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First, Do No Harm: Another Reason to Ditch Routine IVs in Labor

In the latest Listening to Mothers Survey 83% of women reported having intravenous (IV) lines in labor or birth. This number is probably not surprising to many of us – IV’s are part of the routine package of care in most settings, even for low-risk women. Their ubiquitous place in modern obstetrics renders them practically invisible. And although the American Society of Anesthesiologists revised its guidelines in 2007 to encourage clear fluids in labor – which would presumably eliminate the need for IVs in most cases – the practice of routine IVs appears to be continuing unabated. Why? Because the medical model presumption is that it’s nice to have that IV access just in case an urgent complication is lurking around the corner. And besides – IVs are relatively harmless, right?

Wrong. In 2007, I was part of a team that conducted a systematic review (PDF, see p. 34S – 36S) of the research on IV fluids in labor. We found that IVs can cause anemia and that they reduce colloid osmotic pressure – which can lead to swelling in the tissues or lungs (pulmonary edema) of both the laboring woman and her infant. In addition, not all IV fluids are created equal: IV fluids with glucose in them were associated with low blood sugar in newborns, and salt-free fluids increased the likelihood of potentially serious electrolyte imbalances. The body of research also confirmed common sense – that women find IVs uncomfortable and that IVs limit mobility. Finally, we failed to find a single study that supported the notion that IV access improves outcomes when urgent problems arise. Despite this nearly universal belief, no one has in fact studied the question.

This week I happened to see two different bits of news blip onto my radar that raise other troubling concerns about the rampant use of IVs on maternity wards. Both pieces looked at possible harmful effects of the chemicals that may leach out of the plastic IV bags and tubing. A recent NPR story reported on an ongoing study looking at sexual maturity in teenagers who were exposed to high levels of phthalates as infants in neonatal intensive care units. The phthalates came from intravenous lines, including those used for extracorporeal membrane oxygenation (ECMO). The Wall Street Journal posted a short blurb about an animal study showing that another chemical found in IV bags and tubing, cyclohexanone, can trigger health problems in the hearts and neurological systems of the rats that were exposed. We can not – and should not - extrapolate the findings of these studies to possible effects on laboring women and their newborns. But they add new fuel to an already compelling case to do away with IVs whenever safely possible. With no evidence that their routine use is beneficial, a small but consistent body of evidence that they can cause harm, and important questions unanswered, a change in practice is long overdue.

For more information about potentially harmful chemicals used in health care settings and ways to reduce the environmental impact of our health care system, visit Health Care Without Harm. Along with other great resources, HCWH published a booklet with the American College of Nurse-Midwives called Green Birthdays (PDF) in 2001.

Citation: Goer, H., Leslie, M. S., & Romano, A. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by scientific evidence. Journal of Perinatal Education (16)1, 32S-64S.

Do No Harm, New Research, Research for Advocacy , ,

  1. May 30th, 2009 at 17:56 | #1

    First time website visitor…found from someone on twitter…have not even read what this blog has in it. But want to share…
    I gave birth to three children, Used the Bradley method…Never had an iv, never had any drugs, my first was 9lbs 3oz, second 7.5, third 8.3. All babies nursed immediate after the cord was cut-by dad, all 3 have grown to be VERY healthy teenagers, NEVER had ear infections, VERY low amounts of colds.
    I can’t say enough how much I am thankful for having my children natural and not giving them baby food EVER, went right from nursing to food gron from the earth….k, I’ll I’ll stop boasting….

  2. avatar
    Kimberly Wallace, RN
    June 1st, 2009 at 18:52 | #2

    I too agree that Routine IV’s are not necessary to give birth. I am a supporter of natural birth, home birth, and a mother’s right to choose the birthing place that is right for her.

    As a Labor and Delivery nurse however, not having IV access to a mother giving birth in hospital makes me a little nervous; not because I believe it it necessary in a normal, healthy woman giving birth to a normal healthy, baby; it’s the interventions that are routinely done in hospital that I feel may make that IV access necessary, and that is a sad commentary on the way we manage laboring women in hospital. We don’t them to eat, and in spite of the ASA’s guideline revisions, most hospitals still do allow them to drink, placing limits on how well their body can support the energy required of them during labor; physicians often break the amniotic sac without truly (oh, they try to wait until the “presenting part is well applied to the cervix) knowing if that could cause a complication with the placement of the umbilical cord in relation to the baby’s body and the contracting uterus. I could go on and on. Women coming to hospital wanting a non-interventive birth have to be aware of interventions other than the IV…sometimes those interventions are helpful…other times they can create a situation where I need to get an IV in /fast/, but even the small amount of time that takes can be a significant delay when complications arise, particularly in a mother who it not well hydrated…and ice chips are a far cry from adequate hydration for a laboring woman. While I don’t want to have to tether Mom to an IV pole in labor, or indunate her body with unecessary fluids, I would at least like to have venous access (i.e., a “saline well”…a small capped off IV access device that could, if need be, attached to fluids).

    In my experience, (and this is in my experience only, I cannot extrapolate this to the home birthing population in general) when complications arise in home births, and the midwife has found it necessary to transfer, it has been a fairly straightforward process getting an IV started, because Mom has been keeping herself well hydrated, and it’s fairly easy to find a vein. A mother in hospital, who has not been permitted to keep herself hydrated with more than ice chips is unlikely to have veins that are as easy to access.

    I think it is can be more difficult for a mother who wants a natural, non-interventive birth to give birth in hospital…because they are not on familiar turf, they usually are not eating or drinking, they are limited in movement to one small room at best, and by the length of fetal monitoring equipment leads at worst. Even the strongest and most determined of mothers can experience increased pain of labor because of this, and decide on an epidural. Once a mother who has struggled with managing her pain for hours decides on an epidural, she is often /finished/ dealing with her contractions. Often her emotional and physical reserves are exhausted, and she is no longer able to manage her pain as well as she was before she decided on an epidural. Trying to get initial IV access in a mother in this state of mind can be very difficult, prolonging her wait for the much wanted epidural. Having a saline lock in place allows almost immediate access to the fluids required for epidural administration.

    So, I agree that IV’s are not relatively harmless; but if a woman decides to give birth in hospital, IV access (/not necessarily hydration/) may be one of the compromises she might want to consider.

  3. June 3rd, 2009 at 14:06 | #3

    Kimberly, thanks so much for taking the time to leave such a thoughtful response. I agree that it is a sad state of affairs that the main usefulness of IV access in hospital birth is as a safeguard against the side effects of hospital management. I am also thankful that you make the distinction between IV access and IV fluids. While I think neither is needed as a routine measure, sometimes the IV access is what is important but the fluids are given as a “free gift with purchase”, without the acknowledgment that the fluids themselves are a separate intervention. A good example is GBS positive women. Sure, the antibiotics are given IV so the IV port is necessary, but it doesn’t mean we have to run fluids continuously between doses.

    Thanks again for visiting the blog and sharing your perspective!

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