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Sunday
Apr222012

Waterbirth Revisited

Let’s just say, I’ve seen some awesome water births. Peaceful, lovely… the baby sliding out of mama and being caught in her hands just before total ejection… then being lifted to –and out of- the surface, pulled into his or her mother’s breasts for safekeeping. Heartwarming at the very least.

But, as I’ve been re-evaluating all the different aspects of home and hospital birth, I couldn’t let water births go without examination.

There is no doubt that being in the water is calming for a mom, allowing the uterus to “float” off the nerves, diminishing pain considerably. “The midwife’s epidural” it’s been called and I would attest to that many times over. But what of the ick that is a common and pervasive part of birth? “Ick” being bodily secretions like urine, feces, and mucous. We might include blood, sweat, tears and possibly even saliva, even though most people don’t think of those as being too icky.

Mind you, I’ve never had a problem with bodily secretions during birth. (Well, except for that one time when I co-barfed in a metal bowl during one woman’s transition.) Poop, pee, vomit, sweat, saliva, tears, blood, mucous… none of them remotely bothers me… so while I use the word “ick” it isn’t so much that I think of them as icky, but know that, as we delve into the topic, many reading will find some of the normal bodily functions icky, especially when discussed in conjunction with birth.

During birth, it behooves a woman to abandon any societal restrictions she has about bodily functions. That requires a trust in her care providers and a belief that everything she might emit is normal, unless told otherwise (too much bleeding, for example). In fact, midwives are a hilarious bunch that find bodily functions applause-worthy. “You threw up? Fantastic!” or “You’re having lots of loose stools? Great!” And that isn’t to help a woman feel comfortable in her emissions, but because the various actions are positive signs regarding the progression of her labor. Loose stools can herald impending labor and throwing up can be a sign of transition. Women like to be told they are progressing in their labors; bodily secretions can give everyone wonderful clues about those progressions.

But what if the poop and vomit were in the birth pool? Oh, women don’t vomit in the pool, you say? True enough, but they do vomit in the toilet (or whatever is barfed into a bowl goes into the toilet). Poop and pee go into the toilet usually, too. But, in birth, both of those can –and often do- happen in the pool.

This is where I started re-thinking waterbirth.

If mom pees and poops into the pool… and a baby is born into the pool with poop and pee… is that gross or is that not gross? For ages, our birth kits included a fishnet to scoop poop out of the pool, but hasn’t the poop already contaminated the water? And there isn’t a fishnet small enough to get liquid poop or urine out of the water… what of that?

When women have asked these questions, we’ve appeased them with, “it’s diluted to almost nothing” or “it’s only yours,” but are these adequate? Or even true? What if dad gets in and can’t get out to pee? And does dilution make it any better? All kinds of stuff can be in poop and pee, including e coli and group b strep. Do we want to dredge our newborn child through those possibilities?

We poop and pee in the toilet every single day. Would we dunk our child in that water… even after flushing? The thought is nauseating. Why then is it okay to have our newborn come out into the ick of a birth pool?

Suddenly, I understand the requirements of so many birth centers and hospitals to only allow labor in the tubs, but birthing out of the water. I always thought that was a dumb rule and even heard the arguments about why without really thinking the whole thing through; the baby is born in a toilet bowl. Isn’t that kind of gross?

I remember one dad who was in the pool with his wife and as soon as she let him get out, he ran to take a shower even though he had a newborn to cuddle with. We all thought it was kind of silly, but on second thought, did he have the right idea and the rest of us were somewhat deluded?

I used to think I’d love to have a waterbirth. Now, not so much. How have you been able to wrap your head around birthing in a tub with poop, pee, mucous and blood? I look forward to what folks have to say.

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Reader Comments (36)

I have 6 children, labored with them all but one in the water. I only birthed 2 in the water. You do what feels right in the moment. The only excrements I would be concerned about are poop and possibly vomit in the pool. Urine and Blood should be sterile unless you have an infection. You are also not leaving the baby underwater for long. If the babies skin is intact then there should be little avenue for disease to transmit. Vomit should also be disease free unless there is some other infection going on. Stomach acid kills most everything. There is evidence based research that exposure to the vaginal canal helps to colonize the babies GI tract. These babies suffer from fewer cases of asthma and allergies. So what is any different then a few seconds/minutes in a very diluted pool of those same excretions?

