August 21, 1999 should be remembered as a landmark in the history of birth pools.
On that day the British Medical Journal published an unprecedented study about
waterbirth. This study is authoritative for several reasons: The conclusions are
based on large numbers: the authors traced the 4032 babies born under water in
England and Wales between April 1994 and March 1996; the authors belong to a prestigious
department of epidemiology and public health (Institute of Child Health, London,
UK); the report has been published in a respected peer review medical journal.
>From April 1994 to April 1996, all 1500 consultant pediatricians in the British
Isles were surveyed each month by the British Paediatric Surveillance Unit and
asked to report whether or not they knew of any births that met the case definition
of "perinatal death or admission for special care within 48 hours of birth
following labour or delivery in water." At the same time a postal questionnaire
was sent to al National Health Service maternity units in England and Wales in
1995 and 1996 to determine the total number of deliveries in water during the
There were five perinatal deaths among 4032 births in water; that is a rate of
1.2 per 1000. In the context of the UK this rate is similar to low risk deliveries
that do not take place in water. Furthermore, none of these five deaths were attributable
to delivery in water. There were 34 babies admitted for special care; that is
a rate of 8.4 per 1000. Rates of admission for special care of babies born to
low risk primiparous women are significantly higher than for babies born in water.
Give great importance to the time when the laboring woman enters the pool. The
BMJ survey clearly indicates that many women stay too long in the bath. The midwife
should help women be patient enough so that they can ideally wait until five centimeters
dilation to enter the water.
Avoid planning a birth under water. When a woman has planned a birth under water
she may be the prisoner of her project; she is tempted to stay in the bath while
the contractions are getting weaker, with the risk of long second and third stages.
There are no such risks when a birth under water follows a short series of irresistible
Temperature: It is easy to check that the water temperature is never above 37
degrees C (the temperature of the maternal body). The fetus has a problem of heat
- Michel Odent, excerpted from "A
Landmark in the History of Birthing Pools," Midwifery Today Issue 54
Miscellaneous waterbirth facts and tips
- Practitioners throughout the world recognize increased safety for the breech
baby if it is born in water. The most experienced doctor we know of is Herman
Ponette, an obstetrician who practices in Ostend, Belgium. He has attended well
over 2000 waterbirths, including breeches and twins. To him, a frank breech position
as an indication for a waterbirth.
- Perineal trauma is reported to be generally less severe, with more intact
perineums for multips, but some of the literature reports the same frequency
of tears for primips in or out of the water (Burn, Garland).
- A useful way to identify the extent of postpartum hemorrhage is how dark the
water is getting. Can you still assess skin color of the mother's thighs even
though there is blood in the water? A few drops of blood in a birth pool diffuse
and cause the water to change color. A waterproof flashlight comes in handy at
this point. Dropping a flashlight onto the bottom of the birth pool allows you
to look for bleeding as well as meconium during the birth.
- Some hospitals still restrict a woman from laboring in the water if her membranes
are ruptured. Based on the current and past literature, this is absurd. No evidence
exists of increased infectious morbidity with or without ruptured membranes for
women who labor and/or birth in water (Eriksson et al., Garland).
- Some parents are concerned about mother-to-mother infections or contamination
from viruses such as HIV or hepatitis. There is no reason to restrict an HIV-positive
mother from laboring or giving birth in water. All evidence indicates that the
HIV virus is susceptible to the warm water and cannot live in that environment
(Favero). Universal precautions still must be adhered to, however, and proper
cleaning of all the equipment after the birth must be carried out.
- Barbara Harper, Midwifery Today Issue 54
Burn, E., Greenish, K. (1992). Pooling information. Nursing Times 89(8): 47-49.
Garland, D., Jones, K. (1997, June). Waterbirth: Updating the evidence. British Journal of Midwifery 5(6): 371.
Erikkson, 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
Obstetricia et Gynecologieca Scandinavica 75(7): 642-44.
Garland, D., Jones, K. ibid.
Favero, M. (1986). Risk of AIDS and other STDs from swimming pools and whirlpools is nil. Postgraduate Medicine 80(1): 283.
The uterus at full term is a tautly extended, powerful muscle. The point at
which the placenta attaches to this muscle is the deciduas basalis, the decidual
plate, lying right up against the myometrium. The uterus contracts powerfully
as the baby is born, surging down from near the rib cage to around belly button
level. In a normally implanted placenta, the line of cleavage along the decidual
plate opens. The spiral arterioles are sheared off; the next few heartbeats of
maternal blood pour out and the retro-placental clot forms, further detaching
the placenta from the uterine wall due to the pressure of the blood flowing in.
