Waterbirth Position Paper

MANA AND CFM POSITION STATEMENT ON WATER IMMERSION DURING LABOR AND BIRTH

Introduction

Midwives in home and birth center settings focus on supporting and safeguarding normal physiologic birth processes. Increasingly, worldwide evidence demonstrates that normal physiologic birth and skin-to-skin contact in the moments after birth are optimal for the health of mother and baby(see footnote). Water immersion in labor and birth can facilitate normal physiologic birth by offering pain relief, privacy, comfort, warmth and mobility to the motherand is associated with increased maternal satisfaction with the birth experience. Immediate skin-to-skin connection between mother and baby born in water promotes newborn thermoregulation and facilitates bonding. The Midwives Alliance of North America (MANA) and Citizens for Midwifery (CfM) support ongoing access to water immersion during labor and birth across all birth settings.

Evidence for the Safety of Water Immersion During Labor and Birth

Numerous peer-reviewed studies have examined the use of water immersion during birth, collectively suggesting no evidence of increased neonatal morbidity, including low Apgar score, NICU admission, or neonatal injury. Previous studies also suggest that water immersion during birth is not associated with an increase in maternal morbidity such as vaginal tears, infection and hemorrhage. “Maternal & Newborn Outcomes Following Immersion During Waterbirth: The MANA Statistics Project 2004-2009” by Marit L. Bovbjerg PhD, MS, Melissa Cheyney PhD, CPM, LDM and Courtney Everson MA, PhD was published in the Journal of Midwifery and Women's Health January 20, 2016. This is the largest study ever published on this topic, and the first large cohort study reporting outcomes following waterbirth in a U.S. population. The study included over 18,000 births at home and in birth centers with midwives, 35% of which were waterbirths. Findings confirm previous evidence that water immersion during birth is not associated with harm to newborns. Rates of neonatal transfers to the hospital or other hospitalization in the first six weeks of life were comparable between the waterbirth group and the non-waterbirth group. Best neonatal outcomes in this study were among babies born in water, suggesting that midwives used water immersion appropriately by facilitating exit from the water when indicators of difficulty or distress were present. The authors also reported no increased incidence of postpartum transfer for a maternal indication and no increased risk of maternal infection, however they did see an 11% increased risk of vaginal tears, the majority of which were minor.

Benefits of Water Immersion for Mother and Baby

Water immersion during labor and birth is associated with a number of benefits for both mothers and babies. Mothers who use water immersion report feeling relaxed, involved in decision-making, and being more in control. In Baxter, one client stated, “I felt more relaxed in the pool and the atmosphere was great;” another reported, “I felt so relaxed and in control ...”; another stated, "... although I hadn't intended to deliver in the pool I now can't imagine giving birth any other way, it was so much more comfortable than being on a bed." Mothers also report a high perception of pain relief with use of water immersion, and in one study 86% of women reported that they would use water immersion in a subsequent birth. Specific benefits of water immersion during labor and birth include the following:

For mothers

  • Increased comfort and mobility
  • Decreased sensation of pain
  • Promotion of relaxation, and decreased cortisol levels
  • Decreased blood pressure
  • Increased oxytocin and endorphin levels
  • Decreased duration of labor For babies
  • Better oxygenation during labor
  • Easier descent and rotation through the pelvis
  • Promotion of immediate and sustained skin-to-skin contact
  • Decreased disruption of newborn transition and attachment

In addition, because water immersion facilitates normal physiologic birth, it may also be associated with other beneficial health outcomes for mother and baby, including decreased need for intervention during labor and reduced incidence of surgical/instrumental delivery

Research has demonstrated significant differences in birth outcomes for nonwhite populations; for example, African Americans are four times more likely to die from pregnancy-related complications, two times more likely to experience preterm birth and three times more likely to give birth to a low birth weight infant. The majority of research on waterbirth has not focused on differences in outcomes by race or ethnicity; however, according to Jennie Joseph LM, CPM, founder of The JJ Way® and the National Perinatal Task Force, and CEO of Commonsense Childbirth, Inc., “Given the persistent disparities in health outcomes regarding increased maternal morbidity and mortality in communities of color in the US, water labor and birth provide another important tool that reduces the likelihood of interventions. Therefore, laboring and birthing in water can lead to improved outcomes by reducing unnecessary procedures and supporting physiologic birth, a potential lifesaver for women of color and their babies.” The International Center for Traditional Childbearing further advises that "Women of color experience disproportionate rates of infant mortality, regard less of their educational and economic status. Contributing causes include the higher rate of stress that women of color experience. Laboring and birthing in water can create a calming effect and reduce anxiety. Therefore, women of color should be offered and supported in their choice to labor and birth in water."

