In the national surveillance study of morbidity and mortality among babies delivered in water, the perinatal mortality was not different from that associated with a conventional birth. The British Paediatric Surveillance Unit conducted a survey of babies who had been admitted to special-care baby units or who had died following delivery in water between April 1994 and March 1996 (1). Of the 64 reports, 37 followed delivery in water and 27 involved labour in water with delivery outside the pool. Five perinatal deaths occurred among the 4,032 babies born in water in England and Wales, giving a perinatal mortality of 1.2/1000 live births (95% CI 0.4-2.9). This compares with a perinatal mortality of 1.4 (95%, CI 0.7-2.3) for a comparable group of low-risk women having a conventional birth (relative risk 0.9, 99% CI 0.2-3.6).
- UK Midwifery Archives, www.midwifery.org.uk
1: Gilbert RE, Tookey PA. Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. - BMJ 1999; 319:483-7
[The above-cited study] was undertaken by researchers who wrote to 1,500 consultant paediatricians asking them 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.'" This is an extraordinary approach which, as far as we know, has never been applied to any other study of obstetric technology or practices. We are now looking forward to studies of electronic fetal monitoring, ultrasound, or epidural anaesthesia, asking a similar question.
We have found that few hospitals actively promote and support labour or birth in water. Any woman wanting a waterbirth needs to ask some fundamental questions to establish just how likely it is her wishes will be respected and supported. It is fine having a pool, but if less than 10% of women get anywhere near it, what experience are the midwives gaining, and what chance do women really have of using this highly effective form of pain relief?
It is quite astonishing that on the one hand so many obstetric units are unwilling to encourage a form of pain relief that has no side effects and has been shown to be wanted by many women, whilst on the other the staff are only too keen to subject women to a wide range of drugs despite the evidence that exposure in utero to barbiturates and narcotics increases by 4.7 times the risk of drug addiction in teenage years (Jacobson B, 1990).
- Beverley A. Lawrence Beech, AIMS Journal,
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CONFERENCE AUDIOTAPES FOR THIS WEEK'S THEME
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THE USE OF WATER FOR LABOR AND BIRTH, video by Marina Alzugaray
This video explores the therapeutic use of water during the labor and birth of two families. It illustrates the individuality of homebirths and provides an outline for the basic concepts of the use of water.
WATERBIRTH: AN ATTITUDE TO CARE, book by Dianne Garland
A guide to waterbirth in hospital or at home.
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Question of the Week Responses: Waterbirth
Q: We have more and more mothers who want to give birth in water. I've made a literature review and find it's very difficult to draw an objective conclusion about waterbirth. For many years I have practiced waterbirth but it's difficult to give confidence to my colleagues. It's always the same -- people remember only the bad things. I would like to hear reflections on the subject as well as some experiences.
- Dominique Porret, Quebec, Canada
A: On Nov 6, 2001, I had a homebirth/waterbirth. The water was extremely helpful in that it relaxed me, helped me deal with the pain, and relieved my tired sore muscles. It was easy enough for our midwife to monitor me because I was in a bathtub and not a labor pool. Our daughter was brought to the surface immediately. My body heat and some towels helped keep her warm. We noticed no ill effects on the baby and wonderful benefits to the mother. Baby had a 1-min Apgar of 9 and a 5-min Apgar of 10. I highly recommend waterbirth and intend to have my future children this way.
- Erika O.
A: I gave birth to my fourth child in November 2001. She was born in my bathtub at home; my husband was the "midwife." We planned an unassisted homebirth. The waterbirth wasn't really planned, but once I was comfortable in the tub, I didn't want to get out. It was a fantastic experience. I noticed that being in the warm water for second stage helped ease the burning sensations when the labia and perineum stretched. The baby was perfect. The labor was easy. No tears!
- Laura Grout, AAHCC, CD
A: Some issues about waterbirth rarely get asked, let alone answered. I have some real reservations about birth that is planned to take place in the water.
The fad side that insists on birth in the water: I was at a planned waterbirth in which the mother decided she didn't want to be in the water. When her primary midwife insisted that mom get in, she proceeded to get faint and woozy in the water. She was happier on land.
