Women’s Health Today

Lois Wattis, CM, FACM, IBCLC, examines the safety and benefits of labor and birth in water and shows how the tide is turning to allow more women to choose to enjoy a waterbirth.

The benefit of using warm water to reduce the pain of childbirth is now well established and accepted. The use of a shower or hot wet towels for pain relief is common practice in most care settings. Immersion in water reduces opposition to gravity, which provides ease of movement and conservation of energy. When a laboring woman is immersed in deep warm water, the buoyancy enables her to move more easily, allowing freedom to maneuver and work with her contractions, assisting the descent of the baby. The comforting water environment promotes deeper relaxation so that a woman’s hormones respond appropriately, facilitating endorphin release and efficient progress of labor, including a relaxation of the pelvic floor. This alleviates pain and optimizes the progress of her labor (Burns & Kitzinger, 2001). 

Women also know that labor 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. The birthing pool provides an environment that enhances a woman’s sense of privacy—a zone which is her own—permeated only by those entrusted and permitted by the laboring woman (Geissbühler & Eberhard, 2000). 

Immersion in water during labor reduces pressure on the woman’s abdomen. Buoyancy promotes more efficient uterine contractions. This results in better blood circulation and oxygenation of the uterine muscles, as well as more oxygen for the baby during labor. The Swiss study also found babies born in the water had the lowest rate of neonatal infection, and the average Apgar (“Appearance, pulse, grimace, activity, and respiration”) score at 5 minutes was significantly higher after waterbirths (Geissbühler & Eberhard, 2000). 

Other waterbirth studies failed to detect differences in the incidence of neonatal morbidity or mortality between water and land births and found fewer babies adopted deflexed positions during the first stage of labor when their mothers used water immersion for pain relief (Geissbuehler, Eberhard, & Lebrecht, 2002). Water born babies are typically relaxed and alert at birth as their mothers have not required drugs during labor.

No studies have indicated any increased risk association between ruptured membranes and water immersion in labor. If the membranes have been ruptured longer than 18 hours, the risk of infection increases whether the woman is laboring in or out of water. Most caregivers will recommend intravenous antibiotic treatment in this situation, when all other factors relating to the well-being of mother and baby will be taken into account in deciding whether it is appropriate to continue to labor in the water if desired. If everything is normal, it is safe to continue to labor in the water.

It is common for the baby’s heart rate to slow slightly during the pushing phase of the labor 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. 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 if you are somewhere cold) 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 labor. Some caregivers want the third stage of labor 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 (Wattis, 2001).

If the progress of the labor 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 during labor (caused by baby’s bowel action in the amniotic fluid) may be an indication to continue the labor 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.

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 1°C higher than the mother’s measured external temperature, and prolonged temperature elevation may be harmful to the baby (Geissbuehler, Eberhard, & Lebrecht, 2002). If a problem occurs during the expulsion of the baby (dystocia) the woman may be asked to stand to assist delivery of the baby.

Immersion in water offers a laboring 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 postpartum (Thöni & Mussner, 2002).

The safety and benefits of labor and birth in water, supervised by appropriately skilled birth attendants in home and hospital settings have been well proven over the past 25 years. These are further confirmed by two recent studies that found women giving birth in water had a lowered risk of perineal tears, shorter labors and fewer interventions. Babies’ Apgar and Aqua Apgar scores (specially modified Apgar score designed for waterborn babies) were excellent and there were no differences in admissions of babies to the neonatal intensive care unit (Camargo, Varela, Ferreira, Pougy, Ochiai, Santos, & Grande, 2018; Ulfsdottir, Saltvedt, & Georgsson, 2018).

