Chocolate Crepe Cake with White Chocolate Peppermint Mousse

I’m pretty proud of myself for this one.  I have loved crepes for many many years and used to subsist on them in medical school.  This dessert would be perfect for Christmas dinner.  It is chocolate crepes wedged between a simple white chocolate peppermint mousse.  After it has chilled, the whole cake is doused in a glossy chocolate ganache and topped with powdered sugar.   The dessert is sweet but not overly sweet. 

Getting the technique down for making the crepes can take a bit of practice.   The beauty is that if you need some freebies you can easily make another half batch of batter to get enough crepes for the cake.   The first few crepes are rarely perfect.  You need about 20 for the beautiful layering effect.

I’m not usually a big fan of nonstick pans, but they are essential for having good results for the crepes.   I have a dedicated 9 inch crepe pan, however you could use any 9 inch non-stick pan with similar results.    Tricks to making good crepes include making sure your pan is not too hot, medium to low medium heat should be plenty.  The batter should be thin enough to easily coat the whole pan before the batter cooks –the excess can be poured off.  If your batter is too thick, then add some extra milk.  The video here is a good visual however I don’t think the butter to coat the pan is necessary and he doesn’t pour off excess batter. http://www.youtube.com/watch?v=uNIcZSt_I0E

Chocolate Crepe Cake with White Chocolate Peppermint Mousse

For the mousse

2 cups whipping cream

¼ cup powdered sugar

10 oz white chocolate

1 tsp vanilla

1 tsp peppermint extract

3 oz candy canes

For the crepes

2 cups milk

6 eggs

1 cup flour

½ cup cocoa powder

2 tsp espresso powder

¼ cup powdered sugar

2 tsp vanilla

½ stick melted butter

pinch of salt

For the ganache

6 oz semisweet or bittersweet chocolate

½ cup heavy cream

Extra powdered sugar for the top of the cake. 

For the mousse.  In a mortal and pestle or in a plastic bag with the back of a pan, pulverize the candy canes until it is a fine powder.  A few slightly larger pieces of candy cane are ok.  In an electric mixer, whip the cream with the powdered sugar until soft peaks form.  In the microwave on high heat in a glass heatproof bowl, melt the chocolate (if it is a whole block, then chop up the chocolate) for 30 seconds.  Remove and stir.  Again, cook the chocolate in the microwave, this time for 20 seconds.  Stir.  If your chocolate is not completely melted, cook for 10 seconds at a time until melted.  Do not overcook as white chocolate can seize easily.  Fold the white chocolate, peppermint, vanilla and candy canes into cream.  Chill the mousse.

For the crepes—in a blender sift the cocoa and espresso.  Add the eggs, milk, sugar and vanilla.  Blend on high for 30 seconds.  Add the flour and blend until well combined and there are no lumps.  Add the melted butter and pulse for a few seconds.   Strain the batter.  Over medium heat with a nonstick pan, pour about 2 tbsp batter into your 9 inch non-stick pan.  Swirl around the batter until it coats the entire pan and pour off any excess batter back into the bowl.  Cook the crepe until small bubbles form and the edges begin to separate from the sides of the pan.  Flip the crepe and cook for another 10-20 seconds.  Place the crepes on a plate and continue until you run out of batter.  When you are done, place the crepes in the fridge and chill. 

To assemble the cake.  Using a 9 inch springform pan with a piece of parchment paper on the bottom, stack the crepes and place a thin coat of mousse between each crepe.  Continue until your run out of mousse.  Chill.  When ready to glaze with ganache, invert the cake onto a cake stand and remove the base of the springform pan.  To make the ganache, mix the chocolate and cream in a heatproof glass bowl and microwave for 30 seconds, 20 seconds then 10 seconds as above, stirring between each until the chocolate is melted into the cream.  Pour on the cake while it is still cold and spread around the sides to completely frost the cake.  Clean off the excess. 

I made a stencil for the snowflake using the template found here:

http://www.altogetherchristmas.com/crafts/stencils.html.  I printed the stencil and then using an exacto knife cut out a replica on a piece of cardstock.  Then sift powdered sugar over the stencil on the cake.  To slice, run a very sharp knife under hot water and dry.   Serve and enjoy!

Easy as Fudge, Four Ingredient Fudge Pops

Greetings from the faraway lands of third year of residency.  I’m busy.  This is the fourth month in a row that I have to get to work at 5am.  I took advantage of the business to put myself on a diet and start exercising to keep myself sane.  And I lost 15 pounds. 

