Informed Consent Involves More Than Saying "It Could Be Dangerous"

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By Jill—Unnecesarean


Someone claiming to be an anesthesiologist left a comment on an old post about routinely denying all laboring women food in hospitals. I replied and Kathy, who subscribes to comments, jumped in with some insights and questions.

The thread is a bit of train wreck, so I’ve pasted it for you below. Spinal Doc’s replies have it all—all of the classic defensiveness associated with the old I KNOW WHAT I KNOW AND I DON’T NEED TO TELL YOU WHY I KNOW IT AND YOU JUST NEED TO TRUST ME BECAUSE I WENT TO MEDICAL SCHOOL drill that so many of us discuss here.


You will see the following:

Don’t you care about your baby?

We are just concerned about your safety.

YOU try living with the burden of a dead patient!

We are not all bad people

Trust me, there is Real Danger ™



Comparison of the risk of a procedure to a terrorist attack

Claiming that ending the routine denial of food during labor will open the door for obese pregnant women to “gorge on anything they want.” (see Spinal Doc’s last comment)

Evading questions


This mirrors my experience with medical prenatal care and birth, except the CNM and doctor were nice and not hiding under the internet’s veil of semi-anonymity. As I’ve written before, I was told I needed a cesarean at about 38 weeks because I had a suspected macrosomic (big) baby and would be likely to experience shoulder dystocia. In a series of conversations that were not at all hostile, I had my requests for an idea of the likelihood that it would occur met with increasingly dramatic descriptions of shoulder dystocia, the Zavanelli maneuver, broken collarbones, proctoepisiotomies and, of course, death and permanent injury.

While I sympathized with the stress they personally experienced when encountering birth emergencies, I simply wanted some numbers and a more compelling reason to preempt vaginal birth with a planned cesarean than, “I’ve seen shoulder dystocia and it’s really bad. You don’t want that.” I left these appointments with a polite smile, and at one of them, I scheduled a cesarean knowing that there was about a 5 percent chance I would actually keep the appointment. Instead, I showed up a week earlier in labor, refused a cesarean and gave birth normally.

Patients deserve better than this. I do not expect care providers to remember every figure and percentage they’ve ever read off the top of their heads, but I would trust them to look it up and get back to me, even in the time-sensitive window of pregnancy. Spinal Doc’s attempt at a compelling argument was to ask “Have you seen a mother die after aspirating stomach contents during a stat c-section leaving a grieving husband with three motherless children?” and, in spite of apparent access to the internet, Spinal Doc refused to use it to find evidence that support her claims. I am very sorry that she has had a rough time emotionally because a patient aspirated and died, but making non-evidence based procedures, treatments and surgeries routine simply because a care provider doesn’t want to personally experience the death of a patient again is an extreme measure.


The name of the commenter appears under the comment.

Do any of you worry about your children? Have you denied them privileges because you have contemplated the potential risks? Yes food is wonderful! Have you seen a mother die after aspirating stomach contents during a stat c-section leaving a grieving husband with three motherless children? You are all so obtuse. Health care providers are concerned for your safety. We have weighed the risks. When a midwife can’t get the child out and the patient needs a c-section and has a full stomach they are in real danger of aspirating! You can quote statistics until the cows come home, try living with the burden of a dead mom whose silver bullet was a $1.99 Happy Meal!

October 26, 2010 | Spinal Doc



As a “spinal doc,” I hardly see how you speak on behalf of all health care providers. If you want to come back with a real argument and not a screamy, juvenile internet rant, go for it.

Since you’ve weighed the risks, why don’t you tell everyone what the actual risk is of aspiration under general during an emergency c-section? Percentages, please. Don’t forget to cite.

October 26, 2010 | Jill—Unnecesarean



I don’t know if you are angry or passionate. Lots of doc bashing goes on here. We’re not all bad people. While it is true the trends for aspiration have gone down, it is not because the risk of aspiration is less, it is because more C-sections are done under regional anesthesia (spinal/epidural) and the patients can maintain their own airways. In the event of a true emergency, requiring general anesthesia, the risk is very real. It takes 25ml of clear stomach fluid at a pH of 2.5 to cause an aspiration pneumonitis. Add to this a relaxed lower esophageal sphincture (under general anesthesia), rotation and upward displacement of the stomach from the gravid uterus, lying supine with a stomach full of pneumotoxic food and you have the makings of a disaster. The risk of maternal death is 16.7 times greater under general anesthesia, and a majority of those are related to airway management/failed intubation/ pulmonary aspiration. As ansthesiologists our primary concern is moms safety. What is wrong with being safe? The risk is 1:450-1:700

October 27, 2010 | Spinal Doc



That’s much better. I’m surmising from your first few sentences that you feel defensive and that’s why you left the original comment.