Remember that at full term, about 500 mL of blood/min are flowing into the placenta
from the maternal circulation. The uterus firms up around the placenta and clot,
slowing the blood flow. The spiral arterioles clot off. Maternal blood flow to
the uterus drops off rapidly.
The placenta may not be delivered for a while, but the mother's blood does not
continue circulating into the maternal lakes to provide oxygen and other essential
substances tot the baby. Unless implantation is abnormal, the contraction that
births the baby separates the placenta.
Keep an eye on the cord the next birth you attend. At first it is stiff, turgid,
deep blue. Look again at one minute. It is becoming flaccid, gray. True, if you
feel carefully, near the baby's body you can feel a pulse for several hours. But
the flow of heavy blood to the placenta and back is at an end. The little capillaries
in the villi are disrupted, deprived of access to maternal blood. The blood in
the baby's body needs another oxygen source, and a perfect one is available: the
The only safe way to practice waterbirth is to bring the baby out to where it
can breathe directly after birth. Certainly a baby might be supported gently with
its face out and body floating as it transitions from placenta to lungs as the
organ of respiration. In the mother's arms is a good place to accomplish this.
- Marion Toepke McLean, CNM, Midwifery Today Issue 54
MIDWIFERY TODAY ISSUE
54'S THEME IS WATERBIRTH. 14 articles about waterbirth, columns, tricks of the trade, and more!
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footage will take your breath away."
Midwifery Today's Online Forum
I am a natural childbirth educator and have a woman in my class who has congenitally
dysplastic hips and has a very limited range of motion. She walks with the assistance
of two canes. She cannot open her legs if her knees are bent. Does anyone have
any suggestions for her laboring and birth? She very much wants to have a natural
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Question of the Week
Q: What are midwives doing when women test positive
for group beta strep in pregnancy? What protocols are midwives implementing at
the birth and postpartum?
Send your responses to:
Question of the Week Responses
Q: I'm 20 weeks pregnant (first time) and am seeing
a CNM. At our first ultrasound the baby measured great but they told us we are
on the low end of normal for amniotic fluid (an 8). Is there anything I can do
to increase my amniotic fluid? Is this number particularly low? What are the possible
chromosomal effects of having low amniotic fluid?
- Melinda Collins
A: Yes, 8 is a low number for a gestation of 20 weeks. There are no chromosomal
effects for having a low amniotic fluid. Also, a doctor may tell you to drink
a lot of fluid, but really, your body is what controls your amniotic fluid, not
the amount you take in.
- Misha Spencer-WhiteMagpie
A: These are questions your midwife should answer. I wonder if you have
chosen the right midwife if you seek the opinions of strangers worldwide rather
than her? You are trusting her with one of the most intimate times of your life;
surely a fluid-level question isn't too much to ask. Drink lots of water and soak in a tub. The fluid level doesn't affect chromosomes,
but the baby's condition can affect fluid level.
- Evelyn B. Walker
A: Low fluid has nothing to do with chromosomal anomalies--those are determined
at conception. It can influence cord compression and possibly lead to fetal distress.
The mother can increase her intake of water and rest a bit more to facilitate
increasing the amniotic fluid volume. If the baby is growing well, moving well,
and is otherwise fine, it may have no relation to a poor outcome. Usually a repeat
ultrasound is done every four weeks to assess the fluid volume and starting at
34 weeks gestation, nonstress testing (monitoring movements & response to
those movements with a fetal monitor) can help assure a good outcome. It is important
for mom to be aware of fetal movements, especially after 28 weeks. A good indication
of well being would be at least 10 movements per day.
I work in a large private hospital-based practice. We follow lots of "high
risk" women and they have had excellent outcomes in spite of low amniotic
- Sage Brook, CNM
A: An AFI (amniotic fluid index) of 8 is OK. You can increase your fluid
by increasing your water consumption. Low amniotic fluid is usually caused by
failure of the fetal kidneys to produce or inadequate intake of water. Drink,
- Lynda Comerate, RN, BSN, PHN, LCCE, HBCE
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INTERNATIONAL MIDWIVES, please direct your questions, comments, and needs to
"International Connections." We're here to help you!