April 22, 2012 | Unregistered CommenterRachael

There was a celebrated case a few years ago in the UK when a baby died after aspirating fecally-contaminated water from a birthing pool. The two attending midwives were charged with manslaughter, and when they attempted to defend themselves by claiming that the mother refused to leave the pool in spite of their urging, they were told by the court that they should have physically hauled the woman out [!!] and so failed in their duty.

To me, waterbirth is just a gimmick. Humans do not, nor ever have, delivered in water. Even being born with intact membranes ["a caul"] is relatively rare, and the membranes are always instantly ruptured lest the baby aspirate amniotic fluid [sterile] with its first breath.

The more extreme the gimmick, the more some women feel they have to singularize themselves by adopting it, I suppose for bragging purposes because I can't see any other reason for it.

The use of showers, jacuzzis, pools in LABOR, as long as the membranes are intact, is indeed calming and beneficial. Delivering a baby underwater has no intelligent rationale at all.

April 22, 2012 | Unregistered CommenterAntigonos CNM

My hospital gave the option of water birth, but I elected to just labor in the tub and get out for serious pushing. I wasn't so much put off by the bodily fluids (thoug that was a factor) as I was horrified about being totally exhausted and having to worry about keeping the baby clear of the water. It just seemed like an unnecessary thing to have to think about- I wanted to be DONE once I got him out... concentrating on learning to nurse, not concentrating on avoiding accidentally drowning my baby.

April 22, 2012 | Unregistered CommenterMeagan

Before I started attending births through water, I felt the same way. Why would anyone want to immerse themselves in THAT?? But the births ARE so beautiful, gentle and peaceful (generally speaking, anyway). The women I care for who do birth in the water are almost invariably happy with the experience. And surely that is what I am here to do - provide information to allow women to make their own decisions about their births and keep them and their baby safe?
But I agree with all you have said - I still have doubts. I don't think I would want to birth through water (although my daughter had my grandson in the birth centre birthing pool). To date we have had no instances of infections being linked to birthing in the pool, but is it simply a matter of time?

April 22, 2012 | Unregistered CommenterSuz

Really? Have we not established that birth is messy and 'icky', no matter where or how it's done? I watched a birth video recently( hospital birth, mind you) and the mom was pooping as she pushed her baby out. So basically, her baby's face was about an inch or less away from poop as it was being born. You really believe that no babies born in hospital beds, are coming in contact with poop? Their little noses are RIGHT THERE. This mother's poop was loose ( sorry tmi) and there is no doubt some came in contact with the baby's face. Also, what about vernix? Doesn't it have certain anti-microbial properties? So, our only concern is that the baby inhales the water, and how often does that happen? Many hospitals are starting to now allow waterbirths and there is no way that would happen if baby's were inhaling water, even occasionally. There is no conclusive evidence that waterbirth is dangerous, so who cares about the ick factor?

I had a waterbirth. There was no poop, no vomit and almost no blood. The water was remarkably clear. And Antigonos, CNM, I find your comment incredibly insulting. You think we do this for bragging purposes? You obviously don't think very highly of women, do you? Do you want to know why I did a waterbirth? Well, for one, as a survivor of rape, I felt comforted by the privacy the water gave me. There is a little bit of distance given to you when you are in the water, and you just feel more safe and less vulnerable when you are in it, pushing a baby out of your vagina. I appreciate my midwives so much for not accusing me of bragging rights, because they are compassionate like that. Actually, they suggested waterbirth, because they knew my history and they are aware that it is a helpful tool for women who have been sexually assaulted. Furthermore, being in the water is incredibly soothing and helpful with the pain. Pain doesn't stop once you push, you know. what's the point of using water for pain relief during labor and not for pushing? Pushing was the only part of labor that was even painful for me and it was the only time I got in the water. The buoyancy the water gives is also very helpful for getting in a good positon and moving around.

Why do we have to judge women for something that is SO helpful in labor and birth, especially when there is no evidence that shows that it's harmful? I just don't get it.

April 22, 2012 | Unregistered CommenterAmom

I have been to many beautiful water births. I labored in the tub for my second birth, but birthed on the bed.

I am not going to unconditionally defend water birth. I can see definite issues with possible aspiration.

