Water birth

Water birth is a method of giving birth, which involves immersion in warm water. The immersion can mean giving birth to the infant in the water or using it as a tool during the labor process. Proponents believe that this method is safe and provides many benefits for both mother and infant, including pain relief and a less traumatic birth experience for the baby. However, critics argue that the procedure introduces unnecessary risks to the infant such as infection and water inhalation.

History

After a stressful day, people often refer to 'escaping to the bath'; possibly because of the almost mysterious way warm water relaxes us and effects the way we feel physically and emotionally. The first recorded water birth occurred in France in 1803 and in Germany in 1805. Ancient Egyptians believed that their priests were born from water. This spiritual connection to water is still evident today in Christian baptism, and many cultures use water in religious ceremonies. In the 1960s, self-educated Soviet researcher Igor Charkovsky explored the safety and possible benefits of water birth in the Soviet Union. In 1974, French obstetrician Frederick Leboyer published a book advocating the immersion of newly born infants in warm water for the purpose of easing the transition from the womb to the outside world, and to mitigate the effects of any possible birth trauma.

Another French obstetrician, Michel Odent, took Leboyer's work further, using the warm-water birth pool for pain relief for the mother, and as a way to normalize the birth process. When some women refused to get out of the water to finish giving birth, Odent started researching the possible benefits for the baby of being born under water, as well as the potential problems in such births. By the late 1990s, thousands of women had given birth at Odent's birthing center at Pithiviers, and the notion of water birth had spread to many other Western countries.

Water birth first came to the United States through couples giving birth at home, but soon was introduced into the medical environment of hospitals and free-standing birth centers by midwives and obstetricians. In 1991, Monadnock Community Hospital in Peterborough, New Hampshire started to create a protocol for giving birth in water. More than three-quarters of all National Health Service hospitals in the UK provide this option for laboring women.

Benefits

For the baby

Childbirth is believed to be a strenuous experience for the baby. Properly heated water is claimed by proponents to help ease the transition from the birth canal to the outside world because the warm liquid is thought to resemble the intrauterine environment. In addition, the umbilical cord pulsates for longer, helping to remove damaged red blood cells from the babies' circulation and replaces them with fresh, undamaged red blood cells thus reducing neonatal jaundice and increasing the transmission of fetal stem cells. sprague.a 2011 The interaction between mother and baby is increased, as the woman is able to move easily and make eye contact with her alert newborn, and the warm moist air present in the birth room is beneficial for the baby's first breath. The air inhaled is warm and moist, rather than cold and dry. sprague.a 2011 In Australia, many birthing suites now have baths available to use during labour and birth. The majority of water births that occur in Australia, are with women who chose to labour at home with trained midwives. ref sprague.anne ISBN 0-646-44376-3 and many women hire a portable pool to use during labour for pain relief, to increase their feelings of autonomy and to help promote active birth positions, despite where the birth may actually occur water labour water birth: A guide to the use of water during childbirth. A Sprague 2011

For the mother

Relaxation

Research conducted by midwife Annie Sprague Water Labour, Water Birth:A guide to the use of water during childbirth. 2011 found that using a birth pool, spa or deep bath is one of the best ways to reduce maternal tension, promote relaxation and intentionally create a private and welcoming space for women in labour. Women when relaxed, are calmer, feel less stressed, and the atmosphere in the birth room is positively improved. This is helpful for midwives, doulas and other birth attendants as well. Water also provides greater comfort and mobility for women than labour on 'land' as the woman is able to move easily and spontaneously and this assists the baby's descent within the maternal pelvis sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011. Women have found the warm water lowers blood pressure and therefore, it may be an effective method for reducing stress and anxiety. According to the American Pregnancy Association, the reduction of anxiety, allows the mother to focus on the laboring process instead of any tension. Because her muscles are able to relax, it releases pain inhibitors and she is then better able to cope with the pain and have a positive birthing experience. The buoyancy provided by water promotes efficient uterine contractions and better blood circulation. This results in better overall oxygenation, combined with less pain for the mother sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011 This may be why there is less need for use of analgesia such as epidurals, pitocin, etc. Water immersion stimulates a woman's skin so that the nerve fibres that transmit pain are blocked. This is how the 'Gate Theory' of pain works sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011.

