Water birth
Encyclopedia
Childbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
, which involves immersion in warm water. The immersion can mean giving birth to the infant in the water or using it as a tool during the labor process. Proponents believe that this method is safe and provides many benefits for both mother and infant
Infant
A newborn or baby is the very young offspring of a human or other mammal. A newborn is an infant who is within hours, days, or up to a few weeks from birth. In medical contexts, newborn or neonate refers to an infant in the first 28 days after birth...
, including pain
Pain
Pain is an unpleasant sensation often caused by intense or damaging stimuli such as stubbing a toe, burning a finger, putting iodine on a cut, and bumping the "funny bone."...
relief and a less traumatic birth experience for the baby. However, critics argue that the procedure introduces unnecessary risks to the infant such as infection and water inhalation.
History
The first recorded water birth occurred in France in 1803. In the 1960s, self-educated Soviet researcher Igor Charkovsky explored the safety and possible benefits of water birth in the Soviet Union. In 1974, French obstetrician Frederick LeboyerFrederick Leboyer
Frederick Leboyer is a French obstetrician, best known for his 1975 book, Birth Without Violence, which popularized gentle birthing techniques, in particular, the practice of immersing newly-born infants in a small tub of warm water — known as a "Leboyer bath" — to help ease the transition from...
published a book advocating the immersion of newly born infant
Infant
A newborn or baby is the very young offspring of a human or other mammal. A newborn is an infant who is within hours, days, or up to a few weeks from birth. In medical contexts, newborn or neonate refers to an infant in the first 28 days after birth...
s in warm water for the purpose of easing the transition from the womb
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
to the outside world, and to mitigate the effects of any possible birth trauma
Psychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
.
Another French obstetrician, Michel Odent
Michel Odent
Michel Odent is a retired medical doctor. He was born in France in 1930 and studied medicine at Paris University. He is known for his role in the natural childbirth movement and for promoting water birth...
, took Leboyer's work further, using the warm-water birth pool for pain relief
Pain management
Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists,...
for the mother, and as a way to normalize the birth process. When some women refused to get out of the water to finish giving birth, Odent started researching the possible benefits for the baby of being born under water, as well as the potential problems in such births. By the late 1990s, thousands of women had given birth at Odent's birthing center
Birthing center
A birthing center or centre is a healthcare facility, staffed by nurse-midwives, midwives and/or obstetricians, for mothers in labor, who may be assisted by doulas and coaches. By attending the laboring mother, the doulas can assist the midwives and make the birth easier. The midwives monitor the...
at Pithiviers
Pithiviers
Pithiviers is a commune in the Loiret department in north-central France. It is twinned with Ashby-de-la-Zouch in Leicestershire, England....
, and the notion of water birth had spread to many other Western
Western culture
Western culture, sometimes equated with Western civilization or European civilization, refers to cultures of European origin and is used very broadly to refer to a heritage of social norms, ethical values, traditional customs, religious beliefs, political systems, and specific artifacts and...
countries.
Water birth first came to the United States through couples giving birth at home
Home birth
A home birth in developed countries is an attended or an unattended childbirth in a non-clinical setting, typically using natural childbirth methods, that takes place in a residence rather than in a hospital or a birth centre, and usually attended by a midwife or lay attendant with expertise in...
, but soon was introduced into the medical environment of hospitals and free-standing birth centers
Birthing center
A birthing center or centre is a healthcare facility, staffed by nurse-midwives, midwives and/or obstetricians, for mothers in labor, who may be assisted by doulas and coaches. By attending the laboring mother, the doulas can assist the midwives and make the birth easier. The midwives monitor the...
by midwives and obstetricians. In 1991, Monadnock Community Hospital in Peterborough
Peterborough
Peterborough is a cathedral city and unitary authority area in the East of England, with an estimated population of in June 2007. For ceremonial purposes it is in the county of Cambridgeshire. Situated north of London, the city stands on the River Nene which flows into the North Sea...
, New Hampshire
New Hampshire
New Hampshire is a state in the New England region of the northeastern United States of America. The state was named after the southern English county of Hampshire. It is bordered by Massachusetts to the south, Vermont to the west, Maine and the Atlantic Ocean to the east, and the Canadian...
started to create a protocol
Guideline (medical)
A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
for giving birth in water. More than three-quarters of all National Health Service
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
hospitals in the UK provide this option for laboring women.
