Giving Birth In Water – The Benefits of Waterbirth
*Reduce the Length of Labor
*Reduce the Risk of Tearing
Most people find great comfort and repose with water. Perhaps because we begin our lives surrounded in liquid in the womb, this basic familiarity stays with us throughout our lives.
Human beings are comprised primarily of water, and many special characteristics we have link us to aquatic mammals, perhaps carrying the memory of a time when the human species had an “aquatic interlude.” A three-day old fetus is 97 percent water, and at eight months the fetus is 81 percent water. By the time a human has grown to adulthood, the adult body is still 50 to 70 percent water, depending on the amount of fatty tissue.
Human beings’ natural alliance with water is best witnessed in human babies who can swim naturally and easily long before they learn to sit up or crawl. During their first year of life, babies will calmly and happily paddle underwater, gazing around with eyes wide open. When they need to breathe, they naturally paddle toward the surface of the water before taking a breath. Babies instinctively know not to breathe while their heads are still submerged underwater. They wait until they reach the surface of the water before breathing. It seems to be only later that humans lose these instincts and become more prone to drowning.
For thousands of years women have been using water to ease labour and facilitate birth. Wherever there has been even slightly warm water, there have been women bathing in it, using it ritually, and finding great comfort in it, especially in labour.
Soaking in a tub of water to ease labour sounds inviting to most women. If the water is where a woman wants to be and there are no complications, then in the water is where she will feel the most comfortable. When it is time to birth the baby, there is no reason to ask the mother to get out of the water.
When a woman in labour relaxes in a warm tub, free from gravity’s pull on her body, with sensory stimulation reduced, her body is less likely to secrete stress-related hormones. This allows her body to produce the pain inhibitors ‘endorphins’ that complement labour. Noradrenaline and catecholamines, the hormones that are released during stress, actually raise the blood pressure and can inhibit or slow labour.
Waterbirth is simple. Within the simplicity of water labour and birth lies a complexity of questions, choices, opinions, research data, women's experience and practitioner observations.
Over the past five years as more hospitals within the United States examine waterbirth and create programs to support the use of water for labour and birth, newspaper reporters latch onto the sensationalism of this simple option and publish stories of successful waterbirths in local publications. Each reporter does their best to simplify waterbirth and at the same time answer the most common questions. Each story shows a happy beaming mother, a quiet peaceful baby and a proud father, who usually successfully set up a portable birth pool. The surprise headlines like, “watery birth" or “baby's birth goes swimmingly" or “junior makes a splashy entrance," are countered with the simple stories of couples who have made this decision for themselves and are proud of it.
The first and foremost question in everyone's mind and the lead in all of these newspaper accounts is simple:
What prevents baby from breathing under water?
There are several factors that prevent a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns. The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his intercostal muscles and diaphragm in a regular and rhythmic pattern from about 10 weeks gestation on. The lung fluids that are present are produced in the lungs and similar chemically to gastric fluids. These fluids come out into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero. 24-48 hours before the onset of spontaneous labour the fetus experiences a notable increase in the Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements (FBM). With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain. You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about forty percent of the time. When the baby is born and the Prostaglandin level is still high, the baby's muscles for breathing simply don't work, thus engaging the first inhibitory response.
A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping. If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs. If the baby were in trouble during the labour, there would be wide variabilities noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby's birth.
Another factor which is thought by many to inhibit the newborn from initiating the breathing response while in water, is the temperature differential. The temperature of the water is so close to that of the maternal temperature that it prevents any detection of change within the newborn. This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature and yet the babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed.
One more factor that most people do not consider, but is vital to the whole waterbirth and aspiration issue, is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.
The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled. God built this autonomic reflex into all newborns to assist with breastfeeding and it is present until about the age of six to eight months when it mysteriously disappears. The newborn is very intelligent and can detect what substance is in its throat. It can differentiate between amniotic fluid, water, cow's milk or human milk. The human infant will swallow and breathe differently when feeding on cow's milk or breast milk due to the Dive Reflex.
All of these factors combine to prevent a newborn who is born into water from taking a breath until he is lifted up into the air.
