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.

Update on Wednesday, April 25, 2012 at 03:29AM by Navelgazing Midwife

There's been a little bit of discussion about shoulder dystocia and hemorrhaging while being in the water and I wanted to address those here instead of in the comments section since they are really important topics. Also, shallow water and poopy perineums is talked about below.

If a baby isn't coming after the head is born, midwives usually get a mom out of the tub. If the shoulders were merely sticky, the action of lifting the leg over the pool side can be enough... open the pelvis enough... to free the shoulder and allow the baby to be born. Therefore, it is crucial to keep hands under the baby, not only to catch him/her if they are dislodged, but also to protect the head from being bonked on the side of the pool. Shorter women are at more risk of that happening than taller ones.

The mechanism for why the baby might be born when mom is getting out of the pool is, what I believe, the Gaskin Maneuver is all about: opening the pelvis wider. When mom swings her leg up and out, the pelvis opens and can allow the stuck shoulder to slide out from behind the public bone. The Gaskin Maneuver is turning a mother from her back to all fours, another way the mom swings her leg up and around. I've come to believe that if the baby is born after that change in position, the baby was merely "sticky" and not a shoulder dystocia. However, if the baby does not come out after that motion, s/he is definitly a shoulder dystocia.

So, when I've had moms get out of the pool, baby's head out/body in, I've immediately had them on their backs so we could do McRobert's and with other hand maneuvers, have always dislodged the baby. (I love McRobert's, have I said that enough before?)

Only once have I helped manage a shoulder dystocia in the water; we had her stand up. (I have managed shoulder dystocia with a mom standing outside the water before, too.) Awkward! Doing supra-pubic pressure is quite the challenge with a mom lunging against the side of the pool (something a woman could not do with a fishy pool!).

Regarding a hemorrhage, I haven't ever had to manage one with a mom in the pool. Lucky me. It would have been extremely difficult, especially if it was a huge one that required bimanual compression to quell. I'd love to hear from other midwives who have so we can all learn what the experience is like and how they manage it.

Another topic that's come up is the shallowness and lack of warmth of the fishy pools vs. the heated, harder-sided tubs. I haven't had the experience some apparently have seen on YouTube (I don't typically watch births online)... pushing a mom's butt down to keep the baby in the water as it's being born... but would really hope if the mom had that issue, she would either be directed to push on her back or get out of the pool. The risk of aspiration just seems too great to me.

I don't know who you all are that think the perineum has poop on it when the baby's born, but I haven't EVER seen any of mom's fecal matter on the part of her perineum that is in direct contact with the baby's face. There is a good distance between the anus and the introitus of the vagina... especially when the baby is being born... the entire area widens, the gap much further from each other the closer to delivery. In all these 29+ years, in all the babies I've seen born and all the birth photos and videos I've seen, I have never seen bowel movement on a baby. I would be horrified if some novice wiped the mother up instead of down as BM was coming out. Talk about counterintuitive.

So, I vehemently disagree that the perineum is as contaminated with fecal matter as birth pool water.

Hypocrite in the Middle

<snark>

In the last three days, I've been called "hypocrite" twice. It's an epithet I'm pretty used to, actually, so at first it didn't click, but this afternoon, I laughed at what was really happening.

First, I was called a hypocrite by a follower of the SOB (ask someone else if you don't know who that is; she gets no air time here) who, in a comment I did not publish, said:

"How ironic that you deride the next step 'down' from home-birth midwifery (itself a 'step down' from birth in a full-fledged medical setting) as a "luxury" in the mindset of Western women when homebirth with a midwife in the Western world is motivated by the same ill-informed, privileged mindset."

S/He continues:

"Shame on you.  You are just as ignorant and dangerous as the UC'ers you look down on.  But I guess it helps to rationalize your unscientific stance to have someone 'below' you on the industrialized world's substandard birth care 'food chain.'"

Okay, so that's the far right side of the spectrum. Now, let's look left and see what I got this morning. I did not edit.

"Frankly, it is very unfair to call UC dangerous until we have real scientific studies.  Of course how do you study and underground movement?  What sane woman will admitt to planning a UC beforehand when she knows it can bring such negativity and the threat of CPS?"

I'm writing this, debating arguing the point about "scientific studies" and how no one believes them anyway, so who gives a crap if one is ever done on UCs. And that puh-LENTy of women plan UCs ahead of time; wander the Net for 10 minutes and you can find a slew of them.

But then I thought, instead of arguing, I'll just quote some more.

"The statistics I have seen for India is that about 1/2 their total population is anemic.  Do they have insane rates of post-partum hemorrhage?  Yes.  Is post-partum hemmorhage going to be as common in a woman in the US choosing UC who eats meat and follows the Brewer diet?"

*blinking*

Seriously? SERIOUSLY? Am I supposed to address this? Am I supposed to be the one to break it to this woman that anemia does not cause hemorrhage? That the Brewer Diet is bunk (I want to use a far worse word, but am trying to contain myself)? That her enormous ethnocentric ego is flapping about for all of us to see?

Sometimes, I think I could write for hours and hours trying to dispell myths, but it's almost as if no one hears, so, instead, here's more of her quote: 

"We can not get facts about the true risks of UC until we allow it to happen unhindered.  Allowing women to make their own choices, from scheduled 36 week c/s because they are too scared to be pregnant any longer to UC is the only way to empower women and show that we are as capable as men of making our own choices good or bad."

*squinting*

Isn't the very definition of UC, unhindered? I'm even turning my head sideways trying to figure that sentence out, but it makes zero sense.

Now, this empowerment issue. We've covered this before.

No one can empower another person.

WOMEN EMPOWER THEMSELVES.

"...show that we are as capable as men of making our own choices good or bad."

My head hurts already from trying to decipher the messages hidden inside this email, so I'm really at a loss for what to say about my proving I'm as capable as a man in making dangerous (stupid?) choices. Really? Really? Women still feel like they have to prove themselves? Women still compare themselves to men? Apparently, I missed the latest memo.

But, looking at these two readers' comments from afar, the gist of them both is I am a hypocrite, that I say one thing and do another. I say I'm for a woman's choice, but have serious concerns (understatement) about UCs. And I feel births are safer in the hospital in extreme emergencies, but I still support homebirth.

So, in talking to Sarah, telling her of the latest condemning emails, I couldn't help but laugh out loud that if I was being called hypocrite by the left and the right, I must be right smack in the middle!

I wonder if I'm doing something right after all.

</snark>