However, during vaginal delivery, the baby is born onto the perineum. There can be much more concentrated feces, urine, mucus and blood right there than there would be in a birth pool. OK, usually not vomit, but I have never seen someone vomit in the birth pool, and would have a problem with her staying in if she did. Once we start trying to "protect" the baby from the icky stuff that is found around the vagina, we are getting dangerously close to calling the non-sterilizable vagina as unfit for delivery versus the almost sterile cesarean section.

April 22, 2012 | Unregistered CommenterMomTFH

I was grateful to be able to labor in the tub with three of my children, but I always needed to get out before it was time to push. It stopped being soothing -- I needed my feet on the ground. Maybe I needed gravity too?

My midwife is not in favor of birth in poop-contaminated water, FWIW. (I don't know what she would do with a woman who was adamant about staying in the water.)

April 22, 2012 | Unregistered CommenterJamie

Suz, why is "beautiful, gentle and peaceful" worth ignoring the possibility of serious infections?

You say "And surely that is what I am here to do - provide information to allow women to make their own decisions about their births and keep them and their baby safe?"

Yes, that is your job. But risking serious infections isn't keeping them safe. Icky discussion certainly isn't a reason to avoid a practice, but it is a reason to seriously look at the risks and benefits and make a reasoned decision about the practice rather than handwaving away risks because "oh it's so peaceful!"

April 22, 2012 | Unregistered CommenterWhatPaleBlueDot

I found water to be a remarkable tool for pain relief during active labor/transition. I would never agree that women shouldn't have access to water during this part of birth. As for actually birthing in the water, I didn't find it necessary. Water was no longer helping me when I got to the pushing stage of labor, so I got out and delivered on the bed. The water in the pool was clear, though. No pooping or vomit in the tub and the midwives had nets at the ready to remove any debris should it have occurred. If the pool was particularly contaminated or cloudy I don't think I'd want to be in it as a laboring woman and would switch to the shower. I don't see why a hospital or birthing center couldn't develop a set of guidelines for water birth that would promote healthy labors and infants. It doesn't have to be "any type of birth in the water is appropriate" or "no part of labor/birth in the water is appropriate".

April 22, 2012 | Unregistered Commenterhwar

I've been to a lot of water births. When I first started attending them, I worried about infection risk due to fecal contamination, but then I did my research. According to http://www.ncbi.nlm.nih.gov/pubmed/16147851 , there is not an increased risk of neonatal infection during waterbirth. And, according to http://www2.cfpc.ca/local/user/files/%7BE757C7FC-F557-4CED-A956-D73E666774C0%7D/ACOG%20Waterbirth%20%20GBS.pdf, "A single case of early onset newborn Group B Strep was documented among 4,432 hospital births into water in the absence of GBS prophylaxis, suggesting that low risk women giving birth into water have a 300% lower rate of newborn GBS disease newborns than dry, full term births delivered by current GBS guidelines." This information helped me to feel much more comfortable about infection risk in water birth.

April 22, 2012 | Unregistered CommenterKim Pekin, CPM

WhatPaleBlueDot- if we are going to by the science, than we will wait until some legitimate studies have be done before we start condemning waterbirth for what we "think" is icky and risky. Waterbirth is done all over the world now, if it was really that dangerous, we would have case, after case, after case, of babies dying from infections and aspiration. What do we have? Possibly ONE case that is connected to waterbirth. And even that one case is not definitively a result of waterbirth.

April 22, 2012 | Unregistered CommenterAmom

http://www.ncbi.nlm.nih.gov/m/pubmed/21322437/

I found the above study to be a positive, as I have always been GBS positive for each of my 4 pregnancies.

April 22, 2012 | Unregistered CommenterTrish

One thing I've never understood about waterbirth is that it would seem to counteract a couple of the mechanisms by which the baby starts breathing. One is the sudden expansion of the lungs after being squeezed by the birth canal- it's helpful when air rushes in rather than water. Another is the shock of a temp change. I'm not saying a 50 deg room is good, but even a warm 75 deg is a big change from 98.9. The temp change triggers a gasp. These things work together to help the baby take its first breath. Certainly if the first "breath" is fecally contaminated water, it's probably... not good? And then there's the need for a baby to be warm. Harder to maintain in a pool.

However the research I'm aware of doesn't reflect an increased rate of pneumonia, sepsis, low APGARs. So I'm not sure what to think in terms of wb and risk to the baby. There seem to be a number of benefits for the mom. I wonder if some of the benefit to perineal integrity isn't simply that the caregiver is forced to be hands off!

