Episode 188 - Waterbirth Risks and Safety
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. And each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:23] Before we do anything today, I have something exciting to share with you. And for those of you who are listening who are keen to explore water birth as a pain management strategy through labor, which is predominantly what women use water for, water is definitely one pain management option. And in addition, I would encourage you to also plan a range of other pain management tools that you can use because water is not sort of the first line strategy for pain management. There are a range of other things that I would suggest you use before you resort to using water.
[0:59] I kind of at home talk about water birth as like the home birth epidural. The thing you try after you've tried everything else. So when nothing else has worked, it's no longer cutting it, then it's time to get in the water. Now, I don't have time to go through all of those other pain management strategies today in this episode, but I did want to take the opportunity to encourage you to have a look at my guide to giving birth without pain medication. It has everything in there that I would ever suggest for pain management before getting in the pool. It's the things that I've seen my clients use over the last 18 years, the ones who are giving birth at home. And it's the things I used myself. They're strategies that I've seen work time and time again to help manage the pain of labor without medication and before getting in the pool. So the guide to giving birth without pain medication will give you all the information that you will need in order to prepare for a medication-free labor. The link for the guide is in the show notes down below. So go ahead. You can click there now. This is there's no fancy sales page. It would just take you straight to the checkout and it's all yours. It's only $27. In fact, that's cheaper than lunch, but the benefits will last far longer than a single lunch. So go down to the show notes, click the link, get the guide to giving birth without pain medication. Let's get into this episode.
[2:29] Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I've been a private midwife for 18 years, and today I am talking about water birth. The majority of my clients give birth at home, and then the majority of them
[2:46] also give birth in water. And today, I feel like I most definitely must be in the expert category of clinicians who've witnessed and can help assist with water birth.
[2:59] So today, that's what we're talking about, the use of water immersion for labor and birth. And I was prompted to cover this topic, not because water offers an opportunity and a pain management strategy, but as I said, about 80% of my clients choose to give birth in water. But also, there is a doula out there. I love doulas, but this one is a little bit out of line, but she's out there using her social media to tell women that laboring in water is equivalent to smoking through pregnancy in regards to how much oxygen it deprives the baby of. She's saying that it causes hypoxia or low oxygen levels in the baby. When she put this information out there, I got so many social media messages about it. And it occurred to me that I did not have a thorough episode on water birth. And women were asking, is it true? Could it be true that water birth harms babies? So this episode, although it was overdue in general, is in part my response to anybody who suggests that water birth is a dangerous birth option. I'm going to tell you all about water birth, how to do it, the risks and benefits. And next time somebody makes bogus claims on social media about water birth,
[4:13] I can direct them to this podcast episode. So today I'm going to show you the science, physiology, outcomes of water birth with a few educational stories and tidbits to help you understand and prepare for a water birth if that is what you're planning on doing.
[4:29] So as a midwife and researcher, I know with clarity from the evidence, from my experience, because I understand physiology, that water birth is not a danger to babies or women. But today my job is to explain all of this to you in a way that shows you how to come to that same conclusion, but also give you enough information to be able to make your own conclusion. But I do believe that anyone who looks at the evidence in an unbiased way will not find it hard to come to the same conclusion as I have that water birth is not inherently and fundamentally dangerous. It most certainly does not deprive your baby of oxygen in the same way that smoking cigarettes through pregnancy does. Of course it comes with a lot of benefits and I'll give you a few tips and cautions to avoid some of the possible complications that can arise from water birth But once you know these, it's easy to mitigate them. They're not caused by the water itself. It's more due to user error around water birth where you can get some complicating factors. So I'll explain all of that. And I will say that if you look at some research and guidelines, they will make comments about there not being enough evidence to either support or refute the use of water in labour and birth.
[5:48] However, many of these comments and conclusions come out of a lack of randomised
[5:53] control trials on water birth. So these are trials that would have a whole big group of women and they would say to half of them, you're going to have a water birth. and they would say to the other half, you're not going to have a water birth. So that's a randomized control trial. And there is a lack of evidence around water birth from randomized control trials. There's no doubt about that. But there have been surveys to see if this kind of study would even be possible. Is it possible to actually randomize women to a birth location? Because that's really what water birth is. Some people will say water birth is an intervention.
