Guidelines for Water Birth 

The aim of these guidelines is to provide a review of information on labor and birth in water and to suggest possible strategies to minimize the potential hazards to mothers and infants. It can also be used to promote the maternal and infant benefits, which may arise from choosing this type of birth experience, but are not easily quantifiable. It is written with the belief that clinically sound, evidence-based guidelines improve quality of care. These recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual client’s needs, resources and limitations unique to the place of birth and variations in client choices.

Rationale
The therapeutic properties of warm water immersion have been known for centuries. Baths and showers have been used for comfort during labor for many years. Over the past two decades the use of warm water immersion for the birth of the baby has aroused interest in many countries and an increase in the number of women requesting this option for both hospital and out-of-hospital births is occurring.

Evidence
Maternal and neonatal outcomes after water immersion for labor and birth have been assessed in two large surveys over a four year period in England and Wales (Alderdice, Renfrew & Marchant, 1995; Gilbert & Tookey, 1999) Researchers reviewed 4693 and 4032 births, respectively, where water immersion was used and found no difference in outcomes for women and their newborns compared to a cohort group of low risk women who did not use water.

The perinatal mortality rate for these births was comparable to other low risk births in the UK. (Gilbert and Tookey 1999).

This study tried to estimate mortality and morbidity rates for babies delivered in water. The data collected was compared to other sources of data providing similar
estimates for babies delivered conventionally to low-risk women. They examined adverse outcomes, which were reported over a two-year period between 1994 and 1996 from approximately 4,000 births in water. 1500 consultant pediatricians were surveyed and asked to report any cases of baby deaths associated with water birth. None of the five perinatal deaths recorded among the water births was attributable to delivery in water. Admissions to special care baby units were slightly lower for the water-born babies than admissions for other low-risk babies. This was a landmark study in providing significant reassurance about the safety of water birth.

Other researchers (Burns 2001; Lenstrup et al, 1987; Rush et al,1996; & Waldenstrom et al, 1992) have made similar outcome reports. A Canadian randomized control trial reported women experienced less pain after water immersion than their non-immersion counterparts and over 80% of the water immersion group said they would use the tub in subsequent labors (Rush et al, 1996).

In the absence of a substantial body of evidence on the use of warm water immersion for labor and birth, the potential advantages and disadvantages, which follow, are primarily derived from experience.

Eligibility
Water immersion for labor and birth should be available to all clients who request it, who have been screened and who have discussed the risks and benefits with their care provider. Some practices may choose to use a standard informed consent form for the use of warm water immersion.

Water Immersion Defined
Water immersion must be defined at providing a depth of water which enables the mother to sit in water that covers her belly completely and comes up to her breast level or kneel in water on her haunches which comes up to just below her breast level. Any amount of water less than this does not constitute true immersion and will not create the buoyancy effect and produce the chemical and hormonal changes which enhance a more rapid labor. After an initial immersion of approximately thirty minutes the body responds by releasing more oxytocin, but only if the body experiences deep immersion, leading to buoyancy.

When to enter the bath in labor
It has been reported in the literature that labor slows down or stops if the woman enters the bath too soon. Guidelines were established to prevent a woman from entering the bath before the start of active labor, by definition: established labor pattern, dilation of the cervix to 4 cm or greater and the need to concentrate during the contraction. Many hospitals use the 5-centimeter rule – only allowing mothers to enter the bath when they are in active labor and dilated to more than 5 cms. There is some physiological data that supports this rule, but each and every situation must be evaluated and then judged. Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started. The water sometimes has the effect of slowing or stopping labor if used too early. On the other hand, if contractions are strong and regular with either a small amount of dilation or none at all a bath might be in order to help the mother to relax enough to facilitate the dilation. It has been suggested that the bath be used in a “trial of water” for at least one hour and allow the mother to judge its effectiveness. Women report that often the contractions seem to space out or become less effective if they enter the bath too soon, thus requiring them to leave the bath. Then again, midwives report that some women can go from 1cm to complete dilation within the first hour or two of immersion.

The chemical and hormonal effects of immersion take effect after no less than twenty minutes and peak around ninety minutes. It is therefore suggested that a change of environment, such as getting out and walking be recommended after about two hours of initial immersion. The midwife can make an evaluation of the mother’s condition at that time. Getting back in the water after thirty minutes will reactivate the chemical and hormonal process, including a sudden and often marked increase in oxytocin. Usually the mother is no longer than 2.5 hours in the water.