For the baby
ChildbirthChildbirth
Childbirth is the culmination of a human pregnancy or gestation period with the birth of one or more newborn infants from a woman's uterus...
is believed to be a strenuous experience for the baby. Properly heated water is claimed by proponents to help ease the transition from the birth canal
Vagina
The vagina is a fibromuscular tubular tract leading from the uterus to the exterior of the body in female placental mammals and marsupials, or to the cloaca in female birds, monotremes, and some reptiles. Female insects and other invertebrates also have a vagina, which is the terminal part of the...
to the outside world because the warm liquid is thought to resemble the intrauterine environment
Pre- and perinatal psychology
Prenatal and perinatal psychology is an interdisciplinary study of the foundations of health in body, mind, emotions and in enduring response patterns to life...
.
Relaxation
Mothers have found the warm water lowers blood pressure and therefore, it may be an effective method for reducing stress and anxiety. According to the American Pregnancy Association, the reduction of anxiety, allows the mother to focus on the laboring process instead of any tension. Because her muscles are able to relax, it releases pain inhibitors and she is then better able to cope with the pain and have a positive birthing experience. This may be why there is less need for use of analgesia such as epidurals, pitocin, etc..Pain management
Harper reports that water birth is an effective form of pain managementPain management
Pain management is a branch of medicine employing an interdisciplinary approach for easing the suffering and improving the quality of life of those living with pain. The typical pain management team includes medical practitioners, clinical psychologists, physiotherapists, occupational therapists,...
during labor and delivery (Harper 2000). Water birth is a form of hydrotherapy
Hydrotherapy
Hydrotherapy, formerly called hydropathy, involves the use of water for pain-relief and treating illness. The term hydrotherapy itself is synonymous with the term water cure as it was originally marketed by practitioners and promoters in the 19th century...
which, in studies, has been shown to be an effective form of pain management for a variety of conditions especially lower back pain (a common complaint of women in labor). In an appraisal of 17 randomized trials, two controlled studies, 12 cohort studies, and two case reports, it was concluded that there was a definite "benefit from hydrotherapy in pain, function, self-efficacy and affect, joint mobility, strength, and balance, particularly among older adults, subjects with rheumatic conditions and chronic low back pain," (Geytenbeek 2002). Other options for pain control during labor and delivery are epidural anesthesia and intravenous opioids. Epidural anesthesia may be associated with a higher incidence of instrumental delivery with forceps. However, epidural anesthesia does not increase the incidence of cesarean section and has been shown to be a safe alternative for labor analgesia. Full immersion in water promotes physiological responses in the mother that reduce pain including a redistribution of blood volume, which stimulates the release of oxytocin
Oxytocin
Oxytocin is a mammalian hormone that acts primarily as a neuromodulator in the brain.Oxytocin is best known for its roles in sexual reproduction, in particular during and after childbirth...
and vasopressin
Vasopressin
Arginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...
(Katz 1990), the latter which also increases oxytocin blood levels (Odent 1998). The Cochrane Database of Systematic Reviews has found that "the statistically significant reduction in maternal perception of pain and in the rate of epidural analgesia suggest that water immersion during the first stage of labour is beneficial for some women. No evidence was found that this benefit was associated with poorer outcomes for babies or longer labours." It has also been found that in waterbirths the buoyancy of the mother and the baby allow for a gravitational pull. This pull not only opens up the mother's pelvis
Pelvis
In human anatomy, the pelvis is the lower part of the trunk, between the abdomen and the lower limbs .The pelvis includes several structures:...
but also allows the baby to descend more easily.
Intact perineum/decreased episiotomy
Water birth is believed to aid stretching of the perineumPerineum
In human anatomy, the perineum is a region of the body including the perineal body and surrounding structures...
and decrease the risk of skin tears. Support from the water slows crowning of the infant's head and offers perineal support, which decreases the risk of tearing and reduces the use of episiotomy
Episiotomy
An episiotomy , also known as perineotomy, is a surgically planned incision on the perineum and the posterior vaginal wall during second stage of labor. The incision, which can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic , and is sutured...
, a surgical procedure which can cause a number of complications. Indeed, there is a zero episiotomy rate in the waterbirth literature (Harper 2000). Moreover, "perineal trauma is reported to be generally less severe, with more intact perineums for multips (multiparas, or mothers who have had multiple births), but in some literature about the same frequency of tears for primips (primipara, or mothers who are having their first birth) in or out of the water," (Harper 2000; also see Burn 1993 and Garland 1997).
Risks and concerns
A study of some 4000 waterbirths in the UK (1994–1996) concluded: "The similarity in perinatal mortalityMortality
Mortality is the condition of being mortal, or susceptible to death; the opposite of immortality.It may also refer to:* Mortality rate, a measure of the number of deaths in a given population...
and morbidity in low risk women suggests that delivery in water does not substantially increase adverse perinatal outcomes. Overall rates may, however, mask specific benefits and harms, such as water aspiration or snapped umbilical cord." A 2003 review of the medical literature on water births concluded that it showed no benefit to the infant and no clear evidence of reduced labor duration, risk of perineal
Perineum
In human anatomy, the perineum is a region of the body including the perineal body and surrounding structures...
tears, or use of pain medication. There were 64 infants that experienced complications directly attributable to water birth, including bacterial infection, drowning, near-drowning, and fever.