I was never fat, but as happens to most of us, I used to be much thinner.  A couple of months ago, I was reading the 2011 Medscape survey of practicing OB GYNs across the country.  I was shocked at how few docs in my age group exercised and that almost 40% of all OB/Gyns were overweight.  As I am now half done with residency and starting to prepare for life as a practitioner, I want to be healthy and have good habits.

It is amazing how much more energy I have back at my high school weight.  Exercising is easier, and eating vegetables, lean proteins and whole grains doesn’t bottom me out, so I spend less time feeling like I got runover by a Texas truck.   People at work ask me how I lost so much weight, and really the answer is simple.  I downloaded an app for my phone called Lose It that helps you track your daily caloric intake.  I ate between 1300-1500 calories a day for 2 months and exercised.

Now I’m trying to keep a happy balance.  I am back to a 2000 calorie diet, but keeping healthy habits that got me here.  Still, this girl can’t cut out dessert.  So, here is something delicious and rich, but less dangerous than two dozen cookies.   I figure that each of these fudge pops is about 120 calories apiece, but made only from real ingredients. And they couldn’t be easier.  No guar gum or any of that crap. 

Luscious fudge pops

4oz high quality dark chocolate (I just love Callebaut and you can buy blocks at Whole Foods)

1 12 oz can fat free evaporated milk

2 tbsp brown sugar

1 tsp vanilla

Popscicle molds (we bought ours at Target)

Cut the chocolate into fine shards or small pieces.  Over a simmering pot of water on medium heat, place a well fitting bowl with the milk and chocolate.  Whisk continuously until the chocolate is completely melted and the mixture is smooth.  Whisk in the sugar and the vanilla and pour the mixture into your popsicle molds and freeze until hard, about 4 hours or more.  To dislodge, run the pops under warm water for a few seconds.  

Chocolate Dipped Hazelnut Lace Cookies

It's been a while since I posted a nice cookie recipe.  Well this is certainly one I'm proud of.  You’ve gotta make these cookies.  Chewy and crispy, nutty and buttery, bathed in chocolate, these are worth the time.  I based them on the Lacey’s cookies, which are tubs of heaven at Whole Foods, purchased to soothe the pain of a busy night at the hospital.  The cookies capture the same lacelike look, with a slightly less sweet and chewier mouthfeel.  I used Rice Krispies for most of the starch, keeping an airy quality. 

These cookies are very candy-like, in fact the first step is the same as making toffee. In the humid and already hot days of Texas spring, they are best stored in the fridge.  The whipped egg white, which I realized if done by hand takes the same amount of time as a kitchen aid with the right whisk, adds a meringue like quality.  They need to be baked just perfectly, between 6-8 minutes until the edges are darkened but not burnt otherwise the texture isn’t right.  

Makes ~18 cookie sandwiches or 3 dozen unadorned cookies

1/2 cup hazelnuts

2 cups Rice Krispy

1 stick butter

1/2 cup packed brown sugar

1/4 cup honey

1/4 cup cream

Pinch salt

Tsp vanilla

1/4 cup flour

Pinch cream of tartar

1 egg white

6 oz chocolate (dark or milk)

Preheat the oven to 350.  Chop the hazelnuts until they are fine.  In a large bowl combine the cereal and the hazelnuts.  Over medium high heat in a heavy saucepan, combine the butter, sugar, honey and cream.  Bring to a boil and let boil for one minute.  Turn off the heat, allow to cool slightly, and whisk in the flour, salt, vanilla and cream of tartar.  In a small bowl, whisk the egg white until it makes soft peaks.  Add a small amount of the warm butter mixture to the egg and fold in.  Fold the rest of the butter mixture into the egg.  Combine the butter and egg mixture with the cereal and hazelnuts.  On a baking sheet lined with a silicon mat or parchment paper, add a heaping teaspoon of batter, spacing at least 2 inches between cookies as they spread when baked.  Bake for 6-8 minutes until the cookie is lacey and the edges are dark brown but not burnt.  Allow to cool, then transfer to a baking rack. 

Over a pot of simmering water on medium heat, add a snug mixing bowl and chopped up chocolate.  Stir constantly until barely melted.  Smear a teaspoon or so on a cookie and immediately sandwich another cookie on top.  Allow to cool and then place in the fridge for the chocolate to harden.  Enjoy!