Dianne Garland, registered midwife, lead water birth researcher in England and the author of, “Water birth: An Attitude to Care,” says the following:

” Just as labors can be slower or stop out of water, so is true of water. Changes to the woman’s body are normal in labor and each of us will tolerate different lengths of first and second stage. Just as we all deal with different amounts of fatigue and stress, so each woman is individual and should be treated as such in labor. The point of this with water labor and water birth is that as each woman is an individual, so her labor should be cared for, within the normal parameters set by ourselves as autonomous practitioners. Or within the maternity units where we work. Fundamental changes to normal practice may need to be made in units where active management of labor prevails.”
How long is baby in the water after the birth?
Practitioners usually bring the baby out of the water within the first ten seconds after birth. There is no physiological reason to leave the baby under the water for any length of time. There are several water birth videos that depict leaving the baby under the water for several moments after birth and the babies are just fine.

Physiologically, the placenta is supporting the baby with oxygen during this time though it can never be predicted when the placenta will begin to separate causing the flow of oxygen to baby to stop. The umbilical cord pulsating is not a guarantee that the baby is receiving enough oxygen. The safe approach is to remove the baby, without hurrying, and gently place him into his mother’s arms.
What prevents baby from breathing under water?
There are four main factors that prevent the baby from inhaling water at the time of birth:

  1. Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements. 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.
  2. Babies are born experiencing mild hypoxia or lack of oxygen. Hypoxia causes apnea and swallowing, not breathing or gasping.
  3. 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.
  4. 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 interpret what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled.

Summary of benefits for labor and birth in water

  • Facilitates mobility and enables the mother to assume any position which is comfortable for labor and pushing
  • Speeds up labor
  • Reduces blood pressure
  • Gives mother more feelings of control
  • Provides significant pain relief
  • Promotes relaxation
  • Conserves her energy
  • Reduces the need for drugs and interventions
  • Protects the mother from interventions by giving her a protected private space
  • Reduces perineal tearing
  • Reduces cesarean section rates
  • Is highly rated by mothers – typically stating they would consider giving birth in water again
  • Is highly rated by midwives
  • Encourages an easier birth for mother and a gentler welcome for baby

Theoretical Potential Disadvantages

  • Decrease in uterine contraction strength and frequency, especially if entering the bath too soon
  • Neonatal water aspiration
  • Maternal hyperthermia may contribute to fetal hypoxemia
  • Neonatal hypothermia
  • Cord immersion in warm water may delay vasoconstriction, increasing red cell transfusion to the newborn and promoting jaundice
  • Blood loss estimation and assessment not accurate
  • Maternal and Neonatal infection may be increased – not supported by the evidence
  • Risk of acquiring blood-borne infection or sustaining back injury for caregivers

Recommended Criteria for the use of a water pool

  • An uncomplicated pregnancy of at least 37 weeks gestation
  • Established labor pattern – good regular contractions
  • Reassuring fetal heart tones
  • Absence of bleeding greater than bloody show
  • Spontaneous or on-going labor after misoprostol or Pitocin

Contraindications for birth in a water pool
There are no contraindications to labor in water, as evaluated by the literature and from experience.
Immersion is a client/provider decision. Birth in water comes with a few “ABSOLUTE”
contraindications and a few “CONTROVERSIAL” contraindications.

Absolute contraindications

  • Pre-term labor
  • Excessive vaginal bleeding
  • Maternal fever> 100.4, or suspected maternal infection
  • Any condition which requires continuous fetal heart rate monitoring
  • Untreated blood or skin infection
  • Sedation or epidural
  • Fearful Attendant
  • Inflexibility in the client