Most of your comment was explaining how aspiration under general can occur. Here are the stats you have shared:

1. Maternal death 16.7 times higher under general, most of which are due to airway management/failed intubation/ pulmonary aspiration. (Source unknown)

2. The risk of something is 1:450 - 1:700. (Risk of what exactly?)

If a pregnant woman wants to know why she can’t eat anything during labor and that’s what you give her in terms of informed consent, you’ve really told her nothing.

1. What are the odds that a cesarean will be performed under general? (# and percent of all births)
2. How many maternal deaths have occurred in the last decade (or last few decades) that can be directly attributed to aspiration under general?

You state that aspiration trends are down. Down from what? There’s a 1974 study (Baggish) that found that 2% of maternal deaths in the U.S. occurred as a result of aspiration. If it’s down from that, which you attribute to regional anesthesia for cesareans, it sounds like the chance is almost nil for a pregnant woman checking into a hospital for labor.

You might also consider the 2010 study, Restricting oral fluid and food intake during labour, in the Cochrane Database.
We identified five studies (3130 women). All studies looked at women in active labour and at low risk of potentially requiring a general anaesthetic. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.

When comparing any restriction of fluids and food versus women given some nutrition in labour, the meta-analysis was dominated by one study undertaken in a highly medicalised environment. There were no statistically significant differences identified in: caesarean section (average risk ratio (RR) 0.89, 95% confidence interval (CI) 0.63 to 1.25, five studies, 3103 women), operative vaginal births (average RR 0.98, 95% CI 0.88 to 1.10, five studies, 3103 women) and Apgar scores less than seven at five minutes (average RR 1.43, 95% CI 0.77 to 2.68, three studies, 2574 infants), nor in any of the other outcomes assessed. Women’s views were not assessed. The pooled data were insufficient to assess the incidence of Mendelson’s syndrome, an extremely rare outcome. Other comparisons showed similar findings, except one study did report a significant increase in caesarean sections for women taking carbohydrate drinks in labour compared with water only, but these results should be interpreted with caution as the sample size was small.

I would love to hear your case for why NPO should be routine for all laboring women. It’s going to have to be a lot better than “As ansthesiologists our primary concern is moms safety. What is wrong with being safe?”

October 28, 2010 | Jill—Unnecesarean



@Spinal Doc,

A “friend of a friend” died after aspiration from GA, so I know the risk is real; however, this woman died not from an unexpected C-section, but from a planned surgery (tonsillectomy, I think), for which she was properly prepared with no food for X hours before, and whatever other precautions would have been taken 15-20 years ago. Apparently, the risk of aspiration with GA can’t be reduced to zero.

You said, “It takes 25ml of clear stomach fluid at a pH of 2.5 to cause an aspiration pneumonitis.” How long should a person go without food, in order to have a stomach with less than 25ml in it? Also, would the use of antacids help to reduce the level of acidity (that is, increase the pH level), so that even if stomach contents were aspirated, there would be less danger to the woman? Is there a direct correlation of how much “stomach contents” would need to be inhaled, in proportion to the level of acidity? That is, if the stomach contained food of a basic nature which increased the pH level to greater than 2.5, would the patient need to inhale more than 25ml of stomach contents, in order to cause aspiration pneumonitis?