[6:31] However, I'm more in the camp to say water birth is a birth location. So the bed is a birth location. The birth stool is a birth location. The water is a birth location. Hospital, home, you know, these are all places that you could have your baby. Not necessarily an intervention, but, you know, it's not the main point. Just making a point. That was in my own head.
[6:54] So what they found then when they tried to work out, could we even do a randomized control trial? Of water birth. They surveyed women, and this is done before, researchers have asked this question, and only around 15% of birthing women said they would be open to being randomized for such a study. So 85% of women actually want to choose for themselves where they would give birth. So a highly powered randomized control trial on water birth is unlikely to ever occur because this research process, this research method is unacceptable to women. So it's just like studies on a home birth. This is the same situation as we get in when we study home birth. And the Cochrane database of systematic reviews has certainly spoken about this too, is that we can't actually ethically randomize women to a birth location, a birth place. It's not acceptable to them. They just won't do it. So we can't get a big enough randomized control trial to equivalently answer questions about the safety or the impact of water birth.
[8:02] So what we have done is that like with researching home birth, we largely rely on what we call observational studies to make conclusions about the outcomes. So basically what we do is we look back at the outcomes for the women who had water births and do our very best to compare those to the outcomes of women who had their babies on land. And then we can make conclusions about the risks, benefits and outcomes for water birth.
[8:30] So those are the kinds of research papers we will be looking at today, the kinds of studies that look back and have a look at what happens to women when they have their babies in water, what happens to their babies, and how does that compare to women who have their babies on land.
[8:44] But just quickly, before we get into that, hello, Rebels, if you'll just give me 40 seconds of your time, I would like to personally thank the sponsor of this podcast because that means that you get to listen for free.
[8:58] Poppy Child from Pop That Mama is a doula and hypnobirth practitioner, and she's a sponsor for today's podcast. Poppy has an online course, hypnobirthing course. It's called the Birth Box, and it's already helped thousands of women five-star reviews across the board. And you know me, I am very picky about what I will endorse, but I get behind the work that Poppy is doing in the Birth Box. It's practical strategies to help you get ready for labor and birth, but also the challenges of parenting. And with my code, if you type Melanie in at the cart, you'll get 25% off. So if you're preparing for birth, go check it out. You will be so glad you did. The link is in the show notes. Type Melanie at the cart and get 25% off. Thank you, Poppy, for sponsoring this
[9:48] podcast so that everybody else gets to listen completely free. Thank you. Let's get started on today's episode. Okay, let's get talking on water birth. And this is a powerful episode, not only for you women who want to fully understand water birth before you make any plans, or maybe your partner or support people need to hear this before you plan your birth so they can understand water birth too.
[10:13] To the unaware observer, water birth can seem a little alarming. So I would recommend if you're planning a water birth to share this with the people who are going to be supporting you. Maybe it's your doula, midwife, partner, friend, mother, whoever's going to be with you at the birth.
[10:29] And this episode is powerful because also if you want to understand the research for yourself, you can get access to the resource folder. So for every single podcast episode that I research, I create a folder and it has all the research papers for that topic. And if you're on the mailing list at melanethemidwife.com, you'll get access to this. But there was a midwife recently who used the resources for the podcast from this episode to petition for water birth to be introduced in the hospital that she works in. She approached hospital management and the obstetric head said if she could provide some evidence as to the benefit of why they should introduce water in their unit, that they would petition for it. So she printed off the research papers, presented that, and published. They have birth pools in their birth unit now based on her efforts. So don't underestimate the power of research and being informed. So I'll start by explaining the basics of using water for both labor and birth. But first, let's talk about access, your access to water through labor and birth.
[11:41] Is water birth even an option for you? For me as a private midwife, most of our clients choose to give birth at home. And there's only one reason why I would not recommend a woman get into the birth pool to give birth and that is if we have concerns for the baby that we might need to act on. So maybe the heart rate seems unusual and I'm listening very carefully with the Doppler and I want easy access to the woman's belly for accurate auscultation of the heart rate. In some circumstances we might already be planning transfer in this case but if the birth is imminent and I think the baby might need help.
