Waterbirth ' Myths and Realities

Waterbirth – Myths and Realities
Lois Wattis, RN, RM, IPM, FACM, IBCLC
Waterbirth – Myths and Realities
A true story…
A pregnant woman who attended a major hospital for antenatal care and a
booking-in visit was told by a senior consultant obstetrician that she must abandon
her plan to birth in water because her baby would drown. Although the woman
knew the obstetrician’s advice was nonsensical, she found his assertion confronting
and confusing and discussed the comment with her midwife caregiver the next day.
The woman was reassured that labour and birth in water is perfectly safe, and
provides many benefits for herself and her baby when conducted by attendants
skilled in supporting normal labour and birth in water. Whether the obstetrician
was ignorant of the truth or deliberately misinforming the woman is unsure, but in
giving this ‘advice’ he perpetuated the most common myth associated with birth in
water.
No, babies do not drown if they are born underwater. They live in a watery
environment until labour heralds their transition from the uterus to the air-filled world
outside. The stimulus to breath at birth occurs when the baby is exposed to air, plus
the dramatic change of temperature, noise and light.
During a waterbirth this occurs when the baby is lifted up out of the water. His
umbilical cord, his lifeline, continues to provide oxygenated blood while he responds
to the new stimuli and fills his lungs with air for the first time. Simultaneously his
heart function converts to include the oxygenated blood provided by his lungs, no
longer solely relying on the placenta. Delaying clamping and cutting of the umbilical
cord is very beneficial to baby’s transition to life outside the uterus. If allowed the
umbilical cord may continue to pulsate for some time, providing baby with his full
quota of blood volume via the placenta, maximising perfusion of his newly
functioning lung tissues and supporting his transition, unhurried, into his new world.
How does water help the woman during labour?
The benefit of using water to reduce the pain of childbirth is well established
and accepted, and the use of a shower or hot wet towels for pain relief is common
practise in most care settings. When immersed in deep warm water the buoyancy
enables a woman to move more easily than on land, allowing freedom to manouver
and work with her contractions assisting the descent of the baby. Immersion reduces
opposition to gravity, providing ease of movement and conservation of energy.
The comforting water environment promotes deeper relaxation allowing the
woman’s hormones to respond appropriately, facilitating endorphin release and
efficient progress of labour, including relaxation of the pelvic floor. This alleviates
pain and optimises the progress of her labour.1
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Waterbirth – Myths and Realities
Lois Wattis, RN, RM, IPM, FACM, IBCLC
Women who wish to labour and/or birth while immersed in deep warm water
know it is a simple way of assisting them to cope without the use of strong drugs. A
reduction in the use of pain relieving drugs not only benefits the mother who is more
alert and responsive after the birth, but the baby will also benefit considerably.
Women also know that labour in water increases their chances of giving birth
naturally and normally with a minimum of interference or medical intervention. A
prospective observational study in Switzerland in 1999 found waterbirths had the
lowest rate of analgesia use, the lowest episiotomy rate and lowest incidence of 3rd
and 4th degree tears, as well as the lowest maternal blood loss.2 The birthing pool
provides an environment which enhances a woman’s sense of privacy – a zone which
is her own – permeated only by those entrusted and permitted by the labouring
woman. This may be particularly important to women who have been subjected to
sexual abuse in the past.
What about the baby’s wellbeing?
Immersion in water during labour reduces pressure on the woman’s
abdomen, and buoyancy promotes more efficient uterine contractions and better blood
circulation. This results in better blood circulation and oxygenation of the uterine
muscles, and more oxygen for the baby during labour. The Swiss study also found
babies born in the water had the lowest rate of neonatal infection, and the average
Apgar score at 5 minutes was significantly higher after waterbirths.
Other waterbirth studies failed to detect differences in the incidence of
neonatal morbidity or mortality between water and land birth and found fewer babies
adopted deflexed positions during the first stage of labour when their mother’s used
water immersion for pain relief.3 Water born babies are typically relaxed and alert at
birth as their mothers have not required drugs during labour. One study has
demonstrated that babies whose mothers had epidural anaesthesia were still showing
adverse effects of the drug up to six weeks later.4
What about after the birth?
Water offers a labouring woman an environment where she can behave
instinctively and feel in control. When a woman feels in control during childbirth, she
experiences a higher degree of emotional well-being postnatally.5 Many studies have
confirmed that women who give birth in the water have a most satisfying birth
experience.6
Common misconceptions about labour in water
“My waters were broken so it wasn’t safe for me to labour in the water”
No studies have indicated any increased risk association between ruptured
membranes and water immersion in labour. If the membranes have been ruptured
longer than 18 hours the risk of infection increases whether the woman is labouring in
or out of water. Most caregivers will recommend intravenous antibiotic treatment if
this situation occurs, and all other factors relating to the wellbeing of mother and baby
will be taken into account when deciding whether it is appropriate to continue to
labour in the water if desired. If everything is normal it is safe to continue to labour
in the water.