A second article from 2003, signed by four doctors and nurses in the nursing, pediatrics, and obstetrics/gynecology departments at Maine Medical Center, drew attention to a picture of an infant open-mouthed while delivered underwater. While proponents claim that an infant will not breathe if the birthing water is kept at body temperature, no study confirms this. A fetus will breathe amniotic fluid, which is by definition at body temperature.
The American Academy of Pediatrics
American Academy of Pediatrics
The American Academy of Pediatrics is the major professional association of pediatricians in the United States. The AAP was founded in 1930 by 35 pediatricians to address pediatric healthcare standards. It currently has 60,000 members in primary care and sub-specialist areas...
2005 statement on water birth concluded: "The safety and efficacy of underwater birth for the newborn has not been established. There is no convincing evidence of benefit to the neonate but some concern for serious harm. Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent."
As of 2006, the American College of Obstetricians and Gynecologists had not taken an official position on water birth (Schuman 2006), though the UK Royal College of Obstetricians and Gynaecologists
Royal College of Obstetricians and Gynaecologists
The Royal College of Obstetricians and Gynaecologists is a professional association based in the UK. Its members, including people with and without medical degrees, work in the field of obstetrics and gynaecology, that is, pregnancy, childbirth, and female sexual and reproductive health...
and the Royal College of Midwives
Royal College of Midwives
The Royal College of Midwives is a British midwives organisation which has existed under its present name since 1947.-History:The Matrons' Aid Society, renamed the Midwives' Institute in 1881, was founded by Louisa Hubbard and Zepharina Veitch to raise the training and status of midwives...
support water birth for healthy women with uncomplicated pregnancies. Studies that are critical of water birth generally object to or cite evidence from "poorly managed" or un-monitored water birth by inexperienced care providers.
Infection
Another concern is that the water could increase the risk of infection. In a randomized controlled trialRandomized controlled trial
A randomized controlled trial is a type of scientific experiment - a form of clinical trial - most commonly used in testing the safety and efficacy or effectiveness of healthcare services or health technologies A randomized controlled trial (RCT) is a type of scientific experiment - a form of...
of the effects of water labor in Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
, no difference was noted in the low rates of maternal and newborn signs of infection in women with ruptured membrane
Amniotic sac
The amniotic sac is the sac in which the fetus develops in amniotes. It is a tough but thin transparent pair of membranes, which hold a developing embryo until shortly before birth. The inner membrane, the amnion, contains the amniotic fluid and the fetus. The outer membrane, the Chorion,...
s. In a 1999 study of bacterial cultures
Microbiological culture
A microbiological culture, or microbial culture, is a method of multiplying microbial organisms by letting them reproduce in predetermined culture media under controlled laboratory conditions. Microbial cultures are used to determine the type of organism, its abundance in the sample being tested,...
carried out at the Oregon Health Sciences University Hospital, there were no instances of bacteria cultured from the birth pool itself. While Pseudomonas
Pseudomonas
Pseudomonas is a genus of gammaproteobacteria, belonging to the family Pseudomonadaceae containing 191 validly described species.Recently, 16S rRNA sequence analysis has redefined the taxonomy of many bacterial species. As a result, the genus Pseudomonas includes strains formerly classified in the...
bacteria (common in tap water) were present, even those infants that tested positive for the bacteria needed no treatment for infections. In a 2004 study, of the water of a birth pool following birth after filtration and more rigorous cleaning procedures (that had been put in place as a result of the study finding contamination between births) were instituted, high concentrations of E. coli
Escherichia coli
Escherichia coli is a Gram-negative, rod-shaped bacterium that is commonly found in the lower intestine of warm-blooded organisms . Most E. coli strains are harmless, but some serotypes can cause serious food poisoning in humans, and are occasionally responsible for product recalls...
and coliform
Fecal coliforms
A fecal coliform is a facultatively-anaerobic, rod-shaped, gram-negative, non-sporulating bacterium. Fecal coliforms are capable of growth in the presence of bile salts or similar surface agents, are oxidase negative, and produce acid and gas from lactose within 48 hours at 44 ± 0.5°C.Coliform...
contamination were found, along with staph
Staphylococcus aureus
Staphylococcus aureus is a facultative anaerobic Gram-positive coccal bacterium. It is frequently found as part of the normal skin flora on the skin and nasal passages. It is estimated that 20% of the human population are long-term carriers of S. aureus. S. aureus is the most common species of...
and P. aeruginosa
Pseudomonas aeruginosa
Pseudomonas aeruginosa is a common bacterium that can cause disease in animals, including humans. It is found in soil, water, skin flora, and most man-made environments throughout the world. It thrives not only in normal atmospheres, but also in hypoxic atmospheres, and has, thus, colonized many...
