's no evidence at all that this works. Secondly, from a medical point of view, when we look at the placenta it's got a lot of estrogen in it. Commonly, we don't give people estrogen post-partum because it does decrease breast milk and increases the woman's chance of having a blood clot like in her leg or her lungs or something, because she's already really ready to clot. That's just nature's way post-partum.

The other thing we haven't really looked at is the placenta is a filter organ and it has potentially a high metal content in it. That also needs to be discovered. If that's the case, then it is a very dangerous thing. So there's some potential concerns about eating it.

Interviewer: So if it's as dangerous as you say, then why are women having "good results" after eating the placenta?

Debra: All of these are anecdotal results, so one woman may feel that. And, you know, anything we take by pill can have a placebo effect where we think it's doing its job because it's supposed to.

Interviewer: Like a mental thing.

Debra: Yeah, when in reality it may just be her thought that it's going to work. But we don't know. I mean, there's research currently being done, and really, we don't even know what doses women get. We don't know what's contained in the capsule as far as how much placenta, how much progesterone and estrogen is in it. We know there's some, because the placenta is full of that. We don't know how many heavy metals are in it. We don't know if it's really free of bacteria after it's processed, either. So there's a lot of question as to what's being ingested and how much. There's some potential risks, so in saying that we don't know, we like to inform women that this is an unresearched area, and you might find really positive things on the internet that really aren't verified.

Interviewer: So it sounds like to me, hospitals and doctors and even yourself as a certified nurse-midwife, you're not really recommending eating the placenta. Where are the women getting these placentas in the form of pills? I've even read somewhere that they ask for the placenta raw so they can put it in their blender and make it into a smoothie. Where are they even this? Does the doctor just say, "Hey, here's your placenta. Have fun. Go at it?

Debra: Well, there are very few states that have any regulation on the placenta, the disposal of it.

Interviewer: Oh, so the mom can just get it.

Debra: So yeah, all she has to do is sign a waiver that it's her placenta and she can take it home and do what she wants with it. Now traditionally, placentas are refrigerated and then carried off and incinerated in the hospital, so she can sign a consent form to get that placenta.

I would highly advise not eating it raw just because it's been in a really dirty location in the birth process, and may have E. coli on it as well as other bacteria. So in my estimation there's not a lot of research out there yet about what really the woman is ingesting, and I would just say really consider the risks and potential risks and benefits of this, and be really cautious about even ingesting it.

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Debra: If you've been to the dentist you may have heard of laughing gas. Did you also know that it's used for labor pains? Today we'll be talking about nitrous oxide on The Scope.

Announcer: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Debra: I'm Debra Penney and I'm talking today with Michelle Collins, PhD. She's also a certified nurse midwife and the director at Vanderbilt University of the Nurse-Midwifery Program. First of all Michelle, what is nitrous oxide?

Michelle: A lot of people think of nitrous oxide as laughing gas because that's what they know it from the dentist. It is similar to what they use at the dentist, but it's a different concentration. A lower concentration when we use it in labor.

Debra: And tell me, how is it given to women in labor?

Michelle: They inhale it either through a mask or a mouthpiece. The mask goes over their mouth and nose, where the mouthpiece they purse their lips around.

Debra: And can she be up and mobile while she's taking this gas or does she have to be in bed? How does that work?

Michelle: It does allow for a woman to maintain her mobility. So she can be on her birth ball, on her hands and knees on her bed, doing slow dance with her partner, in the rocking chair, any position really.

Debra: What kind of affect does it have on her and does it have any side effects?

Michelle: Probably the largest side effect is about 10% of women will feel nauseous or need to vomit. But that's only 1 out of 10 women. That's probably the most prevalent. Some women get a little bit dizzy when they use it as well.

Debra: What about the baby? How much of this gets to the baby?

Michelle: So there has not been a great deal of research done on nitrous oxide, although we have a large body of what we call anecdotal evidence, meaning it's been used for almost a century in other countries. So we have lots of babies born over lots of years in lots of countries to look at and we've not seen it affect the baby at all after birth. In other words, we don't see sleepy babies or drug affected babies from mom using the Nitrous.