Black and White Cloud Pudding

It's been an interesting month.  I wrote about my experiences as a "black cloud" and what that means as a resident here on Kevin MD.  In honor of my first post to KevinMD, an awesome medical blog with significant collaboration from health professionals all over the country, and my new black cloud status, I made a dark chocolate and whipped cream pudding parfait.


The dense, rich chocolate pudding is layered with a fluffy white cloud of homemade whipped cream.  Are you a black or a white cloud?

Dark Chocolate Pudding and Whipped Cream Parfait
(pudding recipe adopted from Bon Appetit)

For the pudding:
1/2 cup sugar
1/3 cup unsweetened cocoa powder
2 tbsp cornstarch
1/4 tsp salt
1 3/4 cups milk divided
1/4 cup heavy whipping cream
3 oz very dark chocolate (such as 88% cocoa) finely chopped
1 tsp vanilla extract

For the whipped cream:
1 cup chilled heavy whipping cream
1 tsp vanilla
3 tablespoons powdered sugar

Whisk sugar, cocoa, cornstarch and sal tot a blend in a heavy medium saucepan.  Gradually add 1/3 cup milk, whisking until smooth paste.  Whisk in remaining milk and cream.  Using wooden spoon or heatproof spatula, stir mixture constantly over medium heat, scraping bottom and sides of pain until pudding thickens and begins to bubble at edges, about 5 minutes.  Add chocolate; stir until mixture is smooth.  Remove from heat and stir in vanilla.  Allow to cool to room temperature and then refrigerate.

For whipped cream, in chilled bowl, whip ingredients until stiff peaks form.

Soft in the middle--Molten Chocolate Cakes

In my last year of medical school, we were required to do a month in the Emergency Room.  I would get frustrated sometimes when I wasn’t as thorough as I should have been in my physical exam or I didn’t consider every possible diagnosis.  One awesome attending that I worked with, an oddball of sorts who would wear camouflage hunting shirts underneath his white coat and would blast Train songs in the workroom, always reassured me: “You’re not supposed to know everything.  If you did, you wouldn’t have to go to medical school, and then do residency.  You’re like a muffin in the oven.  You just haven’t cooked yet.  You’re soft on the inside.”

If I’m soft on the inside this is how I feel:

After four days of residency, I definitely need more time in the oven.  This month I’m working in the Women’s Emergency Room, which is mostly gynecology and first trimester obstetrics.  It’s definitely a “learning on the job” kind of place.  Fortunately the second year resident I’m working with knows a lot and is helping me a ton and the nurses are very forgiving.   It’s amazing how much nicer people are to you when you can sign orders and write prescriptions.  (It’s also amazing that I can write prescriptions.)

So, all in all, work is scary at times and frustrating at times, but residency is awesome.  I finally get to do what I want to do and my patients consider me their doctor.  And, I also get days off, like today, to bake yummy lava cakes.   Sometimes it’s good to be soft in the middle, as long as you stop and reflect on it and get yourself cookin’.

Molten Chocolate Cakes

From Bon Appetit January 2001

5 ounces bittersweet (not unsweetened) or semisweet chocolate, chopped

10 tablespoons unsalted butter

3 large eggs

3 large egg yolks

1 1/2 cups powdered sugar

1/2 cup all purpose flour

Vanilla ice cream

Fresh rasberries

For cakes:  
Preheat oven to 450°F. Butter six 3/4-cup soufflé dishes or custard cups. Stir chocolate and butter in heavy medium saucepan over low heat until melted. Cool slightly. Whisk eggs and egg yolks in large bowl to blend. Whisk in sugar, then chocolate mixture and flour. Pour batter into dishes, dividing equally. (Can be made 1 day ahead. Cover; chill.)

Bake cakes until sides are set but center remains soft and runny, about 11 minutes or up to 14 minutes for batter that was refrigerated. Run small knife around cakes to loosen. Immediately turn cakes out onto plates.  Serve with ice cream and rasberries.

Torte Reform

Unfailingly, each time I tell somebody that I’m doing OB/GYN, the first thing that they tell me is either, “Ooh babies” or “You’re brave--the malpractice insurance.” I’m naïve. I chose OB/GYN because I am passionate about the field, and because of my love, I feel willing to pay the high insurance and face the threat of lawsuits. Because the only obstetricians I know are part of an academic practice that covers malpractice insurance, they don’t openly discuss, at least with me, their fear of lawsuits. Even so, I think the dread of bad obstetrical outcomes is palpable in each decision that is made on a labor and delivery unit.