.
Slowed labor
Because of the documented relaxing effects of water , laboring in water is sometimes associated with a decrease in the intensity of contractionsContraction (childbirth)
-Throughout menstrual cycle:The uterus frequently contracts throughout the entire menstrual cycle, and these contractions have been termed endometrial waves or contractile waves. These appear to involve only the sub-endometrial layer of the myometrium...
, and is thus thought to slow labor. While home birth experts (e.g. Harper, RN) argue that this must be evaluated on a case-by-case basis, some hospitals have adopted a "5 centimeter" rule, allowing women to enter the tub only once the cervix
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
has already expanded to 5 centimeters (Harper 2000).
Maternal blood loss
For care providers who are inexperienced in delivery in water, it may be difficult to assess the amount of maternal blood loss. While well-developed methods of determining maternal blood loss in water do exist, many providers prefer to deliver the placentaPlacenta
The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. "True" placentas are a defining characteristic of eutherian or "placental" mammals, but are also found in some snakes and...
"on land" for this reason (e.g. the University of Michigan
University of Michigan
The University of Michigan is a public research university located in Ann Arbor, Michigan in the United States. It is the state's oldest university and the flagship campus of the University of Michigan...
hospital).
On the other hand, some doctors and midwives see that waterbirths have been known to reduce the amount of blood loss. The water surrounding the mother lowers the mother's blood pressure
Blood pressure
Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs. When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation. During each heartbeat, BP varies...
and heart rate. Mothers still lose significant amounts of blood through the passing of the placenta
Placenta
The placenta is an organ that connects the developing fetus to the uterine wall to allow nutrient uptake, waste elimination, and gas exchange via the mother's blood supply. "True" placentas are a defining characteristic of eutherian or "placental" mammals, but are also found in some snakes and...
.
Public Acceptance
Water birth is accepted and practiced in many parts of the United StatesUnited States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
, Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...
, Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
, and New Zealand
New Zealand
New Zealand is an island country in the south-western Pacific Ocean comprising two main landmasses and numerous smaller islands. The country is situated some east of Australia across the Tasman Sea, and roughly south of the Pacific island nations of New Caledonia, Fiji, and Tonga...
, as well as many Europe
Europe
Europe is, by convention, one of the world's seven continents. Comprising the westernmost peninsula of Eurasia, Europe is generally 'divided' from Asia to its east by the watershed divides of the Ural and Caucasus Mountains, the Ural River, the Caspian and Black Seas, and the waterways connecting...
an countries, including the United Kingdom
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
and Germany
Germany
Germany , officially the Federal Republic of Germany , is a federal parliamentary republic in Europe. The country consists of 16 states while the capital and largest city is Berlin. Germany covers an area of 357,021 km2 and has a largely temperate seasonal climate...
, where many maternity clinics have birthing tubs. Many independent birthing center
Birthing center
A birthing center or centre is a healthcare facility, staffed by nurse-midwives, midwives and/or obstetricians, for mothers in labor, who may be assisted by doulas and coaches. By attending the laboring mother, the doulas can assist the midwives and make the birth easier. The midwives monitor the...
s and many home birth
Home birth
A home birth in developed countries is an attended or an unattended childbirth in a non-clinical setting, typically using natural childbirth methods, that takes place in a residence rather than in a hospital or a birth centre, and usually attended by a midwife or lay attendant with expertise in...
midwives offer water birth services. At present, water birth is often practiced by those who choose to have a home birth, because the majority of hospitals have not yet installed proper birth pools in their maternity
Maternity
Maternity or motherhood is the social and legal acknowledgment of the parental relationship between a mother and her child.It is specially related with the protection of the baby and the mother within and after the childbirth.-See also:...
wards. In 2006, Waterbirth International listed more than 300 U.S. hospitals that offered such facilities. At least two such hospitals were listed in the 2006 U.S. News and World Report "Honor Roll" of best U.S. hospitals: Barnes-Jewish Hospital
Barnes-Jewish Hospital
Barnes-Jewish Hospital is the largest hospital in the U.S. state of Missouri. It is the adult teaching hospital for Washington University School of Medicine, and is located in St. Louis, Missouri. It is consistently rated one of the top hospitals in the United States by U.S. News & World Report...
in St. Louis, Missouri and the University of Michigan
University of Michigan
The University of Michigan is a public research university located in Ann Arbor, Michigan in the United States. It is the state's oldest university and the flagship campus of the University of Michigan...
hospital in Ann Arbor, MI.