Pain management

Harper reports that water birth is an effective form of pain management during labor and delivery (Harper 2000). Water birth is a form of hydrotherapy which, in studies, has been shown to be an effective form of pain management for a variety of conditions especially lower back pain (a common complaint of women in labor). In an appraisal of 17 randomized trials, two controlled studies, 12 cohort studies, and two case reports, it was concluded that there was a definite "benefit from hydrotherapy in pain, function, self-efficacy and affect, joint mobility, strength, and balance, particularly among older adults, subjects with rheumatic conditions and chronic low back pain," (Geytenbeek 2002). Other options for pain control during labor and delivery are epidural anesthesia and intravenous opioids. Epidural anesthesia may be associated with a higher incidence of instrumental delivery with forceps. However, epidural anesthesia does not increase the incidence of cesarean section and has been shown to be a safe alternative for labor analgesia. Full immersion in water promotes physiological responses in the mother that reduce pain including a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin (Katz 1990), the latter which also increases oxytocin blood levels (Odent 1998). The Cochrane Database of Systematic Reviews has found that "the statistically significant reduction in maternal perception of pain and in the rate of epidural analgesia suggest that water immersion during the first stage of labour is beneficial for some women. No evidence was found that this benefit was associated with poorer outcomes for babies or longer labours." It has also been found that in waterbirths the buoyancy of the mother and the baby allow for a gravitational pull. This pull not only opens up the mother's pelvis but also allows the baby to descend more easily.

Intact perineum/decreased episiotomy

Water birth is believed to aid stretching of the perineum and decrease the risk of skin tears. Support from the water slows crowning of the infant's head and offers perineal support, which decreases the risk of tearing and reduces the use of episiotomy, a surgical procedure which can cause a number of complications. Indeed, there is a zero episiotomy rate in the waterbirth literature (Harper 2000). Moreover, "perineal trauma is reported to be generally less severe, with more intact perineums for multips (multiparas, or mothers who have had multiple births), but in some literature about the same frequency of tears for primips (primipara, or mothers who are having their first birth) in or out of the water," (Harper 2000; also see Burn 1993 and Garland 1997). In addition, it is thought that immersion in water relaxes the maternal pelvic floor muscles and women who labour and give birth in water have a greater rate of intact perineum, fewer tears and no episiotomies performed as warm tissues stretch easier than cold Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011.

Risks and concerns

A study of some 4000 water births in the UK (1994–1996) concluded: "The similarity in perinatal mortality and morbidity in low risk women suggests that delivery in water does not substantially increase adverse perinatal outcomes. Overall rates may, however, mask specific benefits and harms, such as water aspiration or snapped umbilical cord." A 2003 review of the medical literature on water births concluded that it showed no benefit to the infant and no clear evidence of reduced labor duration, risk of perineal tears, or use of pain medication. There were 64 infants that experienced complications directly attributable to water birth, including bacterial infection, drowning, near-drowning, and fever.

A second article from 2003, signed by four doctors and nurses in the nursing, pediatrics, and obstetrics/gynecology departments at Maine Medical Center, drew attention to a picture of an infant open-mouthed while delivered underwater. While proponents claim that an infant will not breathe if the birthing water is kept at body temperature, no study confirms this. A fetus will breathe amniotic fluid, which is by definition at body temperature.

The American Academy of Pediatrics 2005 statement on water birth concluded: "The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent." This statement is refuted by midwife Annie Sprague, who suggests this is one of the most contentious and possibly influential myths surrounding water birth and this fear is not supported by current research, which has shown to the contrary that babies do not breathe underwater (Johnson,P., Birth under water- to breathe or not to breathe. British Journal of Obstetrics & Gynaecology, 1996. 103(March 1996): p. pp 202–208, Otigbah, CM., et al., A retrospective comparison of water births and conventional vaginal deliveries. European Journal of Obstetrics, Gynaecology & Reproductive Biology, 2000. 91. p. 15-20. To summarise, in utero, a term baby breathes approximately 40% of the time and this is not merely a practice for extra uterine life. Forty-eight hours or so before the onset of labour, fetal breathing stops, probably due in part to a secondary rise in the levels of prostaglandin E2, and is thought to prevent a baby inhaling water. The larynx acts as a valve during fetal breathing movements (aided by inspiratory muscles) preventing little intake of amniotic fluid. If any fluid makes contact with the larynx, the fetal dive reflex is triggered and any fluid is then swallowed. The large number of chemoreceptors found in the larynx further supports this process and these receptors help the baby determine which fluids can be inhaled and which can be swallowed. In other words, the baby can recognise that water should be swallowed and not inhaled (Johnson,P., Birth under water- to breathe or not to breathe. British Journal of Obstetrics & Gynaecology, 1996. 103(March 1996): p. pp 202–208, Otigbah, CM., et al., A retrospective comparison of water births and conventional vaginal deliveries. European Journal of Obstetrics, Gynaecology & Reproductive Biology, 2000. 91. p. 15-20. Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth).

