Waterbirth
written by Amanda Breed, CNM

Many women are interested in using water for both labor and birth. Submerging in water is a natural drug-free pain relief method. It can help a woman relax, allowing her cervix to dilate faster. Babies born underwater have a gentle transition from the warm, dark, wet intrauterine environment to the bright, cold, dry air. Water birth is a gentle birth.

A London study of 189 women who gave birth in water found that waterbirth is a “consumer-led trend, mainly pursued by educated middle class women” (Richmond, 2003). These women “wanted a gentle delivery for the baby and thought waterbirth seemed the right medium for this. They felt more in control of their environment in water, and particularly liked the relaxing calming quality of the water, the physical support it gave them and being able to hold their babies immediately after birth”. Waterbirth was in short, “therapeutic”.

At Mount Auburn, we are pleased to offer the use of tubs in five of our six labor suites. These tubs may be used for labor, but are not suitable for waterbirth. In order for a woman to safely birth in the water, she needs to be accessible by three sides. The tubs we have are only accessible from one side. That is why we have an “aquadoula”- basically a big portable pool that we set up in the middle of the room for birthing in water. The aquadoula can only be set up in one of our rooms that has a special hose hook-up to fill the tub.

A woman may birth in water if she has completed at least 36 weeks gestation, the fetal heart rate pattern is reassuring, and the amniotic fluid is clear (not meconium stained). A woman with an epidural, other IV medication or pitocin may not give birth in the water, although pitocin alone does not preclude the possibility of laboring in the tub.

A woman may labor in water as long as her fetal heart rate tracing is reassuring. We can provide intermittent fetal heart rate monitoring in the tub, where we listen to the baby’s heart rate every 15-30 minutes. If continuous fetal monitoring is indicated, we have waterproof wireless electronic fetal monitors that can be used in the tub, however they occasionally need to be charged and don’t work as well under water.

If you are interested in having a waterbirth, we ask that you to be screened for HIV and hepatitis at 36 weeks of pregnancy to protect your birthing providers’ health.

Research has shown a woman laboring in water is less likely to use pain medicine. A large study showed 70% of women who birth in water do not use pain medicine, compared to 58% of women who birth on land (Geissbuehler et al, 2004).

A woman who births in water is less likely to have an episiotomy and will lose less blood as compared to a land birth (Geissbuehler et al, 2004).

Studies have conflicting findings about the effect of waterbirth on lacerations/tearing. Geissbuehler et al found waterbirth had small numbers of severe tearing (third and fourth degree lacerations), whereas Cortes et al found the rate of third degree lacerations doubled with waterbirth. While being in water results in a shorter second stage (pushing phase) of labor, it may or may not lead to less overall perineal trauma.

A review of 12 trials (3243 women) demonstrated that water labor significantly lowered the rate of pain medicine, and shortened the dilation phase (first stage) of labor by an average of 32 minutes. There was no difference in the use of vacuum or forcep assisted births, cesarean sections, use of pitocin, perineal trauma or maternal infection. Also there were no differences in the baby’s five minute apgar score, NICU admissions or neonatal infection rates. These authors comment there is still more research needed before making “robust conclusions”. (Cluett & Burns, 2009).

If a woman has GBS (group beta strep), can she have a waterbirth?

GBS is a common bacteria that lives in our intestines, and sometimes is present in a woman’s vagina. It doesn’t usually cause problems for adults, but can pose a threat to newborns since they have immature immune systems. We screen pregnant women between 35-37 weeks of pregnancy to see if this bacteria is present. Once the bag of waters is broken, we delay the first cervical check as long as possible, and limit the number of cervical checks to reduce the chance of infection. This is especially true when a woman is GBS positive. One may wonder, does being in the water increase the chance of the baby getting a GBS infection? The answer is no. A study showed one out of 4432 waterbirths resulted in a baby with GBS infection, as compared to one in 1450 dry births. These results suggest women “who give birth in water may have a far lower rate of newborn GBS than women who have a dry birth” (Cohain, 2011). While this is only one study, we do feel confident that a GBS positive mother may safely labor and deliver her baby in water.

Women who choose waterbirth may be at lower risk for severe perineal trauma, having baby with low apgars and significant blood loss in general, regardless of whether they birth in water or land. It is difficult to separate if the better outcomes are attributable to the water, or to the women who choose the water.

Nearly all women who come to the Midwives at Mount Auburn use the tubs for at least some of their labor. If you are interested in the possibility of giving birth in the water, please talk to your nurse-midwife at your next office visit.

You can also learn more at the following web sites:

1. www.waterbirth.org
The Global Maternal/Child Health Association and Waterbirth International website offers a photo gallery, birth stories, answers to frequently asked questions, a bibliography, a listing of conferences, and an online store.

2. www.thelaboroflove.com/forum/water
This is part of a couple’s story regarding their decision making process in choosing waterbirth.

3. www.sheilakitzinger.com/WaterBirth.htm
This website belongs to Sheila Kitzinger, a social anthropologist known for her work in pregnancy, birth and breastfeeding. This UK based site lists organizations focused on birth, links to other countries and information on purchasing birth books worldwide. There are also pictures of waterbirth and information on many related birth topics.

References

Cluett, E.R. & Burns, E. (2009). The Cochrane Library, Immersion in water in labour and birth. Wiley Online Library.

“Waterbirth and GBS” Cohain, J.S. Midwifery Today Int Midwife, 2010-2011: (96):9-10.

“Waterbirth and pelvic floor injury: a retrospective study and postal survey using ICIQ modular long form questionnaires” Cortes, E., Basra, R, & Kelleher, C.J. Eur J Obstet Gynecol Reprod Biol, 2011 Mar; 155(1): 27-30.

“Waterbirth: water temperature and bathing time-mother knows best!” Heissbuehler, V., Eberhard, J. & Lebrecht, A. J Perinat Med, 2002;30(5):371-8.

“Waterbirths compared with landbirths: an observational study of nine years” Geissbuehler, V., Stein, S. & Eberhard, J. J Perinat Med, 2004;32(4):308-14.

“Web Site Resources for Waterbirth” Montgomery, K.S. J Perinar Educ, 2003 Fall; 1294):47-48.

“Women’s experience of waterbirth” Richmond, H. Pract Midwife, 2003 Mar;6(3):26-31.

“A pilot study for a randomized controlled trial of waterbirth versus land birth” Woodward, J. & Kelly, S.M. BJOG, 2004 Jun;111(6):537-45.

“The decision-making experience of mothers selecting waterbirth” Wu, C.J. & Chung, U.L. J Nurs Res, 2003 Dec;11(4):261-8.