Newborns who don't pink up after birth: In a popular waterbirth video, the baby didn't pink up for quite a while after birth. I have seen this before. I think that when the cord is floated in the wet warm environment that it is used to, the physiologic message to the circulatory system that says "you have been born" doesn't get sent properly. So the information to switch from uterine circulation to external circulation doesn't convey. Some babies do pink up right away in the water, but the number who look like they're having persistent fetal circulation problems seems higher in the water.
Length of time in the water: Odent states that longer than 1 1/2 hr in the water at a time slows labor. Yet many women, addicted to the idea that the water will get them through, don't want to leave the pool.
Antenatal bleeding in the water: I assisted a waterbirth in which the mother bled enough before birth that it turned the water murky. It seemed that she was having heavier than usual antenatal bleeding, although not likely at a pathological level. We couldn't assess the amount of blood loss in the water. Not only could we not see the mother's vulva or the baby as it emerged, but the water quality was disgusting.
Passing feces in the water: I've been told to use a fish scooper to scoop feces out of the water. I tried it and the fecal matter disintegrated. Within 10-15 minutes, I had a crowning baby and a pool of water filled with flecks of feces. I got mom out of the water and cleaned her with disinfectant from her chin to her knees before welcoming baby out. It wasn't fun for any of us.
Keeping the baby warm: While the part of the baby that is still submerged is kept warm, a significant skin surface is out of the water, and that water is evaporating and cooling the baby. Being covered in a wet blanket doesn't feel warm to me!
Unrealistic expectations: Certainly many women are helped enormously by water, but making it the ticket to coping with labor could lead her to feel betrayed by her expectations if indeed she isn't helped. I prefer to keep water as one of the many tools we can use rather than make it the way of birth.
While truly awful outcomes from waterbirth are few, sometimes people don't use common sense when guiding waterbirth. I have seen film clips of newborns who look like they're in distress in the water, which others are gushing over as a beautiful first swim. There have been instances of hospitalized newborns diagnosed with tap or hot-tub water in their lungs.
When it goes well, it's lovely. The water is crystal clear, there's no stool to scoop away, and if it's in a bathtub all the afterbirth blood can go down the drain, for the easiest cleanup you've ever done! Those who have done lots of waterbirth swear that there is a positive difference in the babies and in the mamatoto bonding. While I haven't seen it, I've been given a more troublesome set of waterbirth scenarios in my caseload than my friends!
- Karen Ehrlich, CPM, LM
A: There is nothing as wonderful as the comfort water offers to a birthing mom. Whether she continues to remain in water and birth her baby there, the positive effects are absolutely wonderful. As we come to communicate around the world we realize women have been birthing in water for eternity.
Water is, as Barbara Harper comments, "like a hundred pair of hands." The hydrostatic pressure created by water is wonderful to mom and baby. The gentleness of the water is phenomenal. If one has ever seen a waterbirth you can understand this. It's important to bring baby up as soon as it's born. This avoids any question about when the placenta separates from the uterus and whether baby is still getting oxygen. As far as a mom tearing it's very rare as the water makes the tissues very pliable from the water saturation. Adding salt to the water keeps the tissue from getting that prune look.
A: It is indeed difficult to locate literature pertinent to waterbirth safety and effectiveness. Midwives are daunted by the practice of waterbirth for a variety of reasons. Because a birth under water is controlled by the laboring woman, it is difficult -- almost impossible -- to inflict medical interventions such as vaginal examinations, and most importantly assist the birth of the baby's head (which many midwives still believe helps prevent perineal trauma). This demotes the midwife to observer of, not participant in the event. Many practitioners find this uncomfortable.
Second, midwives may find that they injure themselves due to the constant vigilance and care as practiced during land births, therefore compromising their back safety.
A combination of these factors along with a human tendency not to change current practice has contributed to the lack of information available. Practitioners of women-led midwifery care must remember that many of the practices we use daily were once viewed in the same light as waterbirth, and the situation will only alter by the provision of accurate research on the subject.