I know next to nothing about the legal system. However, I think as a physician I should learn some basics as lawsuits will most likely, unfortunately, be part of my life. Many healthcare practitioners have told me “tort reform is the answer” and I just nodded my head. I have no clue what tort reform is. According to the Agency for Healthcare Research and Quality, “torts are civil wrongs where the injured person asks for monetary damages from an individual in a situation where there is no contractual relationship.” Thus, tort reform includes legislation that caps payments for non-economic damages when a patient sues a doctor and wins.

As of 2003, 23 states had some tort reform legislated into their government. There is evidence to suggest that tort reform is effective at curbing malpractice fees. For example, in California, legislation was passed in 1975 to lower malpractice costs; by 2000 their insurance premiums increased by 167% whereas in the rest of the nation, fees increased tremendously by 505% [1]. It has also been shown that in California, defensive medicine is less employed and that health care costs are 5-9% lower without significant change in patient outcomes [2].

One of my favorite blogs, Academic OB/GYN, written by Dr. Nicholas Fogelson, recently discussed the importance of change within the country’s legal system in order to produce better obstetrical outcomes over the long term. This is in response to the recent National Institute of Health’s Vaginal Birth After Caesarian (VBAC) Consensus that convened this week. VBAC is a highly contended subject; having a vaginal delivery after a previous caesarian puts a woman at a low but existing risk of the uterus rupturing from the C-section scar being stressed during labor.

Many obstetricians refuse to do VBAC because of fear of litigation due to the risk of uterine rupture. The consensus concluded that VBAC trial was shown to be a safe option for most women [3]. Dr. Fogelson suggests that the apprehension to perform VBAC might be assuaged by “mini-tort reform” in which patients sign a release that in case of a uterine rupture during VBAC, they waive their right to sue. While this is a provocative idea, requiring unlikely consensus and collaboration among a highly divided obstetrical profession, I am not informed or experienced enough to have my own personal convictions on the topic.

I am so protected and coddled as a medical student. I have no concept of what it feels like to be the final decision maker in stressful or liable situations. It is easy to be idealistically devoted to vaginal delivery for every woman who desires it, but to take a stance on the complex and heavily weighted decisions that obstetricians make would be unfair. I do feel with full fervor, however, that it is important to do what is safest and best for our patients. Letting the terror of litigation overrun an entire field of medicine is expensive and can potentially produce worse patient outcomes.

What I am certain about and can propose however, is TORTE reform. As a rich intermediary between a pie and a cookie, this is one topic that there is only one right answer: YES! Tortes are traditionally made with eggs, sugar and nuts. In this recipe, which I very loosely based on a linzertorte, I’ve reformed the composition to have a Southern tinge as a dedication to the pecan pie. The dough is made from chopped pecans and almonds, as is the filling in a pecan pie with mixed nuts spiked with brandy, and it is topped with a gooey chocolate ganache. This is one torte reform we can all agree on (unless you don’t like nuts or chocolate; nobody will ever completely agree).

Nutty Torte Reform with Chocolate on Top

For the crust
½ cup blanched almonds
½ cup pecans
6 tbsp butter cut into cubes, kept cold
1/8 tsp salt
¾ cup cake flour
½ cup powdered sugar
1 egg yolk

For the filling
2 eggs
¼ cup walnuts
¼ cup pecans
¼ cup blanched almonds
(or you could do ¾ cup pecans or use other nuts such as macadamia nuts or hazelnuts)
1/3 cup brown sugar
1/3 cup corn syrup
2 tbsp brandy
2 tsp vanilla
Pinch of salt
Pinch of cinnamon
1 tbsp heavy cream

10 inch tart pan

For the chocolate ganache
1 cup chocolate chips
¾ cup heavy cream
Splash of brandy

Preheat oven to 400 degrees. Toast almonds and pecans for crust in oven for 7 minutes or until golden and fragrant. Toast the nuts for the filling on a separate baking sheet. Allow to cool. Blend in food processor for 30 seconds or until mealy but don’t overwork or it will start to look more like nut butter. Add flour, sugar and salt, pulse a couple of times to blend. Add egg and butter, pulse until blended. With hands, gently bring dough into ball and press into disc, don’t overwork, refrigerate for at least an hour.