I’m going to assume, based on Jill’s final question preceding your latest post and the rate you cite, that “the actual risk is of aspiration under general during an emergency c-section” is 1:450-1:700 First, before I forget, “risk of aspiration” does not equal “death,” does it? That is, not all people who aspirate stomach contents under GA die, do they? So, it looks like out of 450-700 women who have a C/s under general anesthesia, 1 may aspirate — do I have that right? And then, of that number, even fewer will die. I’m not sure what the rate of “GA for C/s” is — either you or Jill may have that number — but let’s say it is 5% of all C/s occur under GA, which I think rather high. Out of 4 million births, with a 34% C/s rate total, and 5% of that under GA, that’s 68,000. If 1/450-700 of these 68,000 will aspirate their stomach contents, that works out to 97-151 women (out of 4,000,000 births, or 0.00002425-0.00003775). So, depending on the risk of death due to aspiration, the risk of death will be even lower.

In looking for “risk of death due to aspiration of stomach contents under general anesthesia,” I found this article written by an OB/GYN which said, “The actual incidence of aspiration during birth is 7 per 10 million births,” which is less than a one in a million; and if the risk of death due to aspiration is even less than the incidence of aspiration, we’re talking about a very rare possibility indeed.

But is there nothing that can be done to reduce even further this slight risk? You said above that one of the problems with aspiration was the supine positioning of the woman. Would it be possible to raise the head of the bed (I know that surgical tables do not allow this, but hypothetically speaking…) so that the woman wouldn’t be supine, and therefore it would be less likely for the stomach contents to be pushed all the way up a sloping (as opposed to horizontal) esophagus? Would it be possible to have something covering the opening of the esophagus, so that if anything were to come up out of the stomach, it would be stopped at the top of the esophagus, and thus not allowed to go into the lungs? The article above cited also seemed to speak favorably of having a little liquid in the stomach — liquid so that it clears out quickly, but *something* which reduces the acidity of the stomach — so that if the stomach contents are inhaled, the acidity level will be less, and therefore less likely to cause a problem if inhaled into the lungs.

On that note, I remember reading a comment several months ago from a woman who had some medical problem which caused her to occasionally regurgitate the contents of her stomach, and occasionally she inhaled them [sorry I can’t be more explicit, but this is what I remember]. She said that of all the times she inhaled food as compared to plain gastric juices, she had a much easier recovery; but the times when she inhaled gastric juices after a period of fasting (like, sleeping overnight), she would usually end up in the hospital with aspiration pneumonia. I thought that interesting, to say the least.

October 28, 2010 | Kathy



Chadwick, HS: Obstetric Anesthesia Closed Claims Update II. ASA Newsletter 63(6):12-15, 1999.
(here is some info)

A government-sponsored study of 230,000 births between 2002 and 2007 found that the C-section delivery rate was 30.5%.
- so 1 in 3 women have a c-section

October 28, 2010 | Spinal Doc



Thank you Kathy! You must consider that your computations are based on a majority of patients who where kept NPO. It is unethical to deisign a study in which women were fed a full meal and the placed under General anesthesia for a C-section. You may find true numbers from other countries or data from the 50’s and 60’s when GA was the norm. This is interesting: Michael Rothschild, a former business professor at the University of Wisconsin, worked out a couple of plausible scenarios. For example, he figured that if terrorists were to destroy entirely one of America’s 40,000 shopping malls per week, your chances of being there at the wrong time would be about one in one million or more. If this played out, would you go shopping?

October 28, 2010 | Spinal Doc



Regarding the C/s rate of 30% vs 34% — the latest annual figures are closer to 33%, but I added an extra percentage point because 1) the C/s rate has increased every year for the past several years, 2) the reported C/s rate may be lower than the actual rate, and 3) the higher the C/s rate, particularly with GA, the greater the likelihood for any single rare negative thing to happen. If you’re wanting to argue that 100% of all laboring women should be kept NPO on the basis that a percentage of a percentage of a percentage of a percentage may die, then the higher the # of any of those percentages, the better it is for your argument. If you want to use 30%, that’s fine by me — it would reduce the # of C/s under GA to 60,000, instead of 68,000 (again, assuming a GA rate of 5% of the total C/s #). I could use 50%, since many hospitals have that C/s rate, but that would still be 133-222 women who would experience aspiration due to GA in a C/s, out of 4,000,000 births; but the likelihood is that with an increase of overall C/s rate, the incidence of GA for C/s would decrease, as more and more women would be given C/s before an actual emergency requiring GA presented itself. Put it this way — if 100% of women had non-emergency C/s as opposed to vaginal births, there would be almost 0 C/s done under GA [some women would still request or need GA, due to known allergy to the medication of an epidural, epidural not working, etc.]. As more hospitals and doctors do C/s prior to an emergent need, they will undoubtedly perform routine C/s under epidural anesthesia that had labor continued would have become emergent C/s under GA. So, if with a 15% C/s rate, 5% of those surgeries would be under GA, I daresay that at 30%, the rate of GA C/s would be less, though perhaps not half the rate; and at 50% C/s rate, the rate of GA C/s would be even less. But, I still don’t know what the average rate of GA C/s is at 30%, or indeed any rate — I’m hypothesizing here. Oh, there would also be a small percentage of women who would need emergency postpartum surgery that would not need C/s but would have GA (D&Cs and emergency hysterectomies and such)