As of 2006, the American College of Obstetricians and Gynecologists had not taken an official position on water birth (Schuman 2006), though the UK Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support water birth for healthy women with uncomplicated pregnancies. Studies that are critical of water birth generally object to or cite evidence from "poorly managed" or un-monitored water birth by inexperienced care providers.

Infection

Another concern is that the water could increase the risk of infection. In a randomized controlled trial of the effects of water labor in Canada, no difference was noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes. In a 1999 study of bacterial cultures carried out at the Oregon Health Sciences University Hospital, there were no instances of bacteria cultured from the birth pool itself.^{[citation needed]} While Pseudomonas bacteria (common in tap water) were present, even those infants that tested positive for the bacteria needed no treatment for infections. In a 2004 study, of the water of a birth pool following birth after filtration and more rigorous cleaning procedures (that had been put in place as a result of the study finding contamination between births) were instituted, high concentrations of E. coli and coliform contamination were found, along with staph and P. aeruginosa.

Slowed labor

Because of the documented relaxing effects of water^{[citation needed]}, laboring in water is sometimes associated with a decrease in the intensity of contractions, and is thus thought to slow labor.^{[citation needed]} While home birth experts (e.g. Harper, RN. Sprague, RM) argue that this must be evaluated on a case-by-case basis, some hospitals have adopted a "5 centimetre" rule, allowing women to enter the tub only once the cervix has already expanded to 5 centimeters (Harper 2000). This is not supported by current research, is not evidence based and each and every situation must be evaluated on its own merits. Indeed, some women find a bath is useful in early labour for its calming effects and to determine if labour has actually started. Because of the relaxing effect of being immersed in water, women may appear to be quieter in labour, and contractions may be described by women as less painful, but this does not stop labour progressing and it is common for women to dilate quickly while immersed in the water Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011.

Maternal blood loss

For care providers who are inexperienced in delivery in water, it may be difficult to assess the amount of maternal blood loss. While well-developed methods of determining maternal blood loss in water do exist, Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011, many providers prefer to deliver the placenta "on land" for this reason (e.g. the University of Michigan hospital). There is no evidence to date to suggest that third stage (birth of the placenta) must be completed outside the pool and the theoretical risk of water embolism has been dispelled by evidence [[Geissbuhler, V. and J. Eberhard, Waterbirths: a comparative study on more than 2,000 water births. Journal of Fetal Diagnosis and Therapy, 200. 15(no. 5): p. pp 291–300. On the other hand, some doctors and midwives see that waterbirths have been known to reduce the amount of blood loss. The water surrounding the mother lowers the mother's blood pressure and heart rate. Mothers still lose significant amounts of blood through the passing of the placenta. Sprague (2011) suggests that women who are anaemic and have a low Hb, a low blood platelet count, have had previous problems with third stage such as a retained placenta or a post-partum haemorrhage, should stand up or leave the pool to complete third stage Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011.

Risks and concerns

A study of some 4000 waterbirths in the UK (1994–1996) concluded: "The similarity in perinatal mortality and morbidity in low risk women suggests that delivery in water does not substantially increase adverse perinatal outcomes. Overall rates may, however, mask specific benefits and harms, such as water aspiration or snapped umbilical cord." A 2003 review of the medical literature on water births concluded that it showed no benefit to the infant and no clear evidence of reduced labor duration, risk of perineal tears, or use of pain medication. There were 64 infants that experienced complications directly attributable to water birth, including bacterial infection, drowning, near-drowning, and fever.

A second article from 2003, signed by four doctors and nurses in the nursing, pediatrics, and obstetrics/gynecology departments at Maine Medical Center, drew attention to a picture of an infant open-mouthed while delivered underwater. While proponents claim that an infant will not breathe if the birthing water is kept at body temperature, no study confirms this. A fetus will breathe amniotic fluid, which is by definition at body temperature.

The American Academy of Pediatrics 2005 statement on water birth concluded: "The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent."

As of 2006, the American College of Obstetricians and Gynecologists had not taken an official position on water birth (Schuman 2006), though the UK Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support water birth for healthy women with uncomplicated pregnancies. Studies that are critical of water birth generally object to or cite evidence from "poorly managed" or un-monitored water birth by inexperienced care providers. Outcomes from the research conducted by midwife Annie Sprague, developed some simple guidelines to inform who should not use a pool for labour and birth. sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011. These included: any woman who does not want to be in the pool or who is afraid of being in the water, women who are less than 37 weeks gestation, increased maternal pulse rate, maternal fever or infection (maternal temperature >37.6C, persistent increased or decreased fetal heart rate, any concern for the baby's health, maternal Pre-eclampsia, complicated pregnancy or presentation, active maternal herpes infection or any women who have used a narcotic analgesic within the previous 3 hours Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011.