Preheat the oven to 300 degrees. On a floured surface with parchment paper, roll out dough. If the dough becomes too sticky, you can press it into the tart pan with your fingers. Prick dough with fork and bake for about 15 minutes. While baking, whisk together filling ingredients. Once crust has started to brown, remove from oven, add filling and bake for another 25 minutes until filling has solidified and crust is brown. Allow to cool.

Over simmering double boiler, whisk together chocolate and cream until blended, add splash of brandy and pour over top of torte while cooling. Refrigerate for a few hours and eat!









1. Hellinger F et al. Malpractice Awards on the Geographic Distribution of Physicians. 2003. US Department of Health and Human Services Agency for Healthcare Research and Qualtiy. http://www.ahrq.gov/research/tortcaps/tortcaps.pdf
2. Kessler, David and McClellan, Mark “Do Doctors Practice Defensive Medicine?” The
Quarterly Journal of Economics, vol. 111, Issue 2, May 1996, pp. 353-390.
3. http://consensus.nih.gov/2010/vbacstatement.htm

BRAINFREEZE!

The first appliance that I bought when I got my own kitchen 4 years ago was an ice cream maker.  I already and a microwave and toaster; an ice cream maker was the next logical purchase.  Every time that I waltzed down the Costco appliances aisle, it was screaming my name.

While purchasing an ice cream maker might seem like an excessive, unnecessary purchase, I think it is not.  Chocolate peanut butter ice cream cakes?  Chocolate chip cookie ice cream sandwiches, homemade?  People love this stuff.  If you make ice cream at home, you will make friends.

The hardest part about making ice cream is remembering to put the maker in the freezer at least a day ahead of time.  Good ice cream is made of so few ingredients that the assembly is simple.  So, you make the ice cream (or frozen yogurt in this case), you freeze it for a few more hours for it to harden up, and you take a spoon directly to the container and BAM!  As you ravenously destroy your homemade delicacy you get a chilling headache running from your eyes to the back of your head.  BRAINFREEZE!

What causes brain freeze or ice cream headache anyway?  Current neurologic models suggest that vascular constriction and referred pain are to blame [1].  A life-saving randomized trial performed at Dalewood Middle School showed that ice cream headaches were more prevalent in the group that ate the ice cream in less than 5 seconds versus the group that savored every last spoonful [2]. 

A survey of over 8000 Taiwanese adolescents showed the prevalence of ice cream headache is about 40% [3].  Boys were more likely to have brain freeze than girls, and older children were more likely to have brain freeze than younger ones.  Those that had chronic migraines were much more likely to have ice cream headache.  The association between ice cream headache and migraine has been shown in the past, however is still disputed considering one study showed that people with brain freeze were less likely to have migraines [4,5]. 

The best brain freeze is self induced.  Therefore, I recommend making this creamy chocolate malt frozen yogurt.  It is very tangy from the yogurt, not like the chemically altered, gooey sugary stuff from the mall, so if you don’t like yogurt, you probably won’t like this either.  The yogurt is strained for about 4 hours beforehand to remove excess water so the result is very creamy with a lot less calories than regular ice cream, although I do add some cream to give a good texture and flavor.

Chocolate Malt Frozen Yogurt
4 cups low fat plain yogurt
1 cup heavy cream
¾ cup sugar
½ cup cocoa powder
½ cup malt powder
Cheesecloth

Place a couple of layers of cheesecloth over a strainer over a bowl.  Add yogurt and cover.

Refrigerate for at least 4 hours until the yogurt has lost most of its moisture.  Sift chocolate powder into cream, add sugar and malt powder.  Stir to combine.  Whisk in strained yogurt and add to ice cream maker as directed.  Freeze until hardened. 


1. Kaczorowski, M., &  Kaczorowski, J. (2002). Ice cream evoked headaches (ICE-H) study: randomised trial of accelerated versus cautious ice cream eating regimen. BMJ: British Medical Journal, 325(7378), 1445-6.

2. Hulihan, J. (1997). Ice cream headache. BMJ: British Medical Journal, 314(7091), 1364.

3. Fuh, J., Wang, S., Lu, S.,  & Juang, K. (2003). Ice-cream headache--a large survey of 8359 adolescents. Cephalalgia, 23(10), 977-81.