[12:21] Either because the heart rate's indicating something unusual or maybe the baby needs help being born in the case of shoulder dystocia or with a breech birth. I might advise the woman not to give birth in the water. Of course, they don't always take my advice. And I recall one woman I cared for. She was planning a V back at home, so vaginal birth after cesarean at home. And labor was going really fast. I arrived with all my gear, but I had not had a chance to fully unpack it yet. I was looking after her, listening to the heart rate, checking everything. And the second midwife had not yet arrived. And soon after I got there, she got into the birth pool that she'd already set up because she felt like she needed to push and she wanted a water birth. And I put the Doppler on her belly to listen to the baby and to the heart rate. And the heart rate was lower than what I was expecting. and because I hadn't been there long, I didn't know what the heart rate pattern had been. How long had this been going on? So as I was considering what to do next, her waters broke in the pool, which is a pretty good sign that the baby is on its way.
[13:31] And I could see in the pool water that there was this big puff of meconium. So the baby had done a poo inside. and when you know when a woman's waters break in the water if it's clear or pink or a normal color then you really don't see a lot but in this case there was a clear puff of dark meconium so I'd arrived not long before then I'd heard the lower heart rate and then this there was this meconium and I and I knew that there would be no time to call for help for an ambulance it It seemed as though the baby was close by, but my second midwife wasn't there yet.
[14:13] I suggested to her that I would love for her to get out of the pool so that any event that eventuated, I would be able to manage outside of the pool and not in, which is a lot more difficult. So I said, I would love for you to get out and have your baby out of the pool on land. And she looked at me with this huge blissful smile on her face and she said, no. Okay. She was quite happy about that. And I mean, I love that she was just so clear about her intentions. And I said, okay, I usually don't suggest birthing in the water when the baby's heart rate is low and when there's meconium, but I will do my very best. And she said, okay.
[14:55] So I'm actually grateful she did not listen to me because she pushed so expertly and her baby was born healthy in the water just before the second midwife arrived and everything was fine. The baby was well. But my point here is that there might be medical reasons for why not to have a water birth.
[15:14] And one of them is if your care provider anticipates that your baby might need help to be born or might need help soon after being born. And this can be the case if your provider suspects shoulder dystocia, breach birth or something unusual happening with your baby's heart rate that indicates maybe it's under more stress than it usually would be. But aside for these reasons there aren't very many other reasons why not to labor in water except for the barriers imposed if you're giving birth in a hospital and this is something for you to understand ahead of time before arriving to the hospital for birth so if you want access to water immersion you have to ask the place that you're giving birth at if there's even access to baths in the room, what their water birth policy is, and try and understand what the barriers are going to be for you to accessing water in their particular facility. Because there could be reasons of just simple policy. Sometimes they have requirements that staff need to be specifically trained for water birth, and maybe there's not many of them who were trained, or perhaps they might not even be there on the day that you arrive for your birth.
[16:26] Consider your own medical issues. The hospital will have some restrictions around your risk factors, not just the babies. And perhaps there's just the simple absence of birth pools in that facility. So it's important that you understand the situation around water birth in that facility so you can gauge what your chances are of actually getting access to water.
[16:48] And then you're in a position to know what the challenges will be and what the barriers will be. And then you can plan a strategy for how to overcome them or navigate them. One of the main issues that you will come up against is that even in hospitals who do have water birth policies, who have staff who've trained in water birth and who have actual pools, they still might only allow women who are considered low risk, and I'm doing inverted commas, low risk to enter the water for labor and birth.
[17:20] But here's my suggestion to you during birth is to assume that you own the space when you get to hospital. And this is a power strategy, the strategy of not asking for permission to do things. So assume that you are just walking into another room in your house and use it as you please. So instead of saying, am I allowed to get in the water or can I use the pool? If you have a plan to labor in water or if you feel like you need it, just turn the water on and get in and use it as if it was your own. There are policies in hospitals about which women are eligible to use water for labor and birth, but the policies are written for staff, not you. The staff are obligated by the policy to inform you of the rules in their hospital, but under no circumstances are you required by law or any other authority to follow the policy. Because the policy is not there for you. It's not your rule book. That's the guide for the staff.
[18:25] So if you want a water birth, you have the authority to pursue that. It's your body and you are an autonomous woman. Assume you own the space and go ahead and get in the pool. So when you arrive in the room, if there's a bath, assume that you own it and assume that you own that space. Don't ask for permission to take your clothes off.