Despite these well-established benefits, the option of labor and birth in water remains unavailable to many birthing women worldwide. Even when birthing pools are provided in hospitals a recent critical analysis of Australian policies and guidelines for water immersion during labor and birth found “the dominant technocratic approach to birth uses the ideas of risk and safety to limit the options that are available to labouring women using water immersion.” The authors noted that the policies and guidelines presented pregnancy and birth as risky events, which became even more risky once a woman enters the water, which in turn led to “discussion of the way in which women needed to be continually monitored, observed and assessed for risk” (Cooper, McCutcheon, & Warland, 2017).

Thankfully, some birth services manage to “walk the tightrope” between the benefits of water immersion and risk management, an example being the newly built Sunshine Coast University Hospital (SCUH) in Queensland, Australia. All eleven birth suites have baths for women to access if desired and attending midwives are skilled in monitoring labor and birth in water. Concerns raised by risk managers of the potential problem of a woman losing consciousness while in the bath were addressed by installation of an electronic hoist above every bath. The hospital service had 3006 births in its first year (2017) and the hoists have not once been needed. Watch this video of the impressive birth suites at SCUH here.

The wheels of change turn slowly, but birth advocates continue to work tirelessly to improve options and safety for childbearing women worldwide. 

References

Burns, E., Kitzinger, S. (2001). Midwifery guidelines for use of water in labour. Oxford Centre for Health Care Research and Development, Oxford Brookes University.

Camargo, J. C. S., Varela, V., Ferreira, F. M., Pougy, L., Ochiai, A. M., Santos, M. E., & Grande, M. C. L. R. (2018). The Waterbirth Project: São Bernardo Hospital experience. Women and Birth. doi:10.1016/j.wombi.2017.12.008

Cooper, M., McCutcheon, H., & Warland, J. (2017). A critical analysis of Australian policies and guidelines for water immersion during labour and birth. Women and Birth, 30(5), 431–441. doi:10.1016/j.wombi.2017.04.001

Geissbühler, V., & Eberhard, J. (2000). Waterbirths: A comparative study. Fetal Diagnosis and Therapy, 15(5), 291–300. doi:10.1159/000021024

Geissbuehler, V., Eberhard, J., & Lebrecht, A. (2002). Waterbirth: water temperature and bathing time mother knows best! Journal of Perinatal Medicine, 30(5). doi:10.1515/jpm.2002.058

Thöni, A., & Mussner, K. (2002). Gebären und geboren werden im Wasser – Vergleichende Studie nach 969 Wassergeburten. Geburtshilfe Und Frauenheilkunde, 62(10), 977–981. doi:10.1055/s-2002-35103

Ulfsdottir, H., Saltvedt, S., & Georgsson, S. (2018). Waterbirth in Sweden – a comparative study. Acta Obstetricia et Gynecologica Scandinavica, 97(3), 341–348. doi:10.1111/aogs.13286

Wattis, L. (2001). The third stage maze. Which practice pathway for optimum outcomes. Pract Midwife. 4(4), 23–27.

Lois Wattis has been a midwife for over 20 years and an International Board Certified Lactation Consultant (IBCLC) since 2002. She has practiced as an Independently Practising Midwife (IPM) in Western Australia for 5 years, providing primary midwifery care and attending home births with the Community Midwifery Program, employed by the Health Department of Western Australia. This government funded service offers care by a known midwife throughout pregnancy, home birth and for 6 weeks postpartum. Lois runs a private lactation consultancy  in Queensland. She has provided professional education for midwives via international journals and the textbook Midwifery Best Practice, as well as speaking at conferences. Lois’ contribution to midwifery education was acknowledged at the International Confederation of Midwives in 2004, when she was awarded a Fellow of the Australian College of Midwives (FACM).

Lois has worked in a specialist role as Clinical Midwife Lactation Consultant in an acute setting for the past decade, assisting term and preterm babies to establish breastfeeding, often working with multiples and babies with genetic and birth related difficulties. Her broad experience has culminated in the creation of these helpful resources: New Baby 101 – A Midwife’s Guide for New Parents. The 5 free “how to” videos support the resources and Lois updates parents daily with information on the New Baby 101 Facebook page.