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Waterbirth – Myths and Realities
Lois Wattis, RN, RM, IPM, FACM, IBCLC
“I got into the pool too early and my labour stopped.”
It’s quite likely that this woman was not in established labour. Water
immersion during the very early latent phase of labour will sometimes relax the
woman significantly and consequently her uterine activity may also reduce. Water
immersion can provide a very useful and safe remedy if the woman’s prelabour
uterine activity is causing discomfort and fatigue, and may allow her to catch up on
some sleep prior to labour establishing.
“So when is the best time to get into the water?”
It’s best to use alternatives to immersion in the pool during early labour, such
as trying different physical positions and mobilisation, massage, sitting or standing in
the shower. When these alternatives are no longer helpful at all it’s probably time to
get into the water. Some caregivers will want to confirm that the cervix dilation is
4cm or more, while others will avoid unnecessary vaginal examinations and be guided
by the woman’s interpretation of her needs and visible signs of labour progression.
“When should I leave the water?”
If the progress of the labour is very slow or stalls it is often helpful to leave the
birth pool and mobilise, take some food and fluids and return to the pool if desired
when the contractions increase in strength and frequency. The woman should get out
of the pool to pass urine, or a bowl or bucket placed under her as she stands in the
pool to urinate. The woman may be asked to leave the pool for vaginal examinations
to be performed although this is not absolutely necessary.
If the progress of the labour deviates from normal the woman may be asked to
leave the water. Problems with the baby’s heart rate, either very slow or very fast
may indicate baby is having difficulties and closer monitoring out of the water may be
indicated. Meconium-stained liquor (caused by baby’s bowel action in the amniotic
fluid) during labour may be an indication to continue the labour out of the pool. If
meconium is present but undetected it may be seen floating out of the baby’s nose,
mouth or ears as the baby is born into the water.
It is common for the baby’s heart rate to slow slightly during the pushing
phase of the labour due to compression of the baby’s head in the vagina. Provided the
descent of the baby progresses normally this is not usually sufficient concern to
warrant leaving the water. Many caregivers want the third stage of labour to be
completed out of the bath so that blood loss can be carefully monitored. Sometimes
the placenta is born soon after the baby. If this occurs in the water it is not a problem.
If the woman’s temperature becomes elevated it may be advisable for her to
stand for a while, or leave the pool to allow her body to cool. The baby’s temperature
is 1degree higher than the mother’s measured external temperature, and prolonged
temperature elevation may be harmful to the baby. If a problem occurs during the
expulsion of the baby (dystocia) the woman may be asked to stand to assist delivery
of the baby.
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Waterbirth – Myths and Realities
Lois Wattis, RN, RM, IPM, FACM, IBCLC
General guidelines for labour and birth in water
It is important for the woman to be well hydrated during labour whether she is
in or out of the water, and to pass urine frequently. It is not advisable to add salt or
essential oils to the water. The woman should be free to leave the bath if desired, and
birth plans should allow for flexibility as well as definition of the woman’s wishes for
the birth.
The baby must be born either fully submerged or fully out of the water, and it
is important for the woman to understand this is her choice at the time of birth. Skin
to skin contact is fundamental to the birth and bonding experience as well as
providing warmth and comfort to the newborn. Drying the baby’s face and head and
applying a hat will also assist in keeping baby warm. Warmth and an undisturbed
environment immediately following the birth are essential for the woman’s
physiological functioning to safely complete the third stage of the labour.7
We believe that waterbirth will lose its ‘outsider’ status and will, in the next
few years, take up a fixed place in obstetrics. It leads to minimal intervention
and is a woman-friendly method and thus results in higher satisfaction of the
mother. ( Thni & Mussner, Reuters Health, Berlin 22/1/03)
References
1.
Burns, E, Kitzinger, S (2001) Midwifery guidelines for use of water in
labour. Oxford centre for health care research and development,
Oxford Brookes University
2.
Eberhard, J & Geissbuehler, V (1999) Influence of alternative birth
methods on traditional birth management, cited in Burns EE. 2004.
3.
Burns, EE (2004) Water: what are we afraid of? Practising Midwife,
7:10, pp17-19
4.
Rosenblatt DB, et al (1981) The influence of maternal analgesia on
neonatal behaviour: II epidural bupivacaine, BrJObGyn, 88:407-13
5.
Green, JM, Coupland, VA, and Kitzinger, JJ.V (1990) Expectations,
experiences and physiological outcomes of childbirth: A prospective
study of 825 women. Birth. 17:1 pp15-25
6.
See 2
7.
Wattis, LJ (2001) The third stage maze – Which practice pathway for
optimum outcomes? The Practising Midwife. 4:4 pp25-27.
For further information:
AIMS publication “Choosing a Water Birth” by Beverley A Lawrence Beech.
The National Childbirth booklet “Labour and Birth in Water – How and
Why You Might Use Water” available from www.nctms.co.uk
www.yourwaterbirth.com provides a comprehensive list of link sites
For specific guidelines for midwives interested in conducting waterbirths, I recommend
- Standard 10-3 “Labour and Birth in Water” 2002, from Women’s and Children’s Hospital,
Adelaide, South Australia
- Govt.of SA – Dept of Health POLICY – BIRTH IN WATER pdf www.health.sa.gov.au

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