4. Raskin NH, Kittle SC. Ice cream headache and orthostatic symptoms in patients with migraine. Headache 1976; 16:222–5.

5. Bird N, MacGregor A, Wilkinson MIP. Ice cream headache-site, duration, and relationship to migraine.  Headache 1992; 32:35–8.

Artery boosting chocolate/Artery busting brownies. Chocolate for your heart. Happy Valentine’s Day!

Ladies (and gentlemen), it is the week of love.  With Valentine’s Day coming soon, and (PS it’s still winter), there’s nothing better than a good chocolate brownie, or a whole pan of them.  Even if you don’t have someone to love, YOU are the most important person in your life.  So, love yourself and make some brownies, pour a glass of wine, and watch a pleasantly cheesy movie.

We ladies are genetically/culturally engineered to love chocolate.  Did you know that chocolate is the most craved food in North America, especially by women1? The proposed theory is both cultural and hormonal.  In a recent study, more pre-menopausal women craved chocolate compared to post-menopausal women, suggesting that menstruation can make us crave chocolate2.  Even so, in this study, hormones do not fully explain a woman’s love for chocolate.  Perhaps it is simply delicious.  Besides, guys love chocolate too!

Maybe our collective love of chocolate isn’t such a bad thing.  There is copious research that shows that certain compounds in cocoa powder called plant derived flavanols can improve cardiovascular health and lower blood pressure3.   A recent Journal of Food Science study shows that these compounds can be retained in baked goods as long as a low pH is maintained 4.  Baking soda, which alkalinizes the cocoa powder and raises the pH, should be avoided.  While making buttery, gooey brownies is probably not as beneficial as pure dark chocolate for your health, there’s a good side to everything with moderation.

Before, brownie recipes were the bane of my existence.  I tried so many.  I tried the fudgy, the cakey, the ones with whipped egg whites, the cocoa powder, the unsweetened, the cheesecake-topped, everything, but they all sucked.  I just want a delicious, moist, chocolaty brownie.  Like the box.  I know I shouldn’t be saying this, but until I whipped up this recipe, the boxed brownies were the best I ever made.  The combination of unsweetend chocolate, oil, butter, plenty of eggs, a bit of flour, and the secret ingredient, Nutella is a great combination.


Since this is a week of love, my dear fiancé tested this recipe which I composed a few months ago and recreated the brownies from my written directions.  In this exercise of not dominating the kitchen, I tried to relax, and together we found the flaws hidden in my instructions.  They turned out delicious. I have repaired these errors, and the recipe is reproducible, so the everyman and woman can enjoy these tasty treats as much as we do. 


Elizabeth’s Nutella Brownies

5 ounces unsweetened chocolate
1 stick butter
¼ cup vegetable oil
¼ cup nutella
1 cup dark brown sugar
1 cup granulated (white) sugar
1 tsp vanilla extract
¼ tsp salt
4 eggs
¾ cut flour

Preheat oven to 350 degrees F.  Grease 9X13 inch baking pan.  Melt butter and chocolate over medium low heat on stove.  When melted, turn off heat, add Nutella and oil, and whisk until smooth.

Allow to cool.  In a large bowl, whisk sugar, cooled chocolate mixture, vanilla and salt until smooth.  One at a time, whisk eggs into mixture.  Whisk in flour until most large chunks are gone and pour into greased baking pan.  Bake for approximately 20 minutes or until sharp knife in center of brownies comes out almost clean.  Allow to cool and enjoy!

1) Weingarten, H., & Elston, D. (1990). The phenomenology of food cravings. Appetite, 15,
231–246.

2) Hormes, JM. and P Rozin. 2009. Perimenstrual chocolate craving. What happens after menopause? Appetite (APPET) 53, no. 2:256-9.

3) Desch, S., et al. 2010. Effect of cocoa products on blood pressure: systematic review and meta-analysis. American Journal of Hypertension 23, no. 1:97-103.

4) Stahl, L., et al. 2009. Preservation of cocoa antioxidant activity, total polyphenols, flavan-3-ols, and procyanidin content in foods prepared with cocoa powder. Journal of Food Science 74, no. 6:C456-61.

Pregnancy Pudding

I love to eat (clearly). And, I love working with pregnant women and delivering babies. Unfortunately, these two passions do not coincide. Sure, pregnant women love to pack on the pounds and devour thousands of calories of delicious treats everyday. But, the second they go into labor, they are banned from consuming anything but clear liquids in almost every labor and delivery suite in America.

