Seana Berglund—www.babymoonservices.com

Editor’s note: This article first appeared in Midwifery Today, Issue 54, Summer 2000.
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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. One of the first and foremost questions in everyone’s mind when they hear of waterbirth stories is simple: How does the baby breathe during a waterbirth?

Inhibitory Factors

Several factors 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 he practices for future air breathing by moving his intercostal muscles and diaphragm in a regular and rhythmic pattern from about ten weeks gestation on. The lung fluids that are present have been produced in the lungs and are similar chemically to gastric fluids. These fluids come up into the mouth and are normally swallowed by the fetus. There is very little aspiration of amniotic fluid in utero.

Twenty-four to forty-eight hours before the onset of spontaneous labor, the fetus experiences a notable increase in prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements (Johnson 1996). With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain. 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 (Fewell and Johnson 1983). 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.

The temperature differential is another factor thought by many to inhibit the newborn from initiating the breathing response while in water. The temperature of the water is so close to 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, yet babies that who 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 which is vital to the whole waterbirth and aspiration issue, is the fact that water is a hypotonic solution and lung fluids in the fetus are hypertonic. Even if water were to travel in past the larynx, it 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—the dive reflex—is associated with the larynx. The larynx is covered all over with chemoreceptors, or taste buds. In fact, the larynx has five times as many taste buds as the whole surface of the tongue. When a solution hits the back of the throat and crosses the larynx, the taste buds interpret the substance and the glottis automatically closes; the solution is then swallowed, not inhaled (Harding, Johnson and McClelland 1978).

This autonomic reflex is built in to all newborns to help them breastfeed, 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 breastmilk due to the dive reflex.

All these factors combine to prevent a baby born into water from taking a breath until he is lifted up into the air.

Baby’s First Breath

What initiates the breath in the newborn? As soon as the newborn senses a change in the environment from the water into the air, a complex chain of chemical, hormonal and physical responses initiate the baby’s first breath. Water-born babies are slower to initiate this response because 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 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, because of this adjustment.

Several things happen all at once in 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 born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted out of the water and into mother’s waiting arms.

All the fluids 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 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 (Karlberg et al. 1987).

Outcomes and Concerns

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 (Gilbert and Tookey 1999).

In the early days of waterbirth, a baby was reported to have died from being born in the water. This particular newborn death was caused not by aspiration but by asphyxiation because the baby was left under the water for more than 15 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 (Harper 1989). This is the reason we bring babies up out of the water within the first few moments after birth.

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 (Rosenthal 1991). If the practitioner does not look 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 want to pick up their own babies need to be reminded not to do it too quickly either.

The inability to accurately assess blood loss in the water is a reason given by some midwives for either not “allowing” the birth to take place in the water or asking mother to get out right away after the baby is born. But blood loss is easy to judge after a few births. 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. It also helps you spot floating debris so it can be removed.

This brings us to the second most frequently asked question regarding waterbirth: Won’t the mother get an infection?

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. 1996; Garland and Jones 1997). The oldest reference that researches the possibility of infection during a bath is mentioned in a 1960 American Journal of OB/GYN.

Dr. Siegel posed the question, “Does bath water enter the vagina?” In his experiment he placed sterile cotton tampons into thirty women and then asked them to bathe in iodinated water for a minimum of fifteen minutes. In all cases when the tampons were removed, there was no iodine present (Siegel 1960). His conclusion states, “We can now stop restricting women from bathing in the later stages of pregnancy and labor.”

Infection control, especially in a hospital setting, requires diligence and the attention to strict protocols between and during births. Cleaning and maintaining all equipment used for a waterbirth will prevent the spread of infection. In a random study conducted at the Oregon Health Science University Hospital in 1999, cultures were done from the portable jetted birth pool before, during and after birth, as well as from the fill hose and water tap source. In all instances no bacteria was cultured from the birth pool but the water tap did culture Pseudomonas (Malby 1999). In a British study of 541 water labors, no serious infections were reported during the three-year period of data gathering. Again, Pseudomonas aeruginosa was the only persistent bacteria discovered in two babies who tested positive from ear swabs. No treatment was necessary (Brown 1998).