You said that my numbers are taken from rates when people are kept NPO — so the 1:450 and 1:700 you cited are from those statistics? It’s true that the rate of aspiration due to GA has gone down since the 50s and 60s when most women were given GA for normal vaginal births, but have there been no improvements in anesthesia technique in that time? Surely the rate would be better now than then! Yes, knowing that a full meal before GA increases the risk of aspiration, it would not be wise to knowingly eat a large meal soon before surgery; but I bet that the fact that you *might* end up in a car wreck minutes after leaving a restaurant and end up needing emergency surgery under GA, does not inhibit you from eating your fill while at the restaurant, just because you *might* need surgery. So, there is a difference between a known and guaranteed surgery, and a mere *possibility* of a surgery, yes?

Now, let’s talk about the assumption of what a woman eats while in labor. My first pregnancy, I went into labor less than an hour after eating a large supper — my water broke, followed by the onset of contractions about half an hour later. The whole labor, up until about half-way through pushing (about 9 hours, minus 20 minutes), I wanted absolutely nothing to eat or drink, and in fact threw up my meal a few hours after labor started. My midwife kept making me drink apple juice (first-time moms usually have long labors, and she didn’t want me to get dehydrated or tired out — not having a crystal ball, we neither of us knew that my labor would be so short), but every time she did, within the next ctx or two, I would throw up all that I had drunk. Finally, about half-way through pushing, I felt shaky as if my blood sugar were low, so I requested and received (and greatly benefited from!) a few sips of apple juice.

My second labor, the ctx were irregular and widely spaced apart, so even though I was in labor for 24 hours, I did not know and accept that I was in labor until my water broke, about an hour before the baby was born. I ate if I was hungry, and drank if I was thirsty, but could not tell you what type nor quantity of food/liquid I had. If I had been deprived of food for 24 hours, I can tell you that I would *not* have been happy, although the first labor, I preferred *not* eating/drinking at all.

So, assuming that 100% of women would eat in labor, if “allowed” to do so might be false. Some might only want a little sip of something here and there; I doubt that very many women would want anything substantial while dealing with contractions, but would naturally gravitate towards things that are light and easily digestible. But again, we are still dealing with a very small percentage of women who *might* be adversely affected; and I think that’s something that women should be able to choose for themselves, rather than having forced on them, no matter how well-meaning the intention. Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience. — C. S. Lewis :-)

Instead of doing a study of feeding women who know they will be having surgery under GA (which is, as you said, unethical), what we could do instead is look at the rates of maternal death, aspiration, and GA in countries that allow and those that do not allow eating while in labor. Of course, you’d have to be careful to compare like with like — it would do no good to compare developed and under-developed countries. It would likely need to be a large, country-wide study, since we are talking about such a minute risk.

In regards to your question about the mall — yes, I think I would go shopping just the same. [Although this is a bigger hypothetical for me than you know, since it’s been some years since I’ve set foot in a mall!] Here is the reason why — I think the risk of my particular shopping mall being destroyed is quite low, because it is rather small and obscure. When the Muslim terrorists attacked us on 9/11, they did not target my county courthouse, although they technically could have; they attacked the WTC and the Pentagon. My local courthouse, like my closest mall, has a much lower risk of being attacked than a high-profile building or mall such as Wrigley Field or the Empire State Building or the White House, or one of these other big and/or important and/or patriotic places. In a similar way, I believe my risk of ever needing an emergency C/s under GA to be somewhat less than the average woman, for a number of reasons.