Out of frustration from trying to find an affordable option for a labor pool/waterbirth
tub for our clients, we have come up with the following option:
- A 60" X 20" Aquarium inflatable pool made by Intex available at
discount stores or on line. These pools cost from $20 to $35 and are of excellent
quality. They have three inflatable clear plastic rings with fish on them so
you can still see through the pool in places and have an inflatable bottom. We
find the 60 inch pool to be the best--any larger takes longer to set up and fill
and is very taxing on any hot water tank.
- Floating thermometer (or any thermometer will do)
- Multisize faucet adapter
- Betadine solution (for cleaning)
- Air pump
- Instructions for set-up, general use and clean-up
- New hose (family purchases and keeps)
This entire set-up costs under $100. Most of our clients want to keep the pools
and purchase their own at the beginning of their third trimester. We try to keep
a couple extra new pools on hand as they can be hard to find at times.
Our labor/birth pools kits are available to all our clients at no cost. The pool
kit is left at their house at around 35 weeks gestation but sometimes we deliver
them sooner if they are experiencing back or other body aches or excessive swelling.
Soaking in a deep pool can provide relief for these discomforts. We had one mom
fill her pool every evening with warm (not hot) water in her living room (she
used a large plastic drop cloth and had lots of towels on hand) and float for
several hours for relief of back pain (she is a well-padded gal and also loved
the feeling of weightlessness while in the water). Her five year old would join
her and it was the perfect treat during a cold winter pregnancy. Learning to relax
in water prior to birth is a great way to help your body become familiar with
this type of relaxation when water therapy is planned for labor and birth.
- Debra Nelson, Traditional Childbirth Assistant
Re: question about the safety of breech [Issue 3:31]:
The concerns you have are based on two different and independent factors:
1. Cerebral palsy: Increased risk is usually a result of the birth itself, which
is why most Obs and CNMs (not having been trained extensively in vaginal breech
births) won't even consider the "risk." The potential problem is with
decreased blood flow and oxygenation of the baby's brain while the head remains
2. Birth defects: Certain birth defects (such as those that result in hydrocephaly)
can prevent the baby from turning into a head-down position, so the defect actually
contributes to the baby remaining breech.
3. Other factors that may predispose to persistent breech presentation: Maternal
pelvic structural variations, uterine fibroids, maternal uterine structural variations,
low-lying placenta or placenta previa, really short umbilical cord or cord wrapped
all around the baby. In short, anything that interferes with the baby turning
around in the womb.
If you have a skilled practitioner who is experienced in handling breech births
and has informed you of the various scenarios that might occur during the birth
as well as indications and plans for additional interventions, your baby should
- Gabrielle Long Wright, CNM
(hospital-based practice in which all breeches are scheduled for c-section)
I had some wonderful feedback forms for my clients that described in pictures
the results of their Pap smears. The forms came in pads about 1/3 page in size,
and showed a graphic of a normal cervical cell, an ASCUS cell, CIN-I and so forth.
Both my clients and I loved them--but I have misplaced the re-ordering information.
Does anyone have it? If so, email me at FlynnCNM@aol.com.
- Cynthia Flynn, CNM, PhD
In response to the question regarding what to expect at a hospital birth with
twins [Issue 3:32]:
It depends on the type of hospital and the individual care provider. Some things
to think about ahead of time and to keep in mind during the birth: monitoring
of two babies is trickier than just one. If continuous monitoring is being used,
nurses tend to get frustrated with trying to keep both babies on the monitor,
especially if mom wants to move around (as she should!). If there is a delay between
the babies' births, how will the practitioner handle it? Manual repositioning
of second twin, ruptured membranes, Pitocin, etc. In the hospital where I work,
all vaginal twin deliveries must occur in the OR (don't even get me started).
During a homebirth in 1998, I had to be transported to the local hospital. My
midwife was diligent in calling ahead and explained the situation to the nurses
in the "women's center." When we arrived, we discovered they hadn't listened to a thing she said to them
on the phone! They had to search for the ultrasound machine, wasting precious
time, and didn't even have a wheelchair ready. I had to walk to my room at 9 cm
dilated with two feet presenting. While my daughter's heart rate shot up to 280
(due to a malformed electrical pathway) the anaesthesiologist messed around trying
to get a spinal started. Finally giving up, they gave me an emergency c-sect with
general anaesthesia; my daughter's 1-minute APGAR was 0. She survived, but I haven't
forgotten the disregard with which they treated my LDEM and the fumbling around
that endangered my daughter's life.
I don't know how to make the hospitals pay attention to midwives in transit; I
am under the impression that it is a dangerous situation we need to remedy.
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