Debra: Well it sounds like a pretty good thing then. If it's that good why aren't we using more of it here in the US? I understand there are only about 100 hospitals that have it available to laboring women.

Michelle: It was actually used in the '50s, and then with the advent of the epidural anesthetic it kind of went out of favor as epidurals rose in popularity. Now in other countries the epidural rate is not what it is, not as high as it is in the United States, so they continue to use nitrous oxide widely. For instance some countries, like Great Britain, 60% of all women in labor use it. Some countries like Norway 80% of women use it in labor.

Debra: So does this nitrous oxide work for every woman?

Michelle: Not every woman is going to take the nitrous oxide just like not every woman likes an epidural or not every woman likes a narcotic. Some women will try it and not like it at all, feel it's not helpful, and move on to something else.

Debra: When hospitals use it, do they have some kind of guideline in place for how it's given, or who gives it?

Michelle: In most places in the US the midwife or obstetrician or family practitioner, or whoever is taking care of the mother, gives an order to the nurse, and the nurse initiates the nitrous oxide. In some hospitals only an anesthesia person initiates it. So it's dependent on the hospital. In birth centers there are only midwives and nurses so they would be the ones doing it at a birth center.

Debra: So it sounds like a pretty good option. What other kinds of affects, other than taking the pain away, does it have any other affects on the mom?

Michelle: It is really good for anxiolytic properties. What that means is it decreases one's anxiety. So for some women it's not the pain of labor that is intolerable, but the anxiety. They're so afraid of the birth process. So it can decrease their anxiety and help their labor along.

Debra: So apart from labor pain, say she's waiting for an epidural that's really her drug of choice, can she still use this nitrous oxide while she's waiting?

Michelle: Yes, that's a good use of it, is for the woman to inhale it while we're having her epidural placed. Helps with the pain, helps with her anxiety and generally gets her through that transition period until the epidural is working well.

Debra: Have you ever seen it abused in the hospital? Or heard of stories with it abused?

Michelle: That's a common misconception and it doesn't appear in the literature as any problem in the European hospitals and we've been using it at Vanderbilt for four years and have not had one instance of that happening.

Debra: So what if a woman tries it and finds out she doesn't really like it?

Michelle: If she inhales a few breaths, part of the advantage of using nitrous oxide is it's a very quick onset. Within about 30 seconds she'll feel an affect, and it also has a rapid offset. Meaning if she doesn't like it, she stops breathing it, takes a couple breaths, and the effect is gone. And that is really one of the advantages of using nitrous oxide.

Debra: What are some of the other advantages?

Michelle: Besides not affecting the baby at all, that we have seen in use, women can also control it themselves, so it's not strapped to their face where somebody else is controlling it. They are empowered to breathe it when they want and not breathe it when they don't want. This makes it a really attractive advantage, and hopefully it will be widely available to women in the US soon.

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Interviewer: Understanding some of the barriers that prevent refugees from receiving equal medical care up next on The Scope.

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Interviewer: Debra Penney is an associate professor in the College of Nursing. She's investigating the barriers to providing standard health care to Iraqi Muslim women including refugees. Before you started this study, why did you suspect that Iraqi women did not receive the same quality of care as, say you or I would?

Debra: I have given care to a lot of different women, and I find that language is one of the biggest barriers for getting good care. It inhibits that data that you can collect from the women, their histories. It inhibits to a great degree the amount of education you can give and the depth of education.

Interviewer: So, how did you go about doing this study and what were you hoping to find out?

Debra: Well, I was really curious if the recent war and the previous Gulf War had an influence on providers' attitudes towards Muslims, in general, just because there had been so much negativity in the media. And I wanted to know if women felt that repercussion in the health care encounter.