Now that I’ve answered your questions, I hope you will answer mine from the previous post — 1) how long does a person have to fast in order to get less than 25ml of stomach contents; 2) is there an inverse relationship between how much “stomach contents” one would have to inhale in order to get aspiration sickness, and the pH level of the stomach acid? 3) could giving antacids prior to surgery (which I think I’ve heard of doing), lower the risk of aspiration sickness and death due to aspiration sickness, by lowering the pH balance and thus reducing the risk of stomach acid destroying delicate lung tissue? 4) out of curiosity, is it hypothetically possible to reduce a person’s risk of aspiration by raising the head of the bed so that he is less likely to inhale stomach acid, or is there some medical reason (other than, “Well, that’s just the way we’ve always done it” or “that’s just the way surgical tables are made”) for a person to be supine during a surgery like a C/s?

I could probably get the answer to the first 3 questions by much searching, but I figure you would probably have learned this in the course of your education, or could easily get it by searching medical journals; and the 4th question is a hypothetical, relying on your wisdom, knowledge and judgment of the situation.

October 28, 2010 | Kathy



SpinalDoc, am I just not asking my questions specifically enough? Let’s try again:

Most of your comment was explaining how aspiration under general can occur. Here are the stats you have shared:

1. Maternal death 16.7 times higher under general, most of which are due to airway management/failed intubation/ pulmonary aspiration. (Source unknown)

2. The risk of something is 1:450 - 1:700. (Risk of what exactly?)

If a pregnant woman wants to know why she can’t eat anything during labor and that’s what you give her in terms of informed consent, you’ve really told her nothing.

1. What are the odds that a cesarean will be performed under general? (# and percent of all births) [The national cesarean rate is not the answer to how many cesareans are performed under general, nor how the percentage of all births that will be performed under general!]
2. How many maternal deaths have occurred in the last decade (or last few decades) that can be directly attributed to aspiration under general?

Answering these questions for a patient would mean that you can truly offer that patient the chance to give informed consent about NPO. If not, you’re telling her that it could happen and, umm, it’s a lot like being scared of terrorists, sweetheart.

I have an article that applies to you perfectly. The Folly of 1 Percent. Only in this case, it would be The Folly of 0.0000007, making even less of a case.

October 28, 2010 | Jill—Unnecesarean



The Chadwick “article” cited answered a question that I didn’t even ask. Here is an excerpt from your article on closed claims:

Lessons Learned
The most recent analysis of the obstetric anesthesia-related liability files reveals similar results to those of our earlier reports. Liability risk in obstetric anesthesia differs considerably from that in nonobstetric practice. Complications involving the respiratory system account for the largest proportion of damaging events in both groups and problems with difficult intubation and pulmonary aspiration are disproportionately represented in the obstetric files. These findings corroborate most anesthesiologists’ belief that the pregnant patient’s airway demands additional attention and care. As for regional anesthesia-related claims, local anesthetic toxicity remains a concern, although the number of such claims appear to be declining. Nerve damage also constitutes a relatively large percentage of claims, although, as with newborn brain injury cases, the relation to anesthesia care is often in doubt.

The most surprising difference between obstetric and nonobstetric claims is the large proportion of claims for relatively minor injuries in the obstetric files. While reducing major adverse anesthetic outcomes in obstetrics is important, attention must be paid to limiting liability risk associated with less severe outcomes like headache, pain during anesthesia and emotional distress. To some extent, the large proportion of relatively minor injuries in the obstetric files may be due to a greater incidence of such problems in these patients. However, detailed review of these files suggests that in many cases, patients were unhappy with the care provided and felt mistreated. Clearly, factors other than major injury are important in motivating a patient to bring a claim.

Therefore, anesthesiologists should attempt to conduct themselves in a manner such that patients will not be motivated to bring a suit for an unexpected outcome. Measures should include establishing and maintaining good patient rapport. Anesthesiologists should become involved in the prenatal education process. A careful preanesthetic evaluation is very important and should occur as early in labor as possible. Special care should be taken to provide patients with realistic expectations of common minor and potential major risks associated with anesthetic procedures. This discussion should be clearly documented in the medical record.

With this citation, you’ve told me that at least part of your concern with ditching routine NPO is legal. Is that in the patient’s interest or your own?

