Waterbirth; thoughts from a care provider, as the client

The practice of waterbirth has always been, to me, the equivalent of a mother choosing which position she desired to labor in. I had not realized until I became a student midwife that not only was there additional benefits to choosing it, but that there is also some opposition against it. Naturally, as a student, I was intrigued to learn what the known benefits and risks are, and why is there opposition against choosing waterbirth.

I started my research by reading the American congress of obstetricians and gynecologists (ACOG) committee opinion on what they referred to as “Immersion in Water During Labor and Delivery” aka waterbirth. Of course, I read it with my water birth experience in mind, so I was finding it very interesting that the complications ACOG was referring to occurring more during waterbirths, I had yet to experience. Although their evidence was very slim, they explained their findings in a way that suggested care providers avoid waterbirth. Still, even ACOG had to admit that “There are insufficient data on which to draw conclusions regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery.” Still they continue with “Therefore, until such data are available, it is the recommendation… that birth occur on land, not in water.” So, their stance is, we cannot prove it is unsafe, but let’s not do it anyways since we didn’t see great benefits in our hospital trials.

The unfortunate part, to me, about ACOG’s statement was that it would turn care providers away from offering waterbirth, and women away from choosing it. Speaking from personal experience as a doula, I had so many clients go on hospital tours in which they would be shown the bath tub and told that the hospital offered waterbirth, yet time and time again when it would come down to it, clients would have to beg the nurses to allow them into the tub, where if they were allowed, it was only for a limited amount of time and they were always told that birthing in the tub was not allowed. So, I know that even though clinical trials were done in hospitals to determine the risks and benefits of waterbirth, the hospital setting also carries a very different mindset on waterbirth which makes it difficult to accept, and therefore the care during waterbirths is different as well.

A prime example of the care affecting the outcome is how ACOG referred to an increased chance of Umbilical cord avulsion (cord “snapping” or cord rupture) as the newborn is lifted or maneuvered out of the water. I see this as an increased chance in the hospital trials because the care providers are so focused on bringing the neonate out of the water quickly following the birth, that they do not take into full consideration the possibility of a short cord. I know this feeling myself, because as a beginning student, I too use to rush to bringing the neonate up immediately after the birth, which in most cases was fine, but sometimes if the neonate was tangled in its own cord I would struggle with bringing them up and then trying to unravel them without letting them become re-submerged. Thankfully my preceptor taught me patience with this and how to unravel the neonate from their cord while still submerged. Once I discovered this and became comfortable with the practice, I desired for more mothers to choose waterbirth and I found managing tangled cords was a breeze in comparison to delivering on land.

Although ACOG was willing to take a step forward to consider the benefits of water birth, their research provided was quickly analyzed by the American Association of Birth Centers (AABC) and Evidence Based Birth. AABC not only analyzed the ACOG trial, but also collected their own data on waterbirth in the birth center environment. AABC’s data demonstrated that “Water birth, with careful selection criteria and experienced providers, does not negatively affect mothers or newborns…. The claim that water birth is dangerous for mothers and babies is not based on prospective population data with skilled birth attendants, but on negative outcome case reports or individual case outcomes reported in a large surveillance study from another country.” Furthermore, Evidence Based Birth went on to prove that ACOG’s evidence was not very accurate “The literature review in the opinion statement was outdated and did not reflect current evidence. Out of 29 references, only six were from the past nine years (2005 or later).” (Evidence Based Birth)

With all the research taken into consideration and including my own experience, I fully plan on keeping waterbirth as part of my practice and I will continue to consider it safe for low risk mom’s and babies. Still, I do believe that having a protocol in place is best to decrease the chances of unnecessary interventions and emergencies. So, I have created my own protocols based on experience.

Non-reassuring fetal heart tones:

When there are non-reassuring fetal heart tones present, I do not allow for clients to be in the water, I will admit, it does come with a slight “catch 22” as the non-reassuring fetal heart tones are often caused by cord compression, and I prefer to untangle cords in the water. The reason for this is if I have any indications that this neonate may require some assistance or resuscitation, I need to have an area is which I can properly asses the neonate and administer assistance while having them lay on a flat surface and still be attached via umbilical cord, I cannot accomplish this with most waterbirths. My only choices with a waterbirth are to place the neonate on the mother’s chest (if she was even in a position in which I could do so) which is not a stable or flat surface, or my only other option it too clamp and cut the cord immediately, which is also not often what is best for the baby. So, in any case that I have non-reassuring fetal heart tones and birth is too imminent for the mother to be transferred, I will have the client out of the water immediately as 911 is being called.

A mother in labor-land

Some women go into “labor-land” when they are close to delivering, this means that they are so focused on their present sensations that they are unable to listen to given instructions. If I have a mother who is experiencing this, it is reason for immediate removal from the water for many reasons. If a mother cannot listen to my instructions she may very well move away from me easily in the water and get into a position in which I am unable to assess the fetus properly, and furthermore, I may not be able to get her out of the water for non-reassuring fetal heart tones, or have her cooperate with my instructions in the case of any other situations i.e. shoulder dystocia. Overall, a mother in “labor-land” is often unable to determine what is safest for her and baby, therefore a mother is “labor-land” in my experience, is best to birth on land.

If the mother passes loose-stool in the water

Easy enough for most to understand, stool is full of bacteria that is not safe for a baby to be born into, therefore it contaminates the water. It is common for a mother to pass solid-stool during delivery, and in these cases the stool can be quickly “scooped-up” and disposed of so that contamination in minimal, but in the case of loose-stool that cannot be scooped-up, it is best for mother to be removed for herself and the baby.

Mom’s with a history of/or at risk for PPH

If a mother is at risk for having a postpartum hemorrhage, I will have a few concerns. If a mother is hemorrhaging the water color changes very quickly and does not allow for visualization of what is occurring underneath the water. To manage the situation, I need to be able to see what is going on, and apply the appropriate medications to control the bleeding, which some medications are administer in areas that are often below the water level. In addition, a hemorrhaging mother will become weak quickly and therefore may not be able to stand and would need to be carried out of the water for the bleeding to be managed, which depending on the size of the mother and the number of persons available to assist, this may be very difficult to accomplish.

Mom’s with history of/or are at risk for shoulder dystocia

Similar to the concerns already listed, shoulder dystocia can be managed in the water, but is often managed with much more control on land. As well, a neonate that experiences shoulder dystocia is at an increased risk for requiring assistance or resuscitation and the mother is at an increased risk of experiencing a hemorrhage.

In conclusion, waterbirth has many benefits, yet also carries some risks as all options do. So it may not be the best choice for every birth, but it is often a good choice that, I believe, should be an option for many.