Surf or Turf? What does evidence show?

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Surf or Turf? What does evidence show?

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It’s not usually long after someone hears that I attend home births that I am questioned if I have ever seen a baby born in the water. Well, not only have I seen many, many babies born in water, I birthed one of my own children in a tub. I have not only seen, but experienced the amazing benefits of hydrotherapy during labor/birth.

This is also a hot button topic in the birth community. Most out of hospital providers find water birth to be safe, relaxing and used by a high percentage of clients. On the other hand, most hospital providers find water birth to be dangerous and inconvenient. So, if you’ll just hang in here, I’m going to delve into the pros vs cons of water birth and address the most commonly held concerns from people who don’t see this type of birth on a regular basis.

According to ACOG (American College of Obstetrics and Gynecology), “ Immersion in water during the first stage of labor may be associated with shorter labor and decreased use of spinal and epidural analgesia and may be offered to healthy women with uncomplicated pregnancies between 37 0/7 weeks and 41 6/7 weeks of gestation. There are insufficient data on which to draw conclusions regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water.”

For those of you unsure what first stage vs second stage is all about, here is a simple explanation. First stage is all of labor leading up to 10 cm and time to push. Second stage is pushing the baby out and birth of the baby. So, basically, ACOG recommends using water to help with the pain of labor contractions but does not recommend birthing in water. The AAP (American Academy of Pediatrics) agrees with this statement while the AABC (American Academy of Birth Centers), ACNM (American College of Nurse Midwives) and RCOG (Royal College of Midwives – the ones that deliver the royal family) all came out with statements saying that labor AND birth are safe options for women. However, ACOG also says “Furthermore, the College recognizes that despite the opinions expressed in this document, a woman may request immersion during the second stage of labor, including giving birth while submerged.” This is my favorite part of their statement. One thing I am very passionate about is helping women to feel informed and empowered to share in decision making for their health and the health of their baby. Unfortunately, this is not usually the opinion of many health care professionals. I have seen time and time again women feel bullied and scare tactics used to convince a woman to do things the way the doctor thinks they should.

So, why is ACOG only supportive of laboring in water and not birthing in water? Well, let’s take a minute and look at each concern. I will also be giving information and international studies that I received from world renowned water birth expert Barbara Harper. I had the privilege and honor of attending her waterbirth workshop in a hospital in central Florida. She has travelled the world (literally, all around the world) and shared her knowledge with hospitals and out of hospital providers alike.

