Waterbirth Demystified

Waterbirth Demystified

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Everyone agrees that, whether be a natural birth or birth by cesarean section, a birth with an epidural or a physiological birth, every birth is life transforming. As a midwife, I have been blessed to support many families during the birth of their child. And of all types of birth, water births continue to amaze me. As the woman enters the water, she appears more relaxed, almost as if her labor had slowed down. In reality, her contractions become more organized and she'll progress much faster. I know, some of you will say why in the world would women want to put themselves or their newborn baby at risk? Hence, I would like to go over some of the most common myths about water birth and refute these misunderstandings.

 

1. Labor in the water cause hypotension (low blood pressure)

During water immersion, the hydrostatic pressure exerted by the water on the body reduces both peripheral edema and peripheral blood pressure. This hydrostatic pressure, which is greater at the bottom of the tub than at the surface, has an effect on the body by gently squeezing it like a tube of toothpaste. It is the pressure from the bottom up, which produces a significant shift of blood volume from the extremities to the chest, thus increasing the blood circulation to the vital organs (heart, lungs, brain and uterus), and improving cardiac and renal output, lung function, and uterine perfusion

2. Women who labor in the water become dehydrated

During water immersion birth, the hydrostatic pressure exerted on the lower extremities causes a fluid shift from the extracellular space into the intravascular space and increases the blood flow to the vital orgasms, including the brain. Thirst cells, located in the brain, control the blood volume. When these cells swell up, thirst is inhibited. This may explain why women who labor in the water may not feel very thirsty. Studies have also demonstrated that oral nutrition is not only safe but actually optimizes outcomes and IV hydration does not improve birth outcomes. Regardless of where the woman labors, she is encouraged to take frequent sips of fluid throughout her labor to keep herself hydrated due to the exertion of energy.

3. Mom’s body temperature can get too hot and baby’s heart rate can get too fast

Waterbirths pose no thermal risk to the mother and her infant as long as the water temperature remains within the physiological range (usually between 95-100). Water transfers heat far better than air. Because of this, water temperature has a profound effect on the body. If the water temperature exceeds 101 degrees Fahrenheit, it could lead to an increase in the mother's body temperature, which could cause the baby's heart rate to increase. If the temperature of the water is too cool (below 80°F), blood is shunted toward the core of the body to maintain body heat. As the water gets colder, muscles work less efficiently. When the water temperature is within physiologic range, more blood is available to working muscles. During water immersion, the water temperature is regularly monitored to ensure that the water temperature is within a comfortable range for the mother, usually between 95-100 degrees Fahrenheit. The mother’s vital signs and the baby’s heart rate are also regularly monitored to ensure that the mother’s heart rate as well as the baby’s remains within normal range.

4. Labor is more likely to slow down or stop

Using water during labor can be soothing to the laboring woman. The relaxing effect of warm water can help the mother take deeper, more calming breaths to help with the discomforts of labor. Immersing in warm water during labor can help decrease adrenaline, the stress hormone. Adrenaline competes for the same receptor sites on the uterus and therefore has been shown to inhibit the effect of oxytocin, the main labor hormone responsible for creating strong and regular contractions. As the laboring woman enters the water, her contraction pattern may appear to slow down a little but because of the unhindered action of oxytocin, her labor pattern becomes more efficient and labor progresses better. Studies show that the length during the first and second stages of labor is significantly shorter with women who labor in the tub.

5. Baby can drown or even die if born in the water

There are various criticisms about water birth and the risk of aspiration of water and drowning. The entry of water into the baby's lungs can be avoided by lifting the baby out to the surface of the water as soon as possible. Babies by themselves will not breathe until exposed to air. Why doesn’t the newborn breathe underwater during a waterbirth? In utero, babies spend nine months in a sea of amniotic fluid. In utero, fetal breathing movements occur about 40% of the time with very little amniotic fluid being actually inhaled. About 48 hours before spontaneous labor, these “practice” fetal breathing movements’ stop, possibly because of a surge in levels of a hormone called prostaglandin E2.  Babies also have an inbuilt physiological reflex, called the Dive Reflex that prevents them from taking a breath until they're out in the open air. When an infant is born in the water and still fully submerged in the water, the larynx instinctively closes when water passes by, and the liquid is swallowed rather than inhaled. When the facial skin receptors come into contact with the oxygen and carbon dioxide in the air, along with cooler temperatures, the breathing movements will get started. It is also critical to know that severely low oxygen levels or high levels of carbon dioxide will trigger the gasp reflex before the baby has a chance to be brought out of the water and could result in water aspiration and drowning. This is why, during labor, your provider will frequently listen to the baby’s heart rate to assess for signs of hypoxia (low oxygen levels). Any baby born underwater should be brought to the surface within 10 seconds in a gentle manner and caution is given to ensure that the baby’s face doesn’t go back underwater.

