A Few Thoughts on Waterbirth
Whenever I ask friends and clients for ideas for blog posts, someone always suggests waterbirth. I keep putting off writing about it and then wondering why I’m procrastinating, maybe because there are so many articles out there already that I wasn’t sure what to add. Recently, I saw a post on Facebook with the latest on risks and benefits of waterbirth from the Cochrane database (Immersion in water in labor and birth on cochrane.org) which essentially came to a fairly inconclusive conclusion:
‘Authors’ conclusions:
In healthy women at low risk of complications, there is moderate to low-quality evidence that water immersion during the first stage of labor probably has little effect on mode of birth or perineal trauma but may reduce the use of regional analgesia. The evidence for immersion during the second stage of labor is limited and does not show clear differences in maternal or neonatal outcomes of intensive care. There is no evidence of increased adverse effects to the fetus/neonate or woman from laboring or giving birth in water. The available evidence is limited by clinical variability and heterogeneity across trials, and no trial has been conducted in a midwifery-led setting.’
While I’m really glad that no increase in adverse effects was found, it bugs me that there’s no research done in a midwifery-led setting, since in practice, the overwhelming majority of waterbirths take place in midwifery-led settings. In the US, at least, that means homebirths and some birth center births. I’m not sure how accurate or useful it is to use statistics from waterbirths in other settings to come up with numbers for out-of-hospital waterbirths. Here’s hoping that the MANA Stats project (check out www.mana.org) will eventually give us good statistics from CPMs on waterbirth benefits and risks!
It also struck me that most of the existing research looks at a really narrow range of risks and benefits, focusing on concrete things like perineal tears or infection. Those are important, obviously, but we need to keep in mind that there are other intangible but equally important concerns to address, like how waterbirth affects the mother’s experience, and even the baby’s. That last is hard to measure objectively, but it bears consideration. We already have an acknowledgement that babies’ experience of birth is different when they are born in water than on dry land; a different APGAR scoring system exists for waterbirth, which allows for the more gradual transition to extrauterine life that waterbirth creates.
So with all that being said, I finally decided I would just sit down and write a few random things about waterbirth that I’ve seen and learned along my path as a midwife. This is mostly anecdotal stuff, while we’re waiting on relevant numbers. I hope it’s useful or at least entertaining…
How does waterbirth work? When people ask me this, they are usually wondering about things like necessary equipment, set up and clean up, and some aspects of the delivery itself, as in how long the baby can safely stay underwater.
In a homebirth setting, unless the family has a tub big enough to birth in comfortably, most waterbirths take place in an inflatable birth pool. I have two of these that I lend out to my families, and they are required to buy their own disposable pool liner. Some families do opt to purchase an inflatable pool of appropriate size.
I normally bring the pool to the family around 37 weeks of pregnancy. They will have a large plastic tarp to protect the floor, an inflator pump to blow up the pool, a new garden hose and an adaptor to hook the hose up to whatever tap they are using to fill the pool.
(Warning: It is wise to test the adaptor ahead of time. It would be a rare laboring woman who took the news calmly that her waterbirth might not happen because someone bought the wrong adaptor.)
It’s best to inflate the pool early on in labor and fill it once everyone is sure this is the real deal. Filling the pool up can take a half-hour or so. I recommend filling it with straight hot water until the hot water is gone. It is easier to add a few buckets of cold water than to try to warm up a big tub of cool water.
Some families wonder if their water is clean enough, or if they should add anything to the water. I even worked with a family once who wanted to run the water through a filter as the tub filled. Basically, tap water that you feel safe to bathe in, cook with, or drink is fine for your water birth. Some practitioners suggest that adding salt to the water may be beneficial (I have no experience with that) but beyond that, i don’t recommend essential oils, bubbles, or anything else that might irritate baby’s eyes or delicate skin, or alter good bacteria baby should be picking up.
When should mom get in? This is a point of debate in the natural birth world. It has been widely observed that for some women getting into the pool in early labor will slow contractions down, as will staying in for more than an hour or so at a stretch. Conversely, sometimes getting into a birthing pool just at the point where contractions feel unbearable will kick labor into high gear and result in a very quick birth from that point on.
I worked with one mom who had birthed naturally many times in the hospital, but never at home before. She was excited about waterbirth but ended up waiting until well into transition before she got in the pool. She got into the water, gave a deep sigh of relief, and pushed out a nine-pound baby with what looked like almost no effort at all. She caught her breath for a second and practically leaped out of the pool and moved to her bed to snuggle with her newborn. “I thought that water birth was very nice,’ she told me later. She had only been in the water for about three minutes, total.