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 1986). Universal precautions still need to be adhered to and proper cleaning of all the equipment after the birth needs to be carried out.

Using disposable liners has become the norm for use with portable birth pools, but attention must also be paid to proper cleaning of drain pumps, hoses, filter nets, taps and any other items that are reused from one birth to the next.

When to Enter the Bath

One issue that is repeated in the literature and voiced in the concern of mothers and their midwives is: When should the mother enter the bath?

Many hospitals use the five-centimeter rule, only allowing mothers to enter the bath when they are in active labor and dilated to more than five centimeters. Some physiological data 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 (Hadad 1996). The water sometimes slows or stops 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 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, allowing 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 one centimeter to complete dilation within the first hour or two of immersion.

Deep immersion seems to be a key factor. If the pool or bath is not deep enough, at least providing water up to breast level and completely covering the belly, then the benefits of the bath may be less noticeable. The warm water will still provide comfort and the mother will benefit from being upright, in control and drug free, but full immersion promotes more physiological responses, the most notable being a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin (Katz et al. 1990). Vasopressin can also work to increase the levels of oxytocin (Odent 1998). The immediate pain reduction felt upon entering the bath is quite noticeable. It is what I refer to as “the aah effect.” The smile, the sound and the inner peace that mothers display are unmistakable. This response can happen at any point in the labor, but most notably when contractions are long and strong and close together.

Some midwives who assume there is little or no progress in dilation because the mother is not displaying any outward signs of discomfort are often surprised to find rapid dilation in the first hour of immersion. Having experienced a waterbirth myself, I can attest to the incredible difference in perception of pain from the room to the water. When I am with a woman in labor I generally assess her pain on a scale of one to ten before she enters the bath. Most report at least a six or greater. Then after no less than half an hour, I will make another assessment. The second subjective answer of course varies from person to person, but the typical response is two to four. The mother is experiencing more than the sum of her physiological responses to warm water immersion. Most women feel inherently safe in the water.

The water creates a wonderful barrier to the outside world. It becomes the woman’s nest, her cave, her own “womb with a view.” If the pool is large enough to include her partner or husband, it then becomes an intimate place for the two of them to labor together and experience the love dance of birth. If the midwife or physician wants to do a vaginal examination while the mother is in the water, it is much easier for the mother to refuse.

The control that women gain by being able to move freely in the water often helps them assess their own progress either by feeling the baby’s movements more intensively or actually being able to examine themselves internally. Women report that the water intensifies the connection with the baby at the same time that it reduces the pain. They can feel the baby move, descend and push through the birth canal. The prospect of the midwife becoming an active observer increases as mothers assume more and more responsibility for the birth and have the ease of mobility in the water. For many reasons, including reducing the risk of infection for the provider, many midwives suggest a hands-off birth for the mother. The water slows the crowning and offers its own perineal support (Garland 2000). This “minimal-touch” approach also gives the mother a greater sense of control over her own birth.

Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but in some of the literature about the same frequency of tears for primips in or out of the water (Burn and Greenish 1993; Garland and Jones 1997). One of the best benefits of waterbirth is the zero episiotomy rate that is reported throughout the literature. The combination of being upright, having the mother in a good physiological position to birth her baby, giving her the freedom of control and not telling her to push when her body is not indicating it, all contribute to better perineal outcomes.

The Waterbirth Choice

Once a woman has experienced a waterbirth she will more than likely want to repeat the experience. If cir-cumstances have changed and the mother is no longer living in a place where waterbirth facilities or practitioners are readily available, she will go to almost any length to recreate the opportunity to give birth in water.