April 22, 2012 | Unregistered CommenterKatie

Dear Barb,

I agree with your thoughts and feelings about water birth. It's difficult for me to admit my concern about cleanliness when faced with how beautiful and emotionally engaging the birth can be, but it seems that it is everyone's (parent's and health care provider's) responsibility to "error on the safe side". I also used to think it was silly for hospitals to allow labor but not birth in the water (I think I thought it was just because doctors were uncomfortable with the mechanics of water birth), but I have to admit their point now. Why not be careful?

Thank you,
Mindy

April 22, 2012 | Unregistered CommenterRCPM

We do have case reports of pneumonia and water aspiration related to water birth.

http://cid.oxfordjournals.org/content/33/9/e103.full
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC154682/
http://www.ncbi.nlm.nih.gov/pubmed/15329532
http://pediatrics.aappublications.org/content/110/2/411.extract
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC557235/

We really need more, larger trials that sufficiently powered to detect differences in mortality before we conclude that water birth is safe. It certainly isn't natural for humans.

April 22, 2012 | Unregistered CommenterBecky

Also, this survey of GBS cases -- does it control for whether the reported studies excluded GBS+ women from waterbirth, as some places do? Is that CFPC link the whole of the article? If that is it, then it is horrible science. It doesn't control for any possible confounding factors, the author doesn't seem to understand some basics of disease transmission and GBS prevention, and is obviously biased. With whom would such drivel have any credence?

April 22, 2012 | Unregistered CommenterBecky

I'm not comfortable in the water...I get too hot, and want to be standing. Love the shower actually and yet am not comfortable dropping a baby in there. I know that I have had poop come out of me as I am pushing, I have felt it and felt the midwife cover it with a wash cloth type thing. I can only imagine how horrible I would feel seeing it float up by me in the water as my baby came out of me. But then again, my babies have been born in their own mec several times. I would love to know actual numbers...dry vs. waterbirth and infection...which is truly higher?

April 22, 2012 | Unregistered CommenterDawn

I feel like a perineum is going to have at least as much fecal contamination as a pool full of water.

At any rate, I am a midwife who does not love waterbirth, though I had two of my own. With my second I was determined to give birth on land, but once I got in during my super intense 2 hour labor I was not getting out. As a mom, what I did not like about my waterbirths was how my babies were "washed" before I could smell and touch them. I think we are countering some of the beneficial colonization that happens during a vaginal birth.

As a midwife, it does seem like more of a pain than its worth, sometimes, especially when birth is fast and care providers and sometimes dads are scrambling to fill the thing. I also don't like the somewhat awkward efforts to keep the wet baby warm while still allowing biological nursing to unfold. I have had a couple times where blood with the head made it more tricky than it needed to be to assist with sticky shoulders or unwrap a cord after the birth. I am a newer midwife and can say that unwrapping cords under water is not my favorite thing in the world, and I am not always as calm about it as the YouTube Midwives all seem to be. At the end of the day, I get it, I support it, I HAD it, but it feels awfully counterintuitive to me.

Also, I dislike the notion that waterbirths are somehow the MOST peaceful and gentlest kind of birth. I think the waterbirth craze has crested, and I am hearing less magical thinking about the wonders of waterbirth, but its still out there. Birth can be beautiful and amazing and perfect on the bed, in the shower, on the bathroom floor - wherever.

About 35% of my births happen in birth tubs. However, I have about 50% first time moms and I find that many of them get out after an hour or so of pushing and then go on and give birth quickly once they're out. But, small sample size and all, might not mean a thing :)

April 22, 2012 | Unregistered CommenterLinsey

Most Australian hospitals offer water birth and teach it in antenatal classes. I must say 2 thing about this. First, the video they show in class carefully avoids mention of any excrement or contamination. The water is crystal clear at all times. Secondly, I found water wasnt comforting at all - even for very early labour.

April 23, 2012 | Unregistered CommenterSnorkel

Aside from the contamination issue of waterbirth, what happens when a major complication occurs? Can you adequately manage a shoulder dystocia in the water? What about a pph? It's got to be extremely difficult to haul a woman out of the tub in either case.

April 23, 2012 | Unregistered Commentermoto_librarian