Water Birth Safety

A water birth is not for all women undergoing labor. Some of the criteria used to select women who are suitable for this mode of natural childbirth include:

• Healthy low-risk pregnancy
• Singleton fetus in cephalic presentation
• 37 weeks or more pregnant
• No HIV, HBV or HCV infection
• Membranes intact or ruptured less than 18-24 hours
• If membranes ruptured, amniotic fluid is clear
• Normal fetal heart rate

There are other conditions as well which must be followed to ensure that a water birth is safe for both mother and infant. The question of a safe birth in water is a vexed one, with American paediatricians and obstetricians pitting their opposition to birth in water to the widespread endorsement of water birth as a safe alternative to land birth in most of Europe.

A woman holds her newborn son right after giving birth, they are still in the birthing pool after labor at home. Image Credit: In The Light Photography / Shutterstock

It is interesting that most medical practitioners agree that immersion in warm water during the first stage is beneficial to the laboring woman in terms of pain relief and shorter duration of labor. However, this opinion is outdated in the views of many experienced midwives who have undertaken and witnessed thousands of water births, besides not being evidence-based. Since 2002, according to one rebuttal, many studies have emerged testifying that water birth is as safe as land birth with respect to neonatal and maternal outcomes.

Despite the American Council of Obstetricians and Gynecologists (ACOG) warning that water birth has no known benefits and has cause for concern of harm, other medical professionals such as Dr. Duncan Neilson, chair of the Perinatology Department and vice president of both Women’s Services and Surgical Services at the Legacy Emanuel Hospital in Portland has reviewed the available evidence and concluded that there is no ground for believing that it poses any danger for mother or infant.

The Framework for Maternity Service brought out by the UK National Health Service and the National Childbirth Trusts have also expressed their opinion that water birth is an alternative to land birth and that all hospitals should, as far as possible, have birthing pools and trained staff to facilitate water birth if the laboring woman so desires.

The benefits perceived include:

• the lack of maternal sedation
• the free play of maternal endorphins and oxytocin on her own and the fetal physiology
• lack of interference with the natural process of childbirth
• the easier descent of the baby through the birth canal when the mother’s weight is supported and she can shift positions freely
• lower incidence of perineal injury with controlled delivery by the mother herself
• spontaneous expulsion of the baby’s head without anyone actually touching it allows natural reflexes to operate

Potential risks most often cited by paediatricians include:

• neonatal aspiration of water, possibly contaminated
• hypothermia
• neonatal infection

However, all available research shows that these are not realistic possibilities during water birth, as explained below.

Aspiration

Studies on fetal and neonatal physiology have shown that there are several inbuilt mechanisms that prevent the inhalation of water, or indeed breathing at all, while the fetal head is still submerged in the water.

Firstly, fetal breathing movements which normally occur in utero starting at 10 weeks cease at at about 4 cm of cervical dilatation. This is thought to be due to the elevated PGE2 levels at this period which inhibits intercostal muscle contraction throughout labor and delivery. This naturally prevents fetal breathing or inhalation during the process of birth.
 

Another factor is the physiological mild hypoxia of the newborn which promotes bradycardia, inhibition of breathing, and swallowing as the first act rather than breathing. Other inhibitory factors include the lack of touch to the head, the lack of contact between fetal chemoreceptors with atmospheric oxygen and carbon dioxide, and the absence of gravitational pull on the head of the neonate until birth is complete and the whole body has slipped into the water.

In water birth under the supervision of trained personnel, the baby is lifted gently out of the water and placed on the mother’s chest, promoting swallowing of the secretions in the mouth and quiet alert newborn physiology. This allows the newborn to start breathing normally without distress or panic.

Hypothermia

Neonatal thermoregulation is enhanced by the increased capillary filling in the skin because of the 20% increase in the newborn’s blood volume by the blood from the cord, as a result of delayed cord clamping.

Even more importantly, the baby is kept on the mother’s chest to continue the skin-to-skin contact between the mother and the infant, which is the best means of keeping the baby warm. The face and head are wiped with a soft dry towel and the back is also covered with a towel. This ensures the baby’s temperature is kept stable after birth.

Infection

A 1960 article by Siegel et al established that water outside the vagina does not enter it by means of an innovative experiment involving a tampon inserted into the vagina of pregnant women, before letting them soak in bathtubs containing water stained with iodine. 15 minutes later the women were helped out, the tampons were removed, and all were still unstained. This means that vaginal infection cannot occur due to bath water entering the vagina under normal conditions.

Laboring women with premature rupture of women who were in latent labor were also studied in 1996 (Eriksson et al, 1996). They were divided into two groups after labor began, one of whom bathed normally while the other group did not. The former had significantly lower incidence of infection even with 72 hours of latent labor, thereby proving that a water birth does not increase the risk of birth infection.

Fecal contamination of bath water is also not a valid hazard because of the dilution effect of the water, which actually only provided the right medium for a healthy colonization of the baby’s gut with vaginal and fecal maternal flora.

Water birth research on group B streptococcus infection has shown that colonization by bacteria is less in these women than with land births. The real point is to ensure, as always, that all equipment used during the water birth is either disposable or can be cleaned very well, adhering to strict infection control policies.

Studies by directors of natural birth centers in the US have led to a statement in 2014 that water birth, using the strict criteria and trained staff, is a positive experience for mothers and neonates. This is true with respect to the following parameters:

• Newborn admission to hospital is less than 1.5%
• Adverse neonatal outcomes as measured by Apgar scores, infection rates, or NICU admission, are below 1% following water birth
• The incidence of any breathing problem following water birth is 1.6%, which is less than that in land-born babies
• No difference or reduced rates of Cesarean section and assisted delivery

Conclusion

European and British health authorities have issued policy guidelines supporting the role of water births in labor and delivery, stating that “the evidence to date fails to reveal any major problems, particularly when midwives and medical staff are adequately educated and practice with care.”

Available research does not have any adverse effect on labor duration, the rate of operative vaginal delivery, or neonatal outcomes, according to the SA First Stage Labour and Birth in Water Policy, though it is true that properly powered and designed trials are few. This is the reason why these countries offer water birth to all eligible laboring women who express a desire for alternatives to medical pain relief during delivery.

References

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4210671/
• http://healthywa.wa.gov.au/Articles/J_M/Labour-and-birth-using-water
• https://www.sahealth.sa.gov.au/wps/wcm/connect/ae527200465ec14d8572ff2e504170d4/Policy-FirstStageBirthInWater-SAHealth-20101221.pdf?MOD=AJPERES&CACHEID=ae527200465ec14d8572ff2e504170d4
• http://www.health.wa.gov.au/circularsnew/pdfs/13357.pdf