So, what does happen to initiate the breath in the newborn? As soon as the newborn senses a change in the environment from the water into the air, there is a complex chain of chemical, hormonal and physical responses, all resulting in the baby breathing. Water born babies are slower to initiate this response due to the fact that their whole body is exposed to the air at the same time, not just the caput or head as in a dry birth. Many midwives report that water babies stay just a little bit bluer longer, but their tone and alertness are just fine. It has even been suggested that water born babies be given the first APGAR scoring at one minute thirty seconds, not at one minute, due to this adjustment.
There are several things that happen all at once for the baby. The shunts in the heart are closed; fetal circulation turns to newborn circulation; the lungs experience oxygen for the first time; and the umbilical cord is stretched causing the umbilical arteries to close down. Nursing and medical schools taught their students for years that the first breath was dependent on the pressure of the passage through the birth canal and then a reflexive opening of the compressed chest creating a vacuum. That action has no bearing on newborn breathing whatsoever. There is no vacuum created. The newborn who is born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted up out of the water and into mother's waiting arms.
All the fluids that are present in the lung alveoli are automatically pushed out into the vascular system from the pressure of pulmonary circulation, thus increasing blood volume for the newborn by 1/5th or 20%. The lymphatic system absorbs the rest of the fluids through the interstitial spaces in the lung tissue. The increase of blood volume is vital for the baby’s health. It takes about six hours for all the lung fluids to disappear.
When we look back at the analysis of the statistics of babies born in water it proves that these inhibitory factors are more than theories. A study conducted in England between 1994 and 1996, and published in 1999, reports on the outcomes of 4032 births in water. Perinatal mortality was 1.2 per 1000, but no deaths were attributed to birth in the water. Two babies were admitted to special care for possible water aspiration. From 1985 to 1999, it is estimated that there have been well over 150,000 cases of waterbirth worldwide. There are no valid reports of infant deaths due to water aspiration or inhalation. In the early days of waterbirth a baby was reported as dying from being born in the water. This particular newborn death was caused not by aspiration, but by asphyxiation due to leaving the baby under the water for more than fifteen minutes after the full body was born.
This is the reason that we bring babies up out of the water within the first few moments after birth. Some people have commented on the long time that some babies remain in the water in the film, “Water Babies: The Aquanatal Experience in Ostend” Video tape is deceiving, but so are our senses. When timed, the film sequence is only forty-seven seconds, but when viewers are asked to judge how long the sequence of immersion for the baby really is, reports range anywhere from one minute to five minutes.
Bringing a baby out of the water too quickly can be just as traumatic but it can also lead to either torn or broken cords. This has been reported by a number of midwives and doctors. If the practitioner is not looking for a torn cord the possibility of the baby needing a transfusion increases. Torn or broken cords can be avoided by bringing baby out of the water slowly and gently. Mothers who desire to pick up their own babies need to be reminded to not do it too quickly, either.
The Many Benefits
Deep immersion seems to be a key factor. If the pool or bath is not deep enough, at least proving water up to breast level and completely covering the belly, then the benefits of the bath may be less noticeable. The warm water will still provide comfort and the mother will benefit from being upright, in control and drug free, but full immersion adds more physiological responses. The most notable being a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin. Vasopressin can also work to increase the levels of oxytocin. Most women feel inherently safe in the water.
The water creates a wonderful barrier to the outside world. It becomes her nest, her cave, her own “womb with a view” If the pool is large enough to include her partner or husband, it then becomes an intimate place for the two of them to labour together and experience the love dance of birth. If the midwife or physician wants to do a vaginal examination while the mother is in the water, it is much easier for the mother to refuse. Her mobility allows her to move quickly to the other side of the pool. Vaginal exams can be easily done in the water, but for Universal Precautions to be maintained, long shoulder-length gloves need to be worn.
The control that women gain by being able to move freely in the water often aids them in assessing their own progress either through feeling the movements of the baby more intensively or actually being able to examine themselves internally. Women report that the water intensifies the connection with the baby at the same time that it reduces the pain. They can feel the baby move, descend and push through the birth canal. The prospect of the midwife becoming an active observer increases as mothers assume more and more responsibility for the birth and have the ease of mobility in the water. For many reasons, including reducing the risk of infection for the provider, many midwives suggest a hands-off birth for the mother. The water slows the crowning and offers its own perineal support. This 'minimal-touch' approach also gives the mother a greater sense of controlling her own birth.
Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but about the same frequency of tears for primips in or out of the water in some of the literature. One of the best benefits of waterbirth is the zero episiotomy rate that is reported throughout the literature. Rosenthal mentions that episiotomies can be done, but no one else offers this suggestion. The combination of being upright, having the mother in a good physiological position to birth her baby, giving her the freedom of control and not telling her to push when her body is not indicating it, all contribute to better perineal outcomes.
Protocols differ from place to place, but as more experience with waterbirth emerges, we find that some previous reasons for asking a woman to leave the bath prior to birth are no longer hard and fast:
Meconium used to mean that the mother would have to leave the pool to birth her baby on the bed to facilitate immediate suctioning. This requirement has relaxed a bit as it has been seen that meconium washes off the face of the baby and even comes out of the nose and mouth while the baby is still under the water. Evidence also shows that suctioning does not improve outcomes.
Tight nuchal cords were a reason to ask mother to stand for the birth so that the practitioner could cut the cord and then deliver that baby. Now, the universal practice is to not even feel for a cord in a waterbirth, unless there has been a very slow second stage and you are afraid of cord compression. No attempt is made to clamp and cut the cord. The body is birthed and then the cord it unwrapped. It is amazing to watch a baby somersault and unwrap begin to unwrap their own cord in the expanse of the birth pool.
Breech position was definitely a reason for a more controlled birth or even an automatic cesarean section. But there are practitioners throughout the world who recognize that there is increased safety for the baby if it is born in water. The most experienced doctor that we know of is Hermann Ponette, an obstetrician who practices at H. Surreys Hospital in Ostend, Belgium. He has attended well over 2000 waterbirths including breeches and twins. He uses a frank breech position as an indication for a waterbirth. There are other reports of a few hospitals in the US attending breech waterbirths and approximately 50 reported breech births in water at home.
Once a woman has experienced a waterbirth she will more than likely want to repeat the experience. To that that end, Waterbirth International gets some pretty interesting referral requests from women all over the world. If circumstances have changed and the mother is no longer living in a place where waterbirth facilities or practitioners are readily available, she will go to almost any length to recreate the opportunity to give birth in water. A research project that Waterbirth International has been conducting for ten years is a survey of women who have given birth in water. On the survey form is a questions that states, “Would you consider giving birth again in water?" With over 1500 surveys collected, there has only been one woman that answered no to that question. On her particular survey she emphatically stated NO in bold print with two exclamation points and then drew an arrow down to the bottom of the page where in very small print she wrote, “this is number seven, I'm done!"
It is hard to think of another ‘method’ of childbirth that receives such praise from women and practitioners alike. Dr. Lisa Stolper is an obstetrician practicing in the quaint New England town of Keene, New Hampshire. She began offering waterbirth to her clients at Cheshire Medical Center in October of 1998. One year later she reported an overall waterbirth rate of 37% for all vaginal births and 33% for all births, including cesarean sections. Her hospital has purchased just one portable jetted birth pool but they use it to labour almost 50% of their clients. They are now considering installing permanent pools to make it available for more women. Her comment about her job as an obstetrician was, “Waterbirth just makes my job so much easier."
One of the final questions that newspaper reporters pose and birthing couples ask is:
How is the baby monitored during a water birth?
With the widespread use of electronic fetal monitoring during labour, one of the concerns is how do you achieve accurate monitoring of the fetal heart rates while the mother is immersed in water.
One of the first companies to recognize the value of creating waterproof monitoring equipment was Huntleigh Healthcare from the UK. That technology has been in place for more than a decade and has improved during that time period. All of the manufacturers of monitors now produce equipment which is waterproof, including hand-held dopplers, monitor leads, and telemetry units.
Waterbirth International has been providing waterproof dopplers for providers and hospitals since 1996. There is a standard set by the American College of Obstetricians and Gynecologists for intermittent auscultation of fetal heart tones. Providers and birth centers which follow this guideline, listen to the baby every 30 minutes in early labour and every 10 minutes during the pushing phase, some listening after every pushing effort. This is easily achieved with a hand-held dopplers.
Information in this article was provided by waterbirth.org. You can visit their website for more information at http//:www.waterbirth.org