Consumer Choice and Shared Decision Making

Shared decision making and informed consent/refusal are central principles of midwifery care, and are increasingly recognized in health care policy in the U.S. Shared decision making is: ...the collaborative process that engages the midwife and client in ongoing verbal and written communication about treatment options. This dynamic process incorporates scientific evidence, clinical expertise, and the client’s preferences and values to determine the plan of care. The process of shared decision making culminates with informed consent, which can be revisited over time. Shared decision making should play a central role in the decision to use water immersion for labor and birth, and this decision should be made in the context of the client's overall care plan. Midwives and clients should discuss the client’s preferences and values, along with the midwife's experience, comfort, and clinical recommendations regarding water immersion. Clients interested in water immersion during labor and birth should choose a midwife who has a high degree of comfort and experience with the use of water immersion, since evidence suggests this may insure better outcomes for mother and baby

Factors that Promote Safety and Success

There are several factors and practice principles that enhance safety and success in waterbirth. Harper and Nutter et al. provide practice recommendations based on available evidence and clinical pearls of wisdom, including the following:

Clients who want to labor or birth in water, who are considered lower risk, and who are educated about the risks and benefits, are considered good candidates for waterbirth.

  • A client’s ability to easily enter and exit the water, or to be assisted from the water at any point, is an important safety factor. Clients with high Body Mass Index should have access to water immersion if they choose as long as there is sufficient help or a mechanism available to facilitate expedient entry into and exit from the water.
  • Water temperature is best kept at or below 100 degrees F to reduce risk of maternal fever and fetal hyperthermia. The mother may choose to labor in cooler water, however water temperature for birth should be warm enough for baby to maintain optimum core temperature and should be monitored frequently while the newborn remains in contact with the water.
  • Blood borne pathogen screening, universal precautions, and thorough tub and equipment cleaning are important infection control practices. Equipment should be cleaned with antibacterial solutions effective against HIV, Hepatitis B and C, rinsed and dried according to manufacturer directions before refilling or relining with a new pool liner. Attention to water quality and freshness are also important in reducing infection risk.
  • The Bovbjerg et al. study as well as several studies in the Nutter et al. review indicate no difference in maternal infection betw een waterbirth and non-waterbirth. The risk of neonatal infection was low and NICU admissions show no difference between waterbirth and non-waterbirth.
  • Women laboring in water through second stage should be monitored with a waterproof doppler as frequently as they would be for non-waterbirth.
  • Normal neonatal physiology and the infant dive reflex allow infants to be safely born completely underwater. Babies are not stimulated to breathe until they experience gravity and have room air on their faces. Babies receive all their needed oxygen via the pulsing cord for several seconds following birth. During the birth, the baby's face should be completely submerged and not exposed to cooler water or air to reduce the risk of aspiration; the baby’ s face needs to be lifted out of the water once birth of the body is completed. If the client changes position during delivery, and is above the water level, it is advised to stay out of the water for the remaining delivery of the baby.
  • Normal physiologic third stage can be managed in the water per the needs or preferences of the client and midwife. If active management is required then assisting the client out of the water is recommended.
  • Midwives should be aware and prepared that third stage may take longer in water because even after baby is brought to the surface, cords take longer to stop pulsing. Ideally cords should be allowed to stop pulsing prior to clamping and cutting, allowing for a gentle and normal physiologic newborn transition and complete transfer of neonatal blood supply to the baby.
  • To reduce the chance of cord avulsion (tearing), providers should assess cord length and avoid tension when bringing the baby to the surface. The ability to quickly assist the mother to stand up to bring the baby with a short cord above the surface of the water is important. Cord clamps should be readily available.
  • Loose nuchal cords can be resolved as the baby is born into the water.
  • Thermoregulation of the baby can be achieved through immediate skin to skin on the client’s chest with partial submersion of the baby in the warm water. Drying the baby’s head will help reduce heat loss.
  • Be aware that babies may be slower to breathe, cry, or pink up during a waterbirth due to a slower transition. The midwife will watchfully monitor other signs of normal newborn transition (such as heart rate, tone, grimace) and respond quickly to any indicators of distress.
  • Research indicates that there is either an equal or reduced rate of blood loss and postpartum bleeding in waterbirth compared to non-waterbirth. Water clarity can be helpful in assessing blood loss. Nutter et al. recommends assisting the woman from the pool if her legs cannot be clearly seen.
  • During waterbirth, babies normally experience uninterrupted skin-to-skin contact that helps to facilitate breastfeeding. However, to further assist breastfeeding, allow baby to do the breast crawl after the client and baby have exited the water. This can be done even if the baby has had an initial feed in the water.
  • A significant factor in increasing success and safety for waterbirth is the experience and comfort level of the midwife. It is important for the midwife to be educated and knowledgeable about maternal and newborn norms in relation to labor and birth in water.

Conclusion

Of births attended by midwives in hospitals and birth centers in the U.S., between 15-64% of mothers used water immersion during labor, and between 9-31% used water immersion during birth. In the MANA Stats study, Bovbjerg et al., 35% of 18,000 women who gave birth at home and in birth centers with midwives delivered in water. This level of use suggests that women consider water immersion a valuable option for labor and birth. Current research suggests that water immersion during labor and birth is safe for mothers and babies, and provides benefits to both. MANA and CfM support the use of water immersion during labor and birth, and believe that it should be made available to birthing families across all birth settings. MANA and CfM encourage all care providers to become educated about the safe use of water immersion during labor and birth, and to engage in a shared decision making process when discussing the option of water immersion with their clients.

References

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