Why?

The story goes back to 1946 when Mendelson wrote a ground-breaking paper showing that pregnant women are at high risk of aspirating their stomach contents into their lungs if they required emergency surgery and intubation (when a breathing tube is placed in the airway for safety during anesthesia) ¹. Since the time that Mendelson’s groundbreaking paper was published, the fear of aspiration has permeated the minds of all OB/GYNs and anesthesiologists, banning food from the labor suite. Aspiration is an absolutely devastating outcome which can cause significant morbidity and can be fatal. Aspiration rarely occurs in the modern day L&D ward, but it should be prevented at all costs.

Can prohibiting oral intake actually prevent aspiration? This has never been proven, and is extremely difficult to study based on the rare occurrences of aspiration. In order to study this properly, there is a need for a very high study volume to detect a difference in aspiration rates for those that eat versus those that don’t. Even so, there is limited data on the effects of labor outcomes for fasting versus eating women.

Recently, an article was written in the NY Times discussing an analysis by the Cochrane Review². The Cochrane Review is a database of meta-analyses of randomized control trials of high quality, and is an excellent, unbiased source of information. This particular review compiled 5 studies looking at studies of eating or consuming sports drinks during labor. They concluded that “there is no justification for the restriction of fluids and food in labor for women at low risk of complications.”

The analysis is complemented by a study recently published in the British Medical Journal³. This study was a randomized trial of 2426 low-risk, non diabetic subjects randomized to clear liquids or a low residue diet. The low residue diet group did not have a statistically significant difference in Cesarean rate, APGAR scores, or vomiting, and thus seemingly did not greatly affect birth outcomes. 

 

I do NOT make any recommendations to eat during labor. The American College of Obstetrician Gynecologists recently published guidelines recommend to not change any rules⁴. Thus, we will continue to fast. Even so, this is an area that needs more well designed, strongly powered studies, especially since many women are so miserable during labor and simply want something to eat. Anesthesiology has advanced incredibly since 1946 and has many new techniques and medicines to prevent aspiration. Beyond this, less than 1% of people require intubation for emergency surgery because epidural and spinal anesthesia are used for C-sections the majority of the time. 

Hopefully, for my sake and the sake of everyone around me, by the time I get pregnant and have babies, the rules will have changed and I can gobble it up. (I didn’t eat during my triathlon, and pooped out in the run coming in 5^th from last!) In preparation, I will make some pregnancy pudding, because what could be better to eat during labor than homemade chocolate peanut butter pudding (maybe toast, but I can dream)? It’s filling, delicious, and easy on the stomach, with carbohydrates and proteins to give you energy for the long push. Most homemade puddings have raw eggs in them (not good for the pregnant ladies), but you can make a great pudding with just milk and cornstarch (and peanut butter and chocolate). And if you’re not gestating currently, feel free to partake as well.

Recipe adopted from Bon Appétit January 2009:

Chocolate peanut butter pregnancy pudding

½ cup sugar

5 teaspoons cornstarch

1/8 teaspoon salt

2 ¼ cups whole milk (honestly, you can do it with skim or 1% and I eliminated the heavy whipping cream from the recipe and replaced it with milk. This is not meant to give you massive indigestion)

1/2 cup creamy peanut butter

4 oz (about 2/3 cups) semi-sweet chocolate chips

1 tsp vanilla

Whisk first 3 ingredients in large saucepan to blend.

Gradually whisk in milk. Whisk over medium heat until mixture comes to boil.

Then boil until thick, whisking constantly about 30 seconds (this step can sometimes take longer, but you’ll be able to see it thickening).

Whisk in peanut butter; boil until thick again, whisking often, about 1 minute.

Remove from heat, add chocolate chips and stir until melted, add vanilla.

Cover and chill at least a few hours ahead of time.

1. Mendelson CL. The aspiration of stomach contents into the lungs

during obstetric anesthesia. Am J Obstet Gynecol 1946;52:191-206.

2. Singata M et al. Restricting oral fluid and food intake during labour. Cochrane Database Syst Rev 2010; 1:CD003930.

3. O'Sullivan, G., et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ: British Medical Journal 2009; 338:784.

3. ACOG Committee Opinion No. 441: Oral intake during labor. Obstetrics and Gynecology 2009. 114(3): 714.