Natural physiologic birth leads to a safer and gentler birth for both mother and baby.   Labour hormones (including higher levels of pain-killing endorphins) work optimally when a labouring woman feels safe, private, unobserved, and uninterrupted.  Labour proceeds faster, with more efficient contractions, less pain perceived, and fewer complications (Buckley, 2004).  Women can relax, surrender and sink deeper into labour.  This results in fewer interventions.  Water birth helps facilitate an environment of privacy, calm, and quiet.  Several studies of labour in water vs. land report positive findings.  Others found no differences but also reported no adverse outcomes, no increase in interventions, nor poorer outcomes.

Mother Benefits

Easier, faster labour:

  • More support: mother isn’t left alone and partner can get in pool to provide close support.
  • Reduced inhibition as mother feels supported and less exposed.
  • Buoyancy allows for easier mobility and relaxed muscles. Less work is used for support and upright positions.  This especially helps women with a physical disability, injury, body-pain or mobility issues to assume positions they may not be able to hold or achieve on land.
  • Fewer vaginal-exams and other interventions.
  • Less back-labour.
  • Easier delivery. Greater pelvic diameters; low back and pelvis aren’t compressed.
  • Fewer & less severe tears with natural counter-pressure on perineum.
  • Less fear & pain with birth.

Pain reduction:

  • Warmth and skin-contact of water may close the “pain gate” (Wall, 1962).
  • Endorphin (natural pain killer) levels increase after 20-30 min of immersion (Frye, 2004).
  • A 2000 study in the UK (Balaskis, 2004, p51) determined waterbirth is an effective method of pain relief. A dramatic reduction of narcotic pain meds was seen (eg 3% vs 60% for pethidine).
  • As with any position changes or new environments, it’s important to wait several contractions or ½ hr before determining the full effect of water on pain.

Baby Benefits:

Gentle transition.  Babies born in water are more settled, alert, and less stressed.

Birth in Water

The mother or father can bring the baby out of the water over 5-7 seconds.  Over-stimulation should be avoided so baby doesn’t gasp for breath while submerged.  If the cord is pulsing then the baby’s getting oxygenated blood.  Midwives report that water-born babies are calmer and slower to transition so might not appear to breath as quickly as land-babies.  First breaths are often smaller and slower.

Special Conditions that Benefit from Water Birth

It’s essential to find a practitioner comfortable and experienced with these conditions in water.  Enning (2004) lists the following as benefiting from waterbirth:

  • Pre-eclampsia- darkness, privacy, water at proper temperature lower blood pressure.
  • VBAC (vaginal birth after Caesarean) – decreased risk of uterine rupture.
  • Big baby, small mama (rare) – waterbirth practices and dynamics create optimal space in pelvis.
  • Malpositioned baby – water allows baby to maneuver in a manner to allow easier birth of head.

When to Get In

Michel Odent (1997) reports that contractions can be boosted or inhibited, depending on how long a woman spends in water.  There’s an initial decrease in stress hormones upon immersion, resulting in higher oxytocin levels and hence stronger contractions.  After a couple of hours the effects can wear off and labour may slow.  The “oxytocin wave” usually carries through to birth if a woman gets in during active labour.  Women who get in earlier often have to get out before transition due to labour slowing.  Birth attendants around the world report the same thing.  Eriksson et al (1997) found that women who entered the pool early had more interventions and longer labour than those who entered after 5cm.  Although laboring upright on land often re-establishes labour, oxytocin augmentation may be required.

When to Get Out

Medical reasons to assist mother out of the tub include significant labour slows or stalls, non-reassuring vital signs in mother or baby, postpartum hemorrhage, suturing, and anytime the baby must be born quickly.  It’s important to rehearse a plan and be prepared for a necessary or quick exit from the pool.

When to get out after a healthy birth is a contentious issue.  Getting out in first hour may interrupt sacred bonding time or decrease maximum oxytocin released during this stage.  However, current recommendations are that mother leave (with the cord intact) to birth the placenta.  In any case, someone must hold baby as mother leaves the pool in case of dizziness, light-headedness, slipping or difficulty getting mother out of pool.  Besides, wet babies are very slippery.

Ideal Temperatures for Waterbirth

The general rule in North America is 32-36C for labour and 36-37.5C for delivery (Wheatly, 2008; Balaskis, 2004).  Cornelia Enning has done extensive research on waterbirth physiology.  She generally recommends lower temperatures and different temperatures for different stages, positions and multiple births (Frye, 2004, p471-3). She found that babies born in cooler water are more active and vigorous.  If a woman feels the need to be in a tub for early labour (pain management etc) the pool should be 35-37C, although Enning’s findings agree with Odent (1997) that submersion in early labour can slow or stall the process.

In 2002 Geissbeuhler et al. conducted research where women chose their water temperature and time in the pool.  Despite ranges of 23-38.9C and 28-364 minutes, maternal and infant body temperatures all stayed within normal range.  Women intuitively know what’s best for them and their babies!