Public Acceptance

Water birth is accepted and practiced in many parts of the United States, Canada, Australia, and New Zealand,^{[citation needed]} as well as many European countries,^{[citation needed]} including the United Kingdom and Germany, where many maternity clinics have birthing tubs. Many independent birthing centers and many home birth midwives offer water birth services. At present, water birth is often practiced by those who choose to have a home birthTemplate:Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011, because the majority of hospitals have not yet installed proper birth pools in their maternity wards. In 2006, Waterbirth International listed more than 300 U.S. hospitals that offered such facilities. At least two such hospitals were listed in the 2006 U.S. News and World Report "Honor Roll" of best U.S. hospitals: Barnes-Jewish Hospital in St. Louis, Missouri and the University of Michigan hospital in Ann Arbor, MI.

References

• Odent M. Birth under water. Lancet 1983:1476-1477.
• Flade, Ines: Rundbrief Nummer 2. Einiges über die Wassergeburt.
• Geburtsberichte, Geburtshaus und mehr e. V. Jena, Jena 1999.
• Schroeter, Ken. "Water Births: A Naked Emperor" Pediatrics, Vol. 114 No. 3, September 2004, pp. 855–858 (critical commentary in a mainstream medical journal)
• Garland, Dianne. Waterbirth: An Attitude to Care, Books for Midwives PR, UK, 2000 1 5947 7067 0
• Harper, Barbara, RN. "Waterbirth Basics: From Newborn Breathing to Hospital Protocols". In Midwifery Today Magazine, 2000.
• Geytenbeek, Jenny. "Evidence of effective hydrotherapy". In Physiotherapy. V. 88(9):514-529, 2002.
• Ros, Andrea, Ricardo Felberbaum, Iris Jahnke, Klaus Diedrich, Peter Schmucker, and Michael Huppe. 2007 "Epidural anaethesia for labour: does it influence the mode of delivery?" In Archives of Gynecology and Obstetrics. V. 275(4):269-274(6).
• Katz, V., et al. (1990, Feb.). A comparison of bed rest and immersion for treating the edema of pregnancy. Obstet and Gynecol 75 (2): 147-51
• Odent, M. (1998, March). Use of water during labor—updated recommendations. MIDIRS 8 (1): 68-9
• Burn, E., Greenish, K. (1993). Water Birth. Pooling information. Nursing Times 89 (8): 47-9.
• Garland, D., Jones, K. (1997, June). Ibid.
• Gilbert, R., Tookey, P. (1999, Aug. 21). Perinatal mortality and morbidity among babies delivered in water:surveillance study and postal survey. BMJ 319(7208): 483-7.
• Office of National Statistics. 2007. "Mortality Statistics: Childhood, infant and perinatal - Review of the Registrar General on deaths in England and Wales, 2005." Series DH3 No. 38. London.
• Schuman, Andrew. 2006. "When parents-to-be ask about water birth." In Modern Medicine.
• Royal College of Midwives. 2006. "Immersion in water during labour and birth." Joint Position Paper no. 1. London, Royal College of Obstetricians and Gynecologists and Royal College of Midwives.
• Zimmerman R, Huch A, Huch R. 1993. "Water birth—Is it safe?" In the Journal of Perinatal Medicine 21:5.
• Johnson, Paul. (1996). Birth under water – to breathe or not to breathe. B J of Obstet Gynecol 103 (3): 202-8.
• Fewell, J.E., Johnson, P. (1983). Upper airway dynamics during breathing and during apnea in fetal lambs. J of Physiol 339: 495-504.
• Harding, R., Johnson, P., McClelland, M. (1978) Liquid sensitive laryngeal receptors in the developing sheep, cat, and monkey. J of Physiol 277: 409-22.
• Eriksson, M., et al. (1996, Aug.). Warm tub bath during labor. A study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation. Acta Obstet et Gynecol Scand 75 (7): 642-644.
• Garland, D., Jones, K. (1997, June). Ibid.
• Siegel, P. (1960). Does bath water enter the vagina? Journal of Obstet and Gynecol 15: 660-1.
• Rush, J., et al. (1996, Sept.). The effects of whirlpool baths in labor: a randomized, controlled trial. Birth 23 (3):136-43.
• Brown, L. (1998, April). The tide of waterbirth has turned: audit of water birth. British Journal of Midwifery 6(4): 236-43.

*Sprague. A. Water Labour, Water Birth: A guide to the use of water during childbirth. 2011.

External links

• BBC News: Water Birth Drowning Risk, 2002
• New Yorks Times: Baby You're Home, 2008
• Water Birth Videos: Published Water birth Videos