Laboring and/or Birthing in Water

Posted in Homebirth

Waterbirth is considered by many researchers, birthworkers, and parents to be a gentle and safe method of childbirth. Despite this, there has been a storm of conflicting information in the media and from professional organizations recently. The American College of Obstetricians and Gynecologists (ACOG) as well as the American Academy of Pediatrics (AAP) released a joint committee opinion in November 2016 about waterbirth that states, ” . . . the safety and efficacy of immersion in water during the second stage of labor [during pushing and birth] have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. Given these facts and case reports of rare but serious adverse effects in the newborn, the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent.”

It is my belief, however, that this document does not accurately reflect the large and growing body of research that supports waterbirth as a reasonable choice for healthy people experiencing normal labor. The ACOG/AAP opinion statement cautions about immersion in water during the second stage of labor. This caution is similar to those in their prior publications, including warnings about a lack of data on the safety and benefits of waterbirth. The joint committee opinion refers to case studies of adverse outcomes, but case studies are not a reliable form of research and should not be the foundation for their conclusion (that waterbirths only be considered as part of “experimental” clinical trials.)

Despite limitations, the best available research indicates that waterbirth is associated with perinatal outcomes similar to those expected in a low-risk population. In other words, healthy birthing parents and their babies generally stay healthy during and after normal labor and waterbirth. Therefore, waterbirth is a reasonable choice for healthy people to make in collaboration with their care providers, given the state of the science.

I agree with the committee opinion’s conclusion that more research about waterbirth is needed, particularly in the U.S., but international studies already support water immersion during childbirth as a safe option. I welcome the ACOG/AAP call for higher quality research regarding the use, safety, and benefit of obstetric interventions, however, the implicit assumption that most obstetric interventions in the U.S. are evidence-based must be examined.  Many routine obstetric interventions have not been subjected to large randomized clinical trials, while others are commonly used or overused despite evidence they are ineffective or harmful (e.g., continuous electronic fetal monitoring in low-risk labors.) In order to ensure access to evidence-based choices in childbirth, evaluation criteria should be applied uniformly to all interventions, rather than selectively to midwife-led care practices such as waterbirth.

Below are FAQs that parents typically ask about laboring and/or birthing in water:

WHY SHOULD I LABOR OR GIVE BIRTH IN WATER?

In a safe and comfortable environment with privacy, support, and reassurance, laboring people are able to release their babies gently and powerfully, an experience shared by the baby. The use of warm water for labor and birth is one way of providing this environment. Some of the benefits of being immersed in warm water during labor and birth include:

  • decreased perception of pain with resulting lower levels of stress hormones (catecholamines)
  • feelings of weightlessness and deeper abdominal muscle relaxation leading to more effective contractions and quicker cervical dilation
  • greater enjoyment of labor process due to complete freedom of movement and deep concentration
  • facilitation of mobility so laboring person can assume any position which is comfortable, greater ease of movement allows the laboring person to get into deep squats and hands and knees positions that open the pelvis and help with fetal descent

WHAT TEMPERATURE SHOULD THE WATER BE?

The water in the tub is usually maintained at a temperature between 95-100oF (35-37.7oC.) The water temperature should not exceed 101oF as this may lead to over heating and resulting fetal heart rate acceleration. It is important for laboring people to continue drinking plenty of fluids. Cold compresses or cool facial mists are welcome comfort measures.

WHEN IS THE BEST TIME TO GET INTO THE TUB?

Laboring people can be encouraged to immerse themselves in a birth tub anytime after active labor begins. If they were to get into the water during early labor, before contractions are strong and close together, the water may be too relaxing and may lead to labor slowing or stopping altogether. This is why many care providers recommend that use of the tub be delayed until labor patterns are well established and dilation of the cervix is at least 5-6 centimeters. The first hour of relaxation in a birth tub is usually the best and can often help laboring people achieve complete dilation in a short amount of time.

WHAT PREVENTS BABIES FROM TAKING A BREATH UNDERWATER?

There are several factors that inhibit babies from beginning to breathe until after they are pulled up out of the water.

  • The water temperature is basically the same as the amniotic fluid in the uterus, so there is no shock of a temperature change.
  • Babies continue to receive oxygen from the umbilical cord until after the cord stops pulsing, so there is no chemical change in oxygen levels prompting inhalation.
  • Newborns have an autonomic reflex, called the dive reflex, which prevents them from inhaling any substance that is in their throat and causes them to swallow instead. This reflex is present for approximately six months after birth and than it disappears.
  • Air breathing begins only after babies are pulled out of the water and exposed to changes in temperature and air pressure. These changes lead to a complex metabolic chain reaction of hormones and chemicals that cause breathing to begin.

HOW LONG DO BABIES SPEND UNDERWATER?

In the U.S., care providers bring babies out of  the water within the first ten seconds following birth. There are several water birth DVDs from other countries that depict leaving babies under the water for longer periods of time, and these babies seem to do just fine. From a physiological perspective, however, there is no reason to leave babies under the water for any length of time after birth. The safest approach is for the laboring person (with assistance, if needed) to bring the baby up through the water immediately after birth onto their chest. The baby’s head, neck, and shoulders should be above the water level, with the chest and lower body remaining in the water for warmth.

HOW ARE BABIES MONITORED DURING WATERBIRTH?

The manufacturers of monitoring equipment and handheld dopplers have developed waterproof models. In typical waterbirths, babies’ heart tones are auscultated every 30 minutes during first stage and every 10-15 minutes during second stage.

More information about waterbirth:

Waterbirth International
Benefits of giving birth in water
Waterbirth video clips
Michel Odent, MD: The Science of Waterbirth
Waterbirth at home

Click here to find local sources for birth tub rental!