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Waterbirth FAQ

Waterbirth FAQ :: Rental Agreement Form :: Waterbirth Resources

A special thank you to Barbara Harper, R.N., founder of Waterbirth International for her kind permission to include some of her waterbirth FAQ’s on my website.

What is waterbirth?

The act of giving birth in water is so incredibly simple. A mother submerges herself in warm, body temperature water during her labor. If she feels like giving birth in that warm buoyant state, there is no need to ask her to leave the water.

The baby has grown in a fluid environment for the past 9 months. Babies adjust very well to being born in a birth pool.

Waterbirth is miraculous.

Is waterbirth safe?

The safety of waterbirth needs to be judged in looking back at the number of cases that have been reported world wide and the number of problems that have occured as a result of birth in water. To date, there has been over 100,000 documented cases of water birth.

What is the temperature of the water?

Water should be monitored at a temperature that is comfortable for the mother, usually between 95-100 degrees Fahrenheit. Water temperature should not exceed 101 degrees Fahrenheit as it could lead to an increase in the mother's body temperature which could cause the baby's heart rate to increase. It is a good idea to have plenty of water to drink and cold cloths for the mother's face and neck. A cool facial mist from a spray bottle is a welcome relief for some mothers as well.

When should I get into the water?

A woman should be encouraged to use the labor pool whenever she wants. However, if a mother chooses to get into the water in early labor, before her contractions are strong and close together, the water may relax her enough to slow or stop labor altogether. That is why some practitioners limit the use of the pool until labor patterns are established and the cervix is dilated to at least 5 centimeters.

There is some physiological data that supports this rule, but each and every situation must be evaluated on its own.

Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started. If contractions are strong and regular, no matter how dilated the cervix is, a bath might be in order to help the mother to relax enough to facilitate dilation.

Therefore, 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. Midwives report that some women can go from 1 cm to complete dilation within the first hour or two of immersion. The first hour of relaxation in the pool is usually the best and can often help a woman achieve complete dilation quickly.

What prevents baby from breathing under water?
Waterbirth Basics
From Newborn Breathing to Hospital Protocols
© Barbara Harper 2000
Printed in Midwifery Today: Issue 54, Summer 2000

Waterbirth is simple.

Within the simplicity of water labor 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 labor 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: How does the baby breathe during a waterbirth?

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 labor 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).[1] 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.[2] If the baby were in trouble during the labor, 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.[3] 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.[4]

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.[5] 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. At some point the placenta detached from the wall of the uterus and stopped the flow of oxygen to the baby. When the baby was taken out of the water, it did not begin breathing and could not be revived. On autopsy the baby was reported to have no water in the lungs and its death was attributed to asphyxia.[6]

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.[7] 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.

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© Barbara Harper 2000 - for reprints contact barbara@waterbirth.org

Footnotes
[1] Johnson, Paul (1996) Birth under water - to breathe or not to breathe. British Journal of Obstetrics and Gynecology, Vol. 103, pp.202-208
[2] Fewell, JE, Johnson, P (1983) Upper airway dynamics during breathing and during apnea in fetal lambs. Journal of Physiology Vol 339, pp 495-504
[3] Harding, R., Johnson, P., McClelland, M. (1978) Liquid sensitive laryngeal receptors in the developing sheep, cat, and monkey. Journal of Physiology, Vol 277, pp 409-422
[4] Karlberg, P. et al. (1987) Alteration of the infant's thorax during vaginal delivery. Acta Obstetrica Gynecol Scandavia. Vol. 41, p 223
[5] Gilbert, R, Tookey, P, (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal Vol 39, 21 August pp 483-487
[6] Personal interviews (1989) Barbara Harper

How do I keep the water clean?

With the pool, you need to start with fresh clean tap water. I include a small bottle of brominating concentrate in your rental kit. I encourage women to use the pool in their last weeks/days of pregnancy in order to relax, reduce any swelling in their feet and ankles and generally to "bond" with their intended place of labor.

To keep the water clean and bacteria free, I suggest adding either a ½ cup of bleach or 2 teaspoons (tsp) of brominating concentrate every other day (every 48 hours).

The only other approach to take is changing the water completely and starting with new water every other day. Standing water, especially warm water does breed bacteria. The treatment of the water is absolutely necessary to prevent bacteria growth.

During the birth, if you happen to lose control over your bowels during pushing (very common), your provider or doula will use the net that is provided in your kit and whisk any debris away. This is a common occurrence, but one that you need not be embarrassed over. There is evidence in the literature on water immersion and waterbirth that supports the opinion that neither mothers nor babies will get an infection if this happens. On the contrary, the infection potential is actually less in the water than on a bed when the same thing happens.

How heavy is the pool?

Water is the main ingredient in the Gentle Birth Pool.

The pool is 5 feet across and 24 inches high.

When filled with 100 gallons of water, the water would weigh 834 pounds. The weight of the pool itself is approximately 47 pounds, so altogether the combined weight is less than 900 pounds.

You'll have to add in the weight of the mother, daddy and baby, too!

Many hospital engineers have asked if the floor of the hospital could support the weight of the pool. When put into the perspective that the weight of the birth pool is equivalent to four large nurses standing in a circle, they chuckle and drop the argument.

Engineers have told us that the weight of the pool is a transient weight - one that is not going to be there very long, as opposed to a permanent weight.

The load bearing weight has been calculated to be 78 lbs per square foot. There has never been an incident of the weight of the pool causing any damage to any hospital, home or birth center.

What do I do when I am finished with the Pool?

You will need to drain the pool and clean and dry the permanent liner. Call me after the baby is born and we can arrange a convenient time that for me to pick up the pool. I will disassemble and remove the pool from your home.