Here we go…

  1. Aspiration – ACOG states “Although it has been claimed that neonates delivered into the water do not breathe, gasp, or swallow water because of the protective ‘diving reflex,’ experimental studies on animals and a vast body of literature from meconium aspiration syndrome demonstrate that, in compromised fetuses and neonates, the diving reflex is overridden, which potentially leads to gasping and aspiration of the surrounding fluid.” According to Barbara Harper in the Journal of Perinatal Education, “There are several mechanisms that prevent the baby from inhaling or gasping while it is still submerged in the water as the head is born and after the full body has slipped into the water. An understanding of these mechanisms is important to appraise the safety of water birth. It is also important to have knowledge of the triggers for newborn breathing and what takes place in the cardiovascular system as the baby transitions from fetal circulation to newborn circulation.” She goes on to list in vivid detail the mechanisms of how the baby transitions from womb to world and lists the studies and doctors that back up her statement.
  2. Infection – ACOG states “Cases of major infection with Pseudomonas aeruginosa (25, 26) and Legionella pneumophila (27–29), two of which were fatal (26, 29), have been observed. Importantly, several of these cases noted additional risk factors for infection, including inadequate pool disinfection (29), heated immersion water (27), pool filling 2 weeks before intended use (27, 29), and using water from a contaminated source (29). Therefore, facilities offering immersion must establish rigorous protocols for maintenance and cleaning of tubs and immersion pools and infection control procedures.” Many hospitals agree with ACOG in allowing a women to labor in water but not birth but they also will not allow a woman to labor in water if membranes are ruptured due to risk of infection. According to Barbara Harper, “In 1960, Dr. Siegel published a study in the Journal of Obstetrics and Gynecology entitled, ‘Does Bath Water Enter the Vagina?’ Pregnant women were put into bathtubs that contained iodine-stained water. Before entering the bath, a sterile, starched white tampon, without a string, was inserted into the vagina. After 15 min of soaking, the women left the bath, the tampons were removed, and not a single one was stained with iodine. Thus, the fear that bath water may infect a pregnant or puerperal woman is not founded on fact, since normally no water enters the vagina. Therefore, restrictions on bathing during and after pregnancy are not warranted on this basis alone. Moreover, this teaching represents another classic example of error. The bottom line in preventing infection and cross contamination in birth pools and equipment is to make everything either disposable or cleanable. Having infection control policies in place for all birth settings, even home births, is necessary to prevent serious infections from occurring, especially with multi-use birth pools and installed bath tubs.” This is an easy one. You can see the concerns listed from ACOG are very rare cases and are all cases where safe protocols were not being practiced. Obviously, you want to use clean, new water in a clean tub. Your care provider should be well versed in this area and can walk you through the steps of sterilization to keep you and baby safe. Also, laboring in water when membranes are ruptured should not be discouraged as studies show that infection from bath water is not a concern.
  3. Cord Avulsion – ACOG states “Umbilical cord avulsion (cord “snapping” or cord rupture) has been observed as the newborn is lifted or maneuvered out of the water.” However, in a study by the AABC (American Association of Birth Centers), “There are reports of umbilical cord rupture, but not at a rate higher than seen with non-water birth.” In my experience, this is more likely to happen with a poorly trained midwife or when the parent is lifting the baby out of the water without any instruction. Again, this is a concern for land or water birth and a trained midwife should reduce the incidence while being ready to assist if avulsion does occur.

For a great in depth article that references all the studies listed above and digs deep into how the studies were conducted and how to come to an evidence based conclusion of the safety and benefits of water birth, click here.

Like I said at the beginning of this article, I have seen many women birth in water and have experienced first hand the benefits. Now that we compared the concerns of water birth with facts, let’s talk a little about why so many women choose water birth and what it’s all about.

  1. Pain relief – If you have ever used a bath to help deal with any type of discomfort; bad cramps, muscle soreness, achiness, stress, then you understand how hydrotherapy can help during labor. As labor progresses and contractions get more intense, water can be the saving grace that a woman needs. Evidence Based Birth says “In seven out of seven studies that looked at the relationship between waterbirth and the need for pain relief, women who gave birth in water used less pain medications compared to women who had land births.”
  2. Transition for baby – A baby lives in water for 9 months and being born in water makes the transition to the world more peaceful. Baby’s born in water usually cry less and adjust to their new environment smoothly.
  3. Clean up – Birth is messy, but it’s way less messy in the tub. After birth in water, a mom can rinse off quickly before heading to bed. There is no concern about getting blood on sheets, mattress, carpet, etc.. There is also less laundry to worry about. Obviously, this one only for the home birth mamas out there.
  4. Length of labor – While studies have mixed reviews, many show that water reduces the time of every stage of labor, including delivery of the placenta.
  5. Blood Loss – Studies show significantly lower amounts of blood loss following water birth compared to land birth.
  6. Tearing – The water helps to soften the tissue at the perineum and reduces the chance of tearing.

Although many women I attend in labor will labor and/or birth in water, not everyone does. This post is not written to convince every woman to birth in water. This post is written to help understand the truth behind the concerns in the medical community regarding water birth and to help women understand why moms are choosing this method. Every mom should labor and birth where she feels the most comfortable as long as there are no safety concerns for her or baby. I only choose this for 1 out of my 4 births. It’s not the only way, but it certainly should be an option.

 

Resources
https://evidencebasedbirth.com/waterbirth/
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Immersion-in-Water-During-Labor-and-Delivery#30
http://c.ymcdn.com/sites/www.birthcenters.org/resource/resmgr/News_-_Documents/AABC_Position_Statement_-_Im.pdf
The Journal of Perinatal Education: Advancing Normal Birth

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