Controversial contraindications

  • Meconium staining in amniotic fluid
  • The presence of meconium should be evaluated with fetal well-being and taken by itself as a reason to ask the mother to leave the water. Meconium washes off the baby in the water. Baby can be suctioned as soon as it has been brought to the surface of the water. Some practices are now only limiting thick meconium cases.
  • HIV, Hepatitis A, B, C, GBS
  • Evidence shows that HIV virus is susceptible to the warm water and cannot live in that environment. Proper cleaning of all equipment after the birth needs to be carried out. Hepatitis should be the discretion of the attending medical caregiver. There is absolutely no evidence that GBS positive cases should be asked to leave the water. Most hospitals allow IV antibiotic administration while in the water.
  • Herpes
  • Some providers will cover the lesion, especially if it has peaked and is sloughing off. Others will require a cesarean. Some feel it is safer to deliver in the water due to the dilution effect of the water.
  • Breech or multiple births
  • In the H. Surreys Hospital in Ostend, Belgium, frank breech is an indication for a water birth. Their vast experience has led them to believe that the absence of gravity, the warm water and the buoyancy create the perfect environment for a hands free breech birth. Labor in water for both breech and multiples is well documented and recommended. This should be a client/provider decision.
  • Induction or augmentation
  • Many hospital practices will now allow mothers whose labors are initiated by Misoprostal or Pitocin to get in the pool as soon as a labor pattern is established. Some even allow mothers with a Pitocin drip to labor in water, as long as fetal heart rate assessment can be monitored with continuous underwater equipment.
  • Intrathecal use
  • A few hospitals will allow a mother into the water after receiving an intrathecal Monitoring of the baby is suggested as continuous, but some hospitals allow intermittent monitoring.
  • VBAC
  • As the controversy over vaginal birth after previous cesarean section continues, it has been noted that mothers who labor for subsequent births have a much higher success rate in giving birth vaginally. Some hospitals refuse to allow women into the water because they don’t provide waterproof continuous fetal monitoring.
  • Shoulder Dystocia or Macrosomia with suspicion of Shoulder Dystocia
  • This is usually considered an obstetric or midwifery emergency by most. Current protocols in most hospitals require the mother who is anticipating a large baby to leave the water. There is mounting evidence that providers find it is easier to assist a shoulder dystocia in the water. It is believed that tight shoulders happen more often because of mom or caregiver trying to push before the baby fully rotates. Better to wait a few contractions, with the head hanging in the water and allow baby to rotate. Because position changes in water are so much easier than dry land, a quick switch to hands and knees or even standing up with one foot on the edge of the pool helps to maneuver baby out. (research indicates that you can’t predict shoulder dystocia).
  • Tight nucal cord
  • Under no circumstances should the cord be clamped or cut under the water. Babies can be delivered through the cord and ‘unwound’ under the water. Be cautious of cord snapping.
  • Water temperature at time of birth
  • Some providers will not allow women to birth in water that is lower than body temperature due to the possibility that the baby will attempt to inhale under the water from a change in temperature. There is no evidence that supports this theory, in fact there is more evidence that now shows that lower water temperatures increase the baby’s muscular activity and awareness. Water babies are slow to start breathing due to the delay in stimulation of the trigeminal nerve receptors in the face and around the nose and mouth. You must consider the birth of the baby from the time it leaves the water, not from the delivery of the baby into the water. German midwife, Cornelia Enning, states that babies are more vigorous at a temperature around 92-95 degrees Fahrenheit. If the mother is comfortable in the water, the temperature is OK for baby with only one restrictive parameter – NEVER higher than 100 degrees Fahrenheit.
  • Placental delivery in water
  • There is no reason not to allow the birth of the placenta in water. Objections include inability to judge blood loss, possible water embolism and inability to contain all the by-products of conception in one place. Evidence now shows that delivery of the placenta is safe, blood loss can be estimated by color evaluation and determination of where the bleeding is arising and there is absolutely no scientific basis for worry over water embolism. Placenta and pieces can be placed in a floating bowl in the water without difficulty. Cutting and clamping of the cord is not recommended with the delivery of the placenta in the water.

Helpful reminders for the use of water immersion for labor and birth

  • Midwives should discuss the potential advantages and disadvantages of water immersion for labor and birth with each woman prior to labor.
  • The fetal heart should be monitored according to accepted guidelines. Use of a waterproof Doppler is recommended.
  • The woman should be encouraged to maintain adequate hydration and leave the pool to urinate at regular intervals.
  • The woman should be asked to leave the water if there are any concerns about her or her baby’s well-being.
  • The water should be kept as clean as possible. Stool and blood clots should be removed from the pool immediately. The pool should be drained, cleaned and refilled if contaminants cannot be easily removed.
  • A small amount of blood often looks like a lot. Undisturbed blood in a pool often congeals at the bottom of the pool into a small clot.
  • The pool or tub should be deep enough for the mother to assume any position comfortably.
  • Encourage mother to help guide her own baby out.
  • Suturing may need to be delayed due to water saturation of tissues.
  • The baby should be born completely underwater with no air contact until the head is brought to the surface, as air and temperature change may stimulate breathing and lead to water aspiration. If a change in position during delivery causes the baby to come in contact with air, the birth should be finished in the air.
  • Care should be taken to avoid undue traction on the cord. There have been reports of cord tearing.
  • The warm water helps maintain the newborn’s temperature to prevent hypothermia. Keep baby submerged with head out only for best heat conservation. Next to mother is best.
  • Encourage breast contact immediately, but breastfeeding is not always possible in the water, especially due to water high water levels.
  • You can insert a footstool or other object (husband) to raise a mother up high enough after the birth.
  • Birth pools should be cleaned completely between uses. Follow the cleaning guidelines for your specific pool.

