In light of recent events, I was interviewed by Boston’s NPR news station to share my opinion and experience surrounding Waterbirth. The article can be found here http://commonhealth.wbur.org/tag/water-birth
ACOG & AAP Joint Statement on Waterbirth
The American College of Obstetricans and Gynecologists and the American Academy of Pediatrics has just issued a joint statement that attempts to take waterbirth out of the hands of midwives and their patients.
The statement follows:
Immersion in water has been suggested as a beneficial alternative for labor, or delivery, or both and over the past decades has gained popularity in many parts of world. Immersion in water during the first stage of labor may be associated with decreased pain or use of anesthesia and decreased duration of labor. However, there is no evidence that immersion in water during the first stage of labor otherwise improves perinatal outcomes, and it should not prevent or inhibit other elements of care. The safety and efficacy of immersion in water during the second stage of labor have not been established, and immersion in water during the second stage of labor has not been associated with maternal or fetal benefit. Given these facts and case reports of rare but serious adverse effects in the newborn, the practice of immersion in the second stage of labor (underwater delivery) should be considered an experimental procedure that only should be performed within the context of an appropriately designed clinical trial with informed consent. Facilities that plan to offer immersion in the first stage of labor need to establish rigorous protocols for candidate selection, maintenance and cleaning of tubs and immersion pools, infection control procedures, monitoring of mothers and fetuses at appropriate intervals while immersed, and immediately and safely moving women out of the tubs if maternal or fetal concerns develop.
ACNM Response to ACOG
The American College of Nurse-Midwives issued the following response to ACOG:
ACNM believes that this committee opinion does not accurately reflect the large and growing body of research that supports water birth as a reasonable choice for healthy women experiencing normal labor and birth. Despite limitations, the best available research indicates that water birth is associated with perinatal outcomes similar to those expected in a low-risk population. In other words, healthy women and their babies generally stay healthy during and after normal labor and water birth. Therefore, water birth is a reasonable choice for healthy women to make in collaboration with their care provider, given the state of the science.
And The Midwives of New Jersey’s Response
How Safe is Waterbirth?
Waterbirth is the single best thing to happen to natural childbirth, ever. When offered within proven guidelines, it is incredibly safe. I can show you 800+ children to prove it. My practice has offered waterbirth since the year 2000 without any complications related to the birth being in the water-aspiration of tub water causing pneumonia or infection/sepsis. We have seen plenty of the normal complications of childbirth that have happened in the tub. We have learned how to manage shoulder dystocia, hemorrhage, abnormal fetal heart tones, and babies requiring resuscitation quickly and efficiently with no more morbidity than if the woman labored and delivered in the air. In fact, waterbirth is believed to decrease the transmission of Group B strep which can cause pneumonia in newborns. An article published by Cohain considers the studies included in a Cochrane review of immersion in water in labour and birth. (Cluett et al). The Cochrane review concluded that “The safety regarding infection and neonatal outcomes are not addressed, and large collaborative trials are needed to answer these critical issues.” Cohain notes that “The literature provides a single case of early onset newborn Group B Strep (GBS) among 4432 waterbirths, suggesting that low-risk women who give birth in water may have a far lower rate of newborn GBS than women who have a dry birth. The last reported rate of newborn GBS for dry births was 1 in 1450.”
Considering water birth in general, the 2006 Joint statement from the RCOG and the Royal College of Midwives “Immersion in Water During Labour and Birth”, whilst making no specific reference to Group B strep, says that:
“All healthy women with uncomplicated pregnancies at term should have the option of water birth available to them and should be able to proceed to a water birth if they wish.”
The Key to Safe Waterbirth
I believe with all my heart and soul that waterbirth is safe in the way that I practice. Our clients sign consents for waterbirth which outline the circumstances in which water labor and birth can occur. I stay with the woman almost continuously in active labor and certainly during the pushing part of labor. I am monitoring the mom and baby very carefully, assessing the safety of laboring and delivering in the tub minute to minute. I believe the key to safety is the presence and assessment of the midwife. I am not sure this is the appropriate mode of delivery for an obstetrician who typically relies on a busy nursing staff to monitor clients during labor until very shortly before the delivery.
Trusting the Birth Process
Waterbirth has changed my practice as a midwife significantly. I have learned how to create a sacred space for women to labor and deliver within and how to take my hands off a normal process. I have virtually eliminated shoulder dystocia from my practice because waterbirth kept me from “helping” the mother deliver her baby’s shoulders and thus wedging the shoulders into the pubic bone. I now use a very hands off approach to ALL of my births with better outcomes. I cannot “protect” a woman’s perineum with my hands in waterbirth and I realized that I was often protecting nothing and breaking a lot. Waterbirth has shown me that it is not important for me to see the vagina or the baby’s head for the delivery to go well. Because the baby will not fall but float, the mother can assume a very commonly preferred position- on her knees with baby delivering beneath her and suffer less difficulty delivering the baby, less perineal trauma and way more autonomy!
The Benefits of Water Immersion
Women will attempt an unmedicated birth if they have the hope of comfort within the tub. Water immersion decreases adrenaline and increases endorphins and oxytocin. So laboring in water is great. But if we do not allow the delivery to occur in the water, we risk disrupting the progress of labor by increasing the pain women experience. I believe there would be much more perineal trauma outside the tub because women are able to tolerate the time it takes to stretch the perineum much better in the tub. Women have often reported to me that even though they had people around them for their waterbirth, they felt completely alone with their baby after the birth, this is nature at its best. The high level of oxytocin, endorphins and adrenalin are the perfect hormonal cocktail for initiation of the most important bond a human ever experiences. I am in the business of changing the world through birth. I believe that showing women how incredible and powerful they are in a natural birth will change them as women and as mothers forever. Waterbirth must remain a birth choice for women in the USA.