- Rebecca Lewis, midwife
Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!
I am a student midwife who has attended an equal number of waterbirths as out of water births (all homebirth settings). Upon birth the pressure of the baby's first big cry forces ducts in the fetal circulatory system to close and shunts to open. This transformation gets newborn circulation going. If the ducts and shunts do not close and open effectively, oxygen is not properly distributed throughout the newborn's circulatory system and can result in respiratory complications. Does the gentle journey from birth canal through water before touching air cause reflexes that force the ducts and shunts to react, to perform less effectively? Babies born in water seem not to cry as vigorously, thus the idea that this birthing is gentler. But I wonder if the trip from the birth canal straight to air is necessary in order for the reflexes in the circulatory system to transform effectively.
- Annie, student lay midwife, CA
I am pregnant with my third, due in July, and am preparing for a homebirth. My first was born by c-sec for cervical dystocia; he was posterior. My second son was VBAC; I had back labor off and on for several days, then severe back labor for over 30 hours. I used epidural and narcotics until he finally went anterior and was born. I am looking for every possible way to avoid back labor, or at least not experience it at the previous degrees. I read Back Labor No More by Janie Mc Coy. The technique seems logical, but I want to know if anyone has seen it work positively.
- Alison Velasco, Lima, Peru
A doula friend commented that by educating women to request natural birth options (in a hospital setting) that are at odds with local protocols was unfair to midwives. She felt that if women really want those totally natural options they should have a homebirth with a midwife. Otherwise they should just accept that if they go to a hospital they are agreeing to the interventions.
I agree that it would be lovely if all low-risk women opted for homebirth, but I feel it's not realistic. It often takes women several births to unlearn what they've been taught about homebirth. As a childbirth educator I deal with all different types of women from many different backgrounds. All I can do is supply them with truthful information. I would be interested in hearing the opinions of midwives out there.
- Amy V. Haas, BCCE, Fairport, NY
The first birth I ever attended was in 1971 at the Rainbow Gathering at Strawberry Lake in Colorado. That was the beginning. In the early days of being a midwife I was lucky enough to be with midwives who believed VBACs were safe. I believe I am one of the few who has early stats (mine) from midwives about home VBACs. I was doing VBACs when some of my midwife friends were telling me I was doing something dangerous and that I was making it bad for them. Now some of them do VBACs. What a wonderful eye opener! I believe in birth, VBACs, attending the births of twins, and even women healing through homebirths. Also, I thank God for underwater births.
I now live in Texas and after 1,236 births, I want to chat with others about midwifery. My heart is with students, and the greatest thing I want to tell them is don't practice defensive midwifery, don't go there. I would like to talk with anyone who wants to about this wonderful profession. I really want us all to preserve it and protect it.
The consumer has changed. I had three children at home starting in 1973 and now three of my grandchildren have been born at home and under water. Waterbirth is 100% of my homebirth practice at this time. It was more than I can speak to deliver my own grandchildren at home. I am proud of my two girls for doing that with me and as a family.
If anyone wants to chat, please write, especially students -- you're my favorite!
- Eveith Miller
I have a mother who was on Paxil during her first 7 weeks of gestation. I have not found much information about this drug. Baby seems to be OK, but it demonstrated a small calcification on the heart. Any light on the matter of embryonic development and this kind of medication? She is due July 2.
- Debbie A. Diaz, homebirth midwife, Puerto Rico
I was really interested to read about people identifying scar tissue on cervixes and massaging it/breaking it down [Issue 4:12]. Could you try to explain to me what it would feel like and how you would go about the massage?
I love the interactions and questions that come through the newsletter. I often store away tips to be used when and if I come across the situation. Breaking down barriers across countries and teaching one another is great. Thanks to Midwifery Today for giving us that opportunity to participate.
- Terry Stockdale, independent midwife, Hobart, Australia
Thank you to all E-News readers for giving us the opportunity to form this web of communication around the world!
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The International School of Traditional Midwifery in Ashland, Oregon is accepting enrollment for 2002 classes that start in May. For information call 541-488-8273, or go to www.globalmidwives.org
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