Depth of Water

When kneeling, the water should cover mother’s belly, just below her breasts.  When sitting the water covers her breasts but not shoulders to allow heat-loss.  When holding her baby she can choose a position to keep the head out of water but body submerged enough to keep warm.

Equipment for Water Birth

Waterbirth equipment includes extra towels, a kettle to boil water, equipment to maintain pool, a floating thermometer, and strainer & container (for debris in pool).  See Homebirth Supplies for a detailed list.

Possible Risks / Common Fears about Water-Birth

Infant inhaling pool water is the number one risk and fear.  An innate, physiological and powerful “Dive Reflex” protects healthy fetuses from inhaling water (Johnson, 1996).   However if a baby is deprived of oxygen the dive reflex may be over-ridden in favour of gasping for air immediately upon birth.  Oxygen-deprived babies almost always show signs of stress during labour such as meconium or heart-rate abnormalities.  In this case birth should take place on land.  With careful monitoring the risk of a stressed baby aspirating water is decreased.  A baby with reassuring heart tones all the way through labour is highly unlikely to develop last minute hypoxia; however it’s a rare possibility.

Normal newborn breathing pattern:

  • Intact cord and placenta help inhibit breathing due to high levels of prostaglandin.  If cord is clamped or cut while baby’s under water it can initiate breathing under water.
  • Babies won’t breathe in body temperature water.  The main breathing stimulant is exposure of cheeks, nose and mouth to air at least 1° cooler than body temperature.
  • Newborn babies may be stimulated to breath with too much handling.
  • When baby tastes fluids the larynx (in throat) automatically closes.  This also prevents babies from aspirating breast milk during feeding.

Assessment of mother & baby may be more difficult.  However, birth attendants who are educated and practiced in water-birth can do accurate assessments.  If unsure the mother is asked to leave the tub.

Dehydration of mother is a risk of waterbirth but can easily be prevented by diligent birth-attendants who hydrate mom and maintain water temperature.

Water embolism:  Some believe it’s possible for water to enter mother’s bloodstream via the uterine placental site.  Others believe it’s impossible as the cervix is swollen and closes after birth, which prevents water from entering.  Balaskis (2004) states there are no known reports.

Cord snapping:  Gilbert (1999) cited a possible link to waterbirth and increased cord-snapping but there is no significant evidence to support this.  In any birth the cord and mama-baby should be treated in a way to minimize or eliminate cord-tension.  Incidence and treatment is the same for water or land.

Polycythaemia (too many red blood cells) has been suggested as a risk (Austin, 1997) but there’s no evidence that water caused it.  Practitioners don’t seem to consider this a risk (Balaskis, 2004).

Contamination of pool water:  Floating debris is removed by birth attendants.  If water gets too messy, mother will leave the pool so it can be drained, cleaned and refilled.

Infection transmission:  Parents’ “germs” generally don’t pose a threat to baby.  Infection rates are very low (Balaskis, 2004).  If baby’s father is in the pool there are no hygiene concerns, as he and mother share the same bacterial environment that baby will share.  Mother’s friendly bacteria are protective to baby.

Conclusion

Waterbirth provides a wonderful and gentle birth experience for both mother and baby.  Often shorter labours with fewer complications are seen.  This in turn leads to a better experience for dads.  Mothers rate high satisfaction with waterbirth experiences, as do fathers and birth attendants.

 

References

Austin T, Bridges N et al. (1997).  Severe neonatal polycythaemia after third stage of labour under water.  The Lancet, 50, 1445-47.

Balaskis, Janet.  (2004). The waterbirth book.   London:  Thorsons.

Buckley, S.J., Dr.  (2005). Gentle birth, gentle mothering.  Brisbane:  One Moon.

Enning, Cornelia.  (2004). Lecture notes from 2004 International Waterbirth Congress, Chicago, IL.

Eriksson M, Mattsson L-A and Ladfors L. (1997). Early or late bath during first stage of labour: a randomized study of 200 women.  Midwifery, 13, 146-148.

Frye, Anne.  (2004).  Holistic midwifery: A comprehensive textbook for midwives in homebirth practice, vol 2.  Portland: Labrys.

Geissbeuhler V et al.  (2002). Waterbirth: water temperature and bathing time – mother knows best!  J Perinat Med, 30(5), 371-378.

Gilbert, Ruth E; Tookey, Pat A.  (1999). Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey.  BMJ, 319, 483-487.

Johnson, Paul.  (1996). Birth under water – To breathe or not to breathe.  BJOG: An International Journal of Obstetrics & Gynaecology.  103(3), vii-vii.

Odent, M., Dr.  (1997). Can water immersion stop labour?  Journal of Nurse-Midwifery,  42(5).

Wall P.D., Melzack R. (1962). On nature of cutaneous sensory mechanisms.  Brain, 85, 331.

Wheatley, Lainna.  (2008). Midwife’s Assistant Orientation class notes.  SLC: Midwives College of Utah.