In my mind, it seems that if getting into the water early in labor slows contractions down, first of all, it’s probably just prodromal labor at this point and not time to try to hasten the process. Second, if water slows contractions during active labor, it’s easy enough to fix the problem—mom can just get out and walk or do something else. It’s good to change whatever you’re doing in labor every so often, anyway. In general, a mom should get into the water whenever she thinks it might feel good and help her relax.
And how good is water as a pain-reliever? It won’t numb you like a good epidural, but if you wanted that, you wouldn’t be giving birth At home anyway, right? Water is incredibly soothing and relaxing to many people, allowing the body to be weightless and feel supported and warm. In addition, the pool offers the laboring mom a small, private, controlled space that may make her feel more secure than a larger, open room where she may feel exposed and vulnerable.
A relaxed mom who feels safe and has sufficient privacy will generally cope with pain much better, and birth more efficiently than one who is stressed by her surroundings. French obstetrician and waterbirth proponent Michel Odent has written extensively on this subject. I especially recommend his book Water, Birth, and Sexuality: Our Primeval Connection to Water and its Use in Labour and Therapy.
As a repeat client of mine described her waterbirth experience:
“My water birth was by far my favorite and easiest. There is just something about warm water and the relief it brings. Crowning had less of the “ring of fire” feeling than it usually does, but I feel that I was more aware of everything I was feeling…From him descending with each push to when he slid back in a bit right before birth, I was aware and could feel it all because there was less discomfort. everything felt lighter. Even laboring in the water brought a sense of relief to my muscles and body when I was tired laboring with my last baby. My favorite part, though, about actually birthing in water was scooping him up out of the water after he was born. It felt less abrupt, gentler, warmer.”
That last is a great point that I discussed a little among midwives and homebirth families, but that I suspect isn’t given enough consideration in general. Babies born in water have a somewhat different experience of entering the world than do their counterparts born on dry land. A waterborne baby transitions slowly from the warm, watery environment of the womb, into a pool of more warm water, and then to mom”s chest, still partly immersed in water, and then eventually to dry land whenever they get out of the pool. This is different than the shock of going from the dark, quiet watery womb straight out into the cold air, noise, and bright light of a dry land birth.
Most waterborne babies are fairly calm at birth. It’s not unusual for a water baby to take thirty seconds or so to cry and begin breathing, even if they are clearly alert and well, with good muscle tone. The transition to extrauterine life is just that gentle and gradual. It is for that reason that a separate APGAR scoring system exists for babies born in water.
These babies are protected from inhaling water by the dive reflex, and normally continue to receive oxygen via the placenta, which is attached to the mom’s uterine wall for several minutes following delivery, so during an uncomplicated birth, it is fine for a baby’s head to be out for a minute or two underwater. A baby will generally not breathe until she is brought out of the water and the cooler room air hits her skin. Of course, there is a limit on how long a baby will be protected by the dive reflex, and the placenta will detach at some point. Any complications during delivery might require the mom to get out of the water. Certainly, once a baby’s head or face has come out of the water, it needs to stay out of the water. It’s just common sense.
At some point, often before the delivery of the placenta, mom and baby will get out of the pool, with plenty of assistance and some warm, dry towels, and move to their bed or wherever they plan to spend the next few hours. At this point, we use an electric submersible pump and hose to empty the pool, and the liner is disposed of. The pool itself needs to be disinfected and left to dry, then deflated and returned to its case.
Generally, that’s all there is to waterbirth, although a few other thoughts come to mind…For example, almost any room in the house that is big enough is fine for setting up a pool, but I did once hear a midwife describe a birth in a very old house, where plaster began falling from the ceiling in the room directly below the pool; presumably, the floor wasn’t quite strong enough for that load. And I know of another situation where a family was planning an outdoor waterbirth, but they had to move indoors and scrap the pool idea for safety’s sake when a heavy thunderstorm with lightning passed through. They did have a nice birth on dry land, at least!
Most women I’ve spoken with who have experienced waterbirth have loved it, and I typically only hear complaints from moms who got out and then delivered before they could get back into their pools, or who couldn’t fill the pool fast enough for a waterbirth! I’m not sure further research is necessary to “prove’ that for many women, laboring and birthing in water is a wonderful experience.