Choosing to birth naturally, without any use of drugs, doesn’t mean one births without pain management. There are many effective measures that work outside pain medicine. Waterbirth is often one of the key strategies to cope with pain in labor and frequently, people become interested in out-of-hospital birth due to waterbirth. This is especially true in the Denver-metro area given the lack of access to waterbirth in hospitals. Most hospitals in the region ban waterbirth and make you get out of the birth tub right when you need it most - when labor is intense and you’re showing signs you might have your baby soon. This is not evidence-based!
Currently, the Center for Midwifery practice at University Hospital is the only hospital that allows births to occur in water. However, according to their reported 2017 statistics on their Facebook page- only 35 people out of a total 436 vaginal deliveries were in water, or about 8%. If you take just their successful natural deliveries, then 35 out of 187 natural vaginal births occurred in water or 18.7%. Most home birth midwifery practices have waterbirth rates in the 40-50% range! It’s surprising to realize, one must choose to birth out-of-hospital to be able to really access waterbirth.
Waterbirth is amazing to experience at home. To birth in your own space, with your own food, comforts and known birth team already facilitates birth and increases relaxation. Then add waterbirth to the dynamic and birth feels much like the natural birth photos and videos you see around the internet- peaceful and intimate! Not to say it isn’t hard work, but anything worth doing always is, isn’t it?
But how does waterbirth work, wouldn’t a baby drown? Babies already are gestating in water, the baby’s amniotic fluid. Waterbirth is the gentle process of the baby moving from one body of water (the amniotic fluid) to the next (the birth tub) and being brought up immediately after to the mother’s arms. To get technical: the fetal lungs are filled with fluid in utero. This fluid keeps the spaces within the lungs open and ready for air after delivery. The existing fluid prevents other fluid from coming into the lungs. It would take tremendous pressure to displace it. It’s not the lungs role to do the breathing in utero. It is the role of the placenta to act as the lungs in utero, receiving nutrients and oxygen and exchanging CO2 and waste. Actually, the lungs in utero have very little blood flow going to them, simply enough to develop. They make only small movements to help “practice breathe”. Babies close to delivery are exposed to increased prostaglandin levels from the placenta that slows or reduces fetal “practice” breathing. If a baby experiences stress in labor leading to low oxygen, initially their reflex is to hold their breath (apnea) and to stimulate swallowing. Newborns, like all mammals, have a mammalian diving reflex protecting them as well from taking in water from a birth tub. It lasts up to 6-8 months old. When in contact with water the epiglottis at the back of the throat automatically closes and prevents water from entering the lungs. The water is then swallowed not inhaled. This mechanism is also what allows babies to breastfeed without aspirating.
But how did we start birthing in water and is it really safe? The short answer: it is a safe option for low risk women! Waterbirth was first reported in in the early 1800’s but it became more popular in the 1980’s and 1990’s. Women found that beyond its ability to help with pain control, laboring in water provided many benefits. It reduced anxiety, lowered blood pressure, allowed for freedom of movement, aided a baby to get into a better position, and slightly shortened labor due to reduced catecholamine (stress) production. Studies have found that delivering the baby in water increases the mother’s sense of well-being, reduces need for pain medication, and decreases the chance of episiotomy, hemorrhage, severe tears and C-section. It does not increase rates of infection, NICU stays, poor Apgar scores or fetal death. (Evidencebasedbirth.com, Bovbjerg et al. 2016).
Research recommends specific guidelines and strategies to best support optimum birth outcomes in water. The biggest study on water birth was done retrospectively through the Midwives Alliance of North America Statistics Project, commonly referred to as MANA Stats (Bovbjerg et al., 2016). The study included data from 18,343 midwife-attended births in the U.S. between 2004 and 2009, with 97.6% occurring at homes and birth centers not attached to a hospital. In the sample, 6,534 people had waterbirths, 10,290 people had land births, and 1,573 people intended to have a waterbirth but left the birth tub and had a land birth. The MANA Stats study reported no difference between waterbirth and land birth groups in Apgar scores < 7 at five minutes or infection rates. There was no evidence of increased risk of newborn death from waterbirth, although the number of deaths was too small to draw firm conclusions (Bovbjerg et al. 2016). An interesting finding in the MANA stats water birth study from 2016 is that those who intended waterbirths but left the pool due to different factors had worse outcomes than land births, and those who planned to birth in water had the best outcomes. This doesn’t mean that waterbirths are safer but that there were good reasons to get out of the tub such as concerns that increased the risk factors in those intending to have waterbirths (fetal heart rate concerns, labor taking too long, wanting pain meds) vs. the lower risk straightforward labors who remained in the water. It shows that midwives know when to get people out of a tub, and have good clinical decision-making skills! (Bovbjerg et al 2016).
Some risks and recommended requirements for waterbirths have been identified in observational studies. Working with providers who carefully control the dynamics of waterbirth, frequently assist in waterbirths and are comfortable with best practices of waterbirth can mitigate most of these risks. Careful conditions must be maintained in a waterbirth. Too hot water can cause the birthing mother to be overheated and a baby’s heart rate to go up, or if a tub is not appropriately cleaned or meeting specifications rare infections may happen such as legionnaires disease. Best practices for water birth are outlined by the joint statement “ A Model Practice Template for Hydrotherapy in labor and birth” (Journal of Midwifery and Women’s Health) released in 2016. Increased umbilical cord tearing was shown in some water birth studies. This is likely due to a baby who had a cord wrapped around them and a provider who was less comfortable with the process either pulled too hard on the cord or rushed the process of getting the baby out of the water. While severe tears were reduced in waterbirths, there was an increase in minor tears (Bovbjerg et al 2016). There was no increase in infection noted in waterbirths overall regardless if the birthing person’s water was broken. Thus when guidelines are followed babies are safe.
Very rarely, babies that are in severe distress, as exhibited by poor fetal heart tones, will move beyond the initial period of holding their breath and swallowing into a gasping reflex. Birthing mothers who were not helped out of the waterbirth tub with a baby in this severe state of distress where a gasping reflex occurs can aspirate tub water and be more difficult to resuscitate. However, a meta-analysis in 2017 by Vanderlaan et al., looked at 6 combined studies that provided data on the need for resuscitation between waterbirth and land birth. The researchers did not find a difference in this outcome between groups, even after restricting to only the highest quality studies.
These studies show it is important for a care provider to be comfortable with waterbirth, through frequent interactions with the unique process. Midwives in the out-of-hospital setting are the experts in normal natural birth and simply help people birth in water more often. They have a less anxious approach to water birth, leading to a more gentle facilitation of birth in water. Home birth midwives show good judgment in assessing risk factors for waterbirth and know how to provide those birthing with the support and access to this important tool for natural birth. To learn more about home birth go to Newleafmidwifery.com or Denvermidwivescollective.com.
Bovbjerb, M. L., Cheyney, M., Everton, C. (2016). Maternal and Newborn Outcomes Following Waterbirths: The Midwives Alliance of North American Statistics Project, 2004-2009 Cohort. J Midwifery Womens Health, 61(1), 11-20.
Vanderlann, V., Hall, P.J. And Lewitt, M. (2017b). Neonatal Outcomes with Water Birth: A Systematic Review and Meta-analysis, Midwifery. Manuscript accepted, article in progress.