Also, one of the “lessons learned” is that you should take special care to “provide patients with realistic expectations.” A scenario of terrorists attacking U.S. malls does not do this.

October 28, 2010 | Jill—Unnecesarean



I was simply making an analogy with the mall scenario. The ASA NPO guidelines state that clear liquids (water, black coffee, Jello, apple juice) may be consumed in moderation up to 2 hours prior to elective surgery. There is a buffer on this (about 90minutes for 25 ml) But many factors can influence Gastric emptying time (Obesity, Diabetes, Opiod based pain medicine, Progesterone, Solid food). Some foods are far more toxic (for example the oil from peanuts is fatally toxic to the lung). The primary c/s rate is about 25%. So, 1in 4 primies will get sectioned (probably from failure to wait). The Obesity epidemic mirrors the c/s rate map on your web site. Obese women are more likely to be c/s. They probably received some form of narcotic (stadol demerol) for pain, or have an epidural with fentanyl in it. GDM is high in obese pregnant women, so we must consider diabetes. Lord knows their progesterone levels are high. Hey, here is a brilliant concept, lets now let them gorge on anything they want! You can’t go without food for 1/2 day? People fast all the time. Pregnant women fast. Clear liquids, fine. Large meals while laboring, sell crazy somewhere else. Legal ramifications? Why don’t you ask Courtroom Mama. Unless your into same sex marriage, I’m not your “sweetheart”.

October 30, 2010 | spinal doc



You’re simply evading questions and your comment is disorganized (and mostly nonsensical). Maybe next time you can support your claims with evidence. If your hospital only lets women labor for half a day before sectioning them, that’s a problem, as labors often last much longer than 12 hours, Spinal Doc. If you’re having trouble separating “eating” from gorging,” that’s another problem.

Re. the sweetheart comment, that was not directed at you. Read the sentence again and you’ll see that it was something condescending to say to a patient (“it’s a lot like being scared of terrorists, sweetheart.”), just as it’s condescending to tell someone that they should just trust that you know what you’re doing in recommending NPO when you can’t tell them why with actual numbers.

October 30, 2010 | Jill—Unnecesarean



Ok, so some foods are more toxic than others — might be beneficial then to write up a list of the “top ten” worst and best foods to consume in labor, instead of just saying, “DON’T EAT ANYTHING!!! NO MATTER HOW LONG YOUR LABOR IS!!! NO MATTER HOW HUNGRY YOU ARE!!! (Because a small percentage of 30% of all laboring women may have a C/s under GA, and a small percentage of them may aspirate on their stomach contents, and a small percentage of *that* percentage may die or have severe negative sequelae.)”

I’m glad to see that you admit that most C/s are unnecessary and due to “failure to wait” — I hope you’ll be able to work in your hospital to bring down the rate of unnecesareans, although I can see that might be difficult not being an OB. However, there have been a few studies in different hospitals that showed that if doctors waited for labor progression for an extra 2 hours (instead of calling for a section after just an hour or two of “stalled labor”), that there was no increase in problems for either mother or baby, and instead it increased the rate of vaginal birth, which are better for mother and baby (barring complications). Perhaps asking OBs what they think of those studies, and why or why not they don’t alter their practice style in the light of that evidence would get them to think about it (not confrontational, but just, “Hey, I was online and I saw this study about…”).

Certainly if doctors are routinely sectioning women after “half a day” of labor (the time stated as being easy for a laboring woman to fast), then they are performing a great number of unnecesareans. This undoubtedly increases the chance of aspiration, in addition to the other problems with C/s, if the more C/s that are done, the more that are done under general, as some women will not be able for one reason or another to have an epidural, and, as stated above, even following NPO protocol does not guarantee that a person under GA will have no aspiration. I wonder what the rate of unnecesareans has to be, in order to make the rate of C/s (even following NPO protocol in labor) more dangerous for aspiration, than allowing all women to eat light foods in labor if hungry. There has to be some sort of curve or slope, in which the rate of aspiration due to unnecesarean even when 100% of women are NPO is equal to or greater than the rate of aspiration due to only necessary C/s when all woman are allowed to eat (within sensible recommendations) but the C/s rate is low.

October 30, 2010 | Kathy


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