A research project that Waterbirth International has been conducting for ten years is a survey of women who have given birth in water. One question on the survey form asks: ‘Would you consider giving birth again in water?” With over 1,500 surveys collected, only one woman answered no to that question. On her particular survey she emphatically stated no in bold print with two exclamation points and then drew an arrow down to the bottom of the page where in very small print she wrote, “This is number seven, I’m done!”

It is hard to think of another “method” of childbirth that receives such praise from women and practitioners alike. Dr. Lisa Stolper is an obstetrician practicing in the quaint New England town of Keene, New Hampshire. She began offering waterbirth to her clients at Cheshire Medical Center in October 1998. One year later she reported an overall waterbirth rate of 37 percent for all vaginal births and 33 percent for all births, including cesarean sections. Her hos-pital has purchased just one portable jetted birth pool, but they use it for the labor of almost 50 percent of their cli-ents. They are now considering installing permanent pools to make them available for more women. Her comment about her job as an obstetrician was, “Waterbirth just makes my job so much easier.”

There are so many areas of waterbirth to explore. Waterbirth is more a philosophy of nonintervention than a method or way to give birth. Waterbirth combines psychology, physiology, technology, humanity and science. Waterbirth is ancient and yet new at the same time. Waterbirth embodies a spiritual aspect of birth that is hard to express. Cynthia, who gave birth in water, said it better: “The water made me so completely connected to my body and my baby. The water held me and cradled me so that I could surrender more completely to this amazing and wonderful grace that was happening to me. This is the way that God intended childbirth to be” (from the Waterbirth International Parent Survey).

References:

• Brown, L. 1998. “The Tide of Waterbirth Has Turned: Audit of Waterbirth.” Brit J Midwif 6 (4): 236–43.
• Burn, E, and K Greenish. 1993. “Pooling Information.” Nursing Times 89 (8): 47–49.
• Eriksson, M, et al. 1996. “Warm Tub Bath during Labor: A Study of 1385 Women with Prelabor Rupture of the Membranes after 34 Weeks of Gestation.” Acta Obstet Gyn Scan 75 (7): 642–44.
• Favero, M. 1986. “Risk of AIDS and other STDs from Swimming Pools and Whirlpools Is Nil.” Postgraduate Medicine 80 (1): 283.
• Fewell, JE, and P Johnson. 1983. “Upper Airway Dynamics during Breathing and during Apnea in Fetal Lambs.” J Physiol 339:495–504.
• Hadad, F. 1996. “Labor and Birth in Water: An Obstetrician’s Observations over a Decade.” In Waterbirth Unplugged, 96–108. London: BFM Press.
• Harding, R, P Johnson and M McClelland. 1978. “Liquid Sensitive Laryngeal Receptors in the Developing Sheep, Cat, and Monkey.” J Physiol 277:409–22.
• Garland, Dianne. 2000. Waterbirth: An Attitude to Care. London: Books for Midwives Press.
• Garland, D, and K Jones. 1997. “Waterbirth: Updating the Evidence.” Brit J Midwif 5 (6): 368–73.
• Gilbert, R, and P Tookey. 1999. “Perinatal Mortality and Morbidity among Babies Delivered in Water: Surveillance Study and Postal Survey.” Brit Med J 39:483–87.
• Harper, Barbara. 1989. Personal interviews.
• Johnson, Paul. 1996. “Birth Under Water: To Breathe or Not to Breathe.” Brit J Obstet Gynaec 103:202–08.
• Karlberg, P, et al. 1987. “Alteration of the Infant’s Thorax during Vaginal Delivery.” Acta Obstetrica Gynecol Scandavia 41:223.
• 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.
• Malby, Polly. 1999. Personal communication.
• Odent, M. 1998. “Use of Water during Labor: Updated Recommendations.” MIDIRS 8 (1): 68–69.
• Rosenthal, M. 1991. “Warm-water Immersion in Labor and Birth.” Female Patient 16:44–51.
• Siegel, P. 1960. “Does Bath Water Enter the Vagina?” J Obstet Gynecol 15:660–61.
• Waterbirth International Parent Survey.