The other part is there are very few studies done on women and Muslim women seem to be a curiosity for most Americans, so I was really curious to see if some of the discrimination that had been going on in public was actually transferred to the health care encounter. And I found that it wasn't as far as providers, but there were subtle forms of racism and stereotyping bias that are just common to human nature that did exist. And I wanted to know what their barriers were in accessing health care.

Interviewer: So, what were some of the main themes that came out of these interviews?

Debra: One of the main things that Iraqi women struggled with was they're familiar with western medicine basically. They have MRIs and they go to the doctor to get whatever they treatment they need, and their health care system was pretty comparable before to the wars to ours. When they came here they are taken by either international Rescue Committee or Catholic Community Services as an agency with an interpreter who picks them up, usually drives them to their appointment.

It's a great service, at least they have somebody there, but they were really floored because they could only mention two things that were wrong with them or that were a problem. And then the health care visit itself is limited by time. So not only do you need more time to interpret, but at the same time they were cut short because the need for interpretation and how much time that takes.

Interviewer: And you were talking earlier about just who is doing the interpreting can really affect the outcome of this visit.

Debra: Women, several women had said that they were stifled because not just the time limits, but they didn't have a female interpreter. And they came right out and said, "We're going to express a lot more if we have a female interpreter." So, actually, in their whole description of their interpreter, once they had kind of a regular one from one of these agencies, they really found that that personal interpreter was a friend, an advocate and a support person for them in the visit. And they did trust them and that was a really good thing.

Sometimes families would opt out. They had a car, they knew how to drive and get around after a few years, and they didn't want a stranger, an interpreter that they didn't know so they would take one of their kids who knew English a little better, or say a husband interpreting for a wife. And that worked fine until they got to personal questions of either gynecological nature or something like that because in their families they don't mention that. And for a daughter to hear about her mother's menstrual problems or something was very disconcerting for them. So, I term that cultural distress.

Other things that might be just common place that we need to ask as women's health providers are, "Do you have any sexual problems that you want to talk about?" because a lot of times patients aren't willing to bring these up on their own. So, we ask this question and we work from a template sometimes on an annual exam, and sometimes we forget that, oh gee, this question might be really offensive to someone who just doesn't normally think like we would in the US about people having sexual preferences.

Interviewer: So, the standard questions that you're supposed to ask, as a health care provider, just may be totally offensive in this case?

Debra: Yeah, and it's hard to filter that all the time and to know enough about a culture to know what is going to be offensive and what isn't.

Interviewer: Yeah, right. And what about from ... well, I guess that touches on the health care provider's side. I mean what did you learn from them about barriers to proper care?

Debra: So, the knowledge that the providers had was pretty good. They understood Ramadan, they understood fasting. They adjusted medicines to that. I was pretty impressed, but the depth of what they knew of the individual woman and how it might have differed from the majority was still lacking. These providers saw lots of refugees.

So we have Afghani and Somali and Sudanese and Iranian and Jordanian, and they may all wear the headscarf or the hijab. So, a lot of providers got them a little bit confused as far as their identity. They may have mixed up the fact that most Iraqi women are fine with birth control whereas Somali women aren't. So, they would get some of the characteristics confused, and wearing that headscarf did label them as Muslim and kind of put them in a little box.

Interviewer: So, now that you kind of have this understanding that there are specific issues with these women and receiving the care they need, I mean, what we can do with this information, how can we move forward?

Debra: One of the things that women complained about was the repetitive nature of questions, and that means a medical assistant comes in and take questions, then the doctor comes in and repeats the questions. So, precious time in the encounter is used up by repeating questions. So, I think somehow streamlining that and also having more times for patients. Maybe having an initial visit where the whole family comes and they get to know them a little better so they'll have a basis to work from.

The whole concept of having like a health care guide or a health care worker, that's actually part of the clinic that speaks the language that sees these people on a regular basis and is part of the clinic would be really helpful. And I believe that is covered under the Affordable Care Act. So, that's something that needs to be instituted to give these women better care. And also the providers are at a loss a lot of times. They do the best they can with the time limit, but this could be a really good asset to the health care encounter.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.