6. Babies born in the water have lower Apgars.

Some babies can be slower to initiate breathing; this is particularly common with waterbirth babies. These babies have good tone and slowly turn from blue to pink. As long as the cord is left intact, the placenta is still oxygenating the baby; their color change may be the only obvious indication that they are making the transition. It can be difficult to even notice them begin to breathe. Most importantly, they need their placental circulation. While the cord is intact the baby is still receiving some oxygen, which is better than none. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets into the lungs via external methods of resuscitation. Studies show that Apgars scores are unaffected by waterbirth. Neonates of women who had a waterbirth were less likely to experience a low 5-minute Apgar score, neonatal transfer to the hospital, and hospitalization or neonatal intensive care unit admission in the first 6 weeks when compared to non-waterbirth neonates.

7. Baby can get cold in the water

There are several ways to help the baby achieve thermoregulation in the water. As long as the cord is left intact, baby’s blood continues to circulate back and forth between the baby and the placenta, transferring heat from the mother to her baby. When the baby is placed skin-to skin against the mother’s chest, her body will conduct heat to her baby. Lastly, to make sure that the baby does not get cold after the birth, the baby’s body should stay under the water with the baby’s head secure above the water. The head can be dried with a warm towel. Covering the baby’s body with a blanket is not necessary and may in fact contribute to heat loss by evaporation. If the baby is well he/she can stay with his/her mother in the water.

8. Baby can get an infection if born in the water

One major concern about waterbirth deliveries is the risk of infection for the mother and the newborn from microbiological contamination from fecal and skin flora of the mother and environmental bacteria from the water system. However, birth itself is not a sterile procedure. When a woman births, her baby is born with its face just a couple of centimeters from the rectum and often stool is released during the expulsion stage of birth. Baby’s exposure to beneficial bacteria from the mother is actually important for proper colonization of the gut and respiratory tract during the birthing process. During a waterbirth, these bodily fluids and substances are diluted to such a degree; this dilution may protect babies during delivery. Studies demonstrate that there is no significant increase of admissions to neonatal ICU and that babies born in the water are less likely to receive antibiotics. There is no increase in the number of maternal infections or poor healing of perineal tears in women who had given birth in water. Of course, there are strict protocols in place to ensure that tubs and the water are kept clean.

9. What if the umbilical cord breaks?

An umbilical cord tear is also called umbilical cord “snap,” “rupture,” or “avulsion”. Researchers have hypothesized that there may be an increased risk of cord tearing from unnecessarily rapid or extra forceful traction on the cord as the baby is lifted out of the water. It is important for providers to learn how to avoid excess traction as they calmly help the mother guide the baby’s head out of the water. Recommendations for preventing cord tears include: recognize the potential for umbilical cord tears, be familiar with the signs that it has occurred, lower the water level slightly just before birth so that the baby does not have to travel as far to get out of the water, but keep the water level high enough so that the entire baby can be born underwater, have cord clamps immediately available in case the cord tears, assist the mother in bringing the newborn to the surface calmly and gently, avoid excess cord traction, and thoroughly examine the newborn and cord immediately after birth.

It’s important to remember all choices have benefits and risks – including other forms of labor pain relief. There’s no current evidence to support concerns during a waterbirth as long as proper protocols are being followed. In order to ensure the safety of our water births, we have rigorous protocols in place for candidate selection; monitoring pregnant women at appropriate intervals; moving women out of the tubs if maternal or fetal concerns develop; maintaining and cleaning tubs and immersion pools; and following infection control procedures.

Whether or not waterbirth calls to you, we encourage you to be open to the journey that birthing your child will offer. Find care providers and doulas that will empower you to move safely and confidently through the territory of your labor and birth experience. Take the time to meet new people who are also expecting – finding a community to support you, as you become a parent, sign up for a childbirth class like Bradley or HypnoBirthing. Most of all, give yourself space and time to be present to the wonder of growing a new life in your body, and prepare to be transformed by the victory of giving birth to your child.

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Homebirth

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