As when caring for any mother or newborn, the midwife is responsible for using her clinical judgment, responding appropriately to problems that may arise, and for documenting her actions.

References

References

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Balaskas, J (2004) The Water Birth Book. London: Thorsons.

Beake, S. (1999) Water birth: a literature review. MIDIRS Midwifery Digest Vol 9 pp 473-477.

Burns, E. (2001) Water birth, MIDIRS Midwifery Digest, Supplement 2, S10 – S13.

Burns, E & Kitzinger, S (2000) Midwifery Guidelines for Use of Water in Labor, Oxford Brookes University: Oxford.

Eckert, K; Turnbull, D; MacLennan, A. (2001) Immersion in water in the first stage of labor; A randomized controlled trial. Birth, 28 (2) p 84-93.

Enkin, Keirse, Neilson, Crowther, Duley, Hodnett and Hofmeyr (Eds) (2000) Control of Pain in Labour, in A Guide to Effective Care in Pregnancy and Childbirth Third Edition, Oxford University Press: Oxford.

Enning, C. (2003). Water birth Midwifery: A training book. Hippokrates, Stuttgart, Germany.

Eriksson, M. Mattsson, L. Ladfors, L (1997 Sept) Early or late bath during the first stage of labour: a randomized study of 200 women. Midwifery, vol. 13 No 3 pp. 146-148.

Garland, D., Jones, K. (June, 1997). Water birth: updaing the evidence. British Journal of Midwifery Vol 5. No 6,368-373.

Garland, D. (Dec. 2002). Collaborative Water birth audit – “Supporting Practice with audit” MIDIRS Midwifery Digest, Vol 12, No 4, Dec 2002, pp 508-511.

Garland, D., Crook, S. (March 2004) Is the use of water in labour an option for women following a previous LSCS. MIDIRS Midwifery Digest Vol 14, No 1 pp 63-67.

Geissbuehler, V., Eberhard, J., (2000) Water births: A comparative study, a prospective study on more than 2000 water births. Fetal Diagnosis and Therapy Sept-Oct; 15(5):291-300.

Geissbuehler, V., Eberhard, J., Lebrecht, A., (2002) Water birth: Water temperature and bathing time – mother knows best! Journal of Perinatal Medicine 30(2002) 371-378.

Gilbert RE & Tookey PA (1999) Perinatal mortality and morbidity among babies delivered in water: Surveillance study and postal survey. British Medical Journal, 319(7208) p483-487.

Harper, B (Summer 2000) Water birth Basics: from newborn breathing to hospital protocols. Midwifery Today, 54: 9-15, 68.
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Johnson, Paul. (1996). Birth under water-—to breathe or not to breathe. British Journal of Obstetrics and Gynaecology, 103: 202-208.

Lenstrup, C., Schantz, A., Berget, A., Feder, A., Roseno, H. (1987) Warm tub bath during delivery. Acta Obstetrical Gynecology Scandinavia, 66, 709-12.

Mackey, M. (2001), Use of Water in Labor and Birth, Clinical Obstetrics and Gynecology, Vol 44, No 4, pp 733-749.

Nikodem, VC Immersion in water in pregnancy, labour and birth. (Cochrane Review). In the Cochrane Library, issue 4, 2002. Oxford: Update Software.

Odent, M (1998 March) Use of water during labour – updated recommendations MIDIRS Midwifery Digest, Vol 8, No 1 pp 68-69.

Rush, J, Burlock, S. Lambert K (1996) The effect of whirlpool baths in labour: A randomized controlled trial. Birth, 23, p. 136-143.

Waldenstrom U & Nilsson C. (1992) Warm tub bath after spontaneous rupture of the membranes. Birth, 19 p 57-62.

Water birth International (2004) unpublished Water birth Parent Survey, a retrospective analysis of over 3000 births in water.

Water birth International (2006) Guideline for a safe water birth.