[18:48] Just it's your space. I think I've said that enough. You don't have to get your care provider's permission. They will be surprised though if they come in and find you in the bath. So just be prepared to work with that. And you can tell them that you're going to do it to prepare them. And they may need to alter the way that they're monitoring your baby. And it might be against their policy. So they'll need to do some documentation. But you certainly don't have to ask for permission. But they will be doing a whole lot of documentation out the back there. And they will have to alter the way that they're caring for you because certain monitoring, fetal monitoring methods won't work in the water. So they will definitely need to adapt.
[19:33] So here we have a problem where only low-risk women are allowed, allowed to enter the water. However, the medicalization of birth is continuing. And so we're gradually classifying every little thing in pregnancy and birth as a risk factor. And therefore, more and more women are being classified as high risk and less women are even qualifying to use the water. So I actually think it's a unicorn situation to walk into a hospital that is not hostile towards water birth and then have access to a midwife who's comfortable with water birth and a hospital who's got the right facilities. And for you to be low risk. So if you have managed to have a water birth in a hospital facility or anywhere,
[20:19] you are definitely one of the lucky and privileged ones to have access. So this is the main issue with water birth is access. Now, fortunately, as hospitals update their facilities over time, more and more of them are making sure they accommodate birth pools, big, nice birth pools in the birth space.
[20:38] But water birth is still restricted from women who have a BMI over 35. If you have a previous history of postpartum hemorrhage, if your waters are broken for over 24 hours, if you're having an induction, you'll be advised not to access the water. The policies are different in every single hospital. So you can ask for the water birth policy and understand what things will restrict you from getting access. Okay, now before I go any further into the water birth risks and benefits, let's talk about.
[21:07] Why your baby isn't at risk of drowning during a water birth or while being born in water. And here I'll also include circumstances where we recommend that women don't birth in water, and then we'll talk about the research and outcomes. So I once taught a class of senior school girls in a high school, and I taught them about childbirth. I'm not a teacher. I was called in specifically for this class. And I showed them a water birth video. And in the video, the baby's head was born in water. The woman was planning a water birth. And then there was this usual gap that happens where the contraction stops. So the head is out and everyone's waiting for the next contraction. So the rest of the baby can be born. And the whole classroom erupted. They were screaming and yelling at the screen, push the baby out, push the baby out. And they were so aggravated that I had to stop the video and explain to them that this was a normal gap in the birth process. The baby was fine underwater. The baby's head was born. It was completely safe to wait the minutes that feel very long, wait the minutes before the next contraction for the woman to push the rest of the baby out. Now, the next time I taught that class, I made sure to mention that before putting the video away. So what happens when the baby's head comes out? Why isn't the baby drowning?
[22:36] Let's start. So the baby is attached to the mum by the placenta and the cord. And that's where the baby's getting all the oxygen, nutrients and everything that it needs from its mum.
[22:47] So the lungs, when they're in utero, they only have enough blood supply to keep the tissue alive. And although the baby is doing breathing movements in utero to get their diaphragm and chest muscles and everything ready to breathe when it's actually born. They're not breathing air in utero. Their lungs are somewhat sort of collapsed. If you imagine sort of like a sponge that's been clenched shut, so gripped shut, their lungs are full of fluid and they're being supplied by blood, but there's no oxygen in there. So for all intents and purposes, like they're drowned from the get-go of their development. There's no room for extra fluid at that point. Their lungs are full. They're not using them for oxygen transfer yet.
[23:38] So their whole circulation while they're in utero is actually different to once they become air breathers. Their blood circulation, once they breathe air and their lungs expand and fill with air, there's all these trap doors that close within a baby's body to completely redirect oxygen flow so that now when they're air breathers, the blood that sources the lungs is now collecting oxygen to be distributed around the body. That was not originally what happened when they were in utero. And so when people say, oh my gosh, how can the baby breathe underwater? When the baby's underwater, it's still using its in utero mechanisms for oxygen transfer and supply. It's not reliant upon air. Just because it's born, it doesn't mean it's breathing air yet.
[24:32] So for a baby who's well and born underwater, the cord keeps pulsating because it's continuing to deliver oxygen as it did when the baby was born. And so a way, I guess, of explaining this is babies born into water, they're coming from water into water. Because the environment doesn't really change at all, it's just an extension of the womb to have a water birth. However, there is a bit of, because the baby gets squeezed to come out, there is some experience banning of the lungs, the baby will be inspired to breathe at some point. But a baby has what's called a dive reflex. So their skin can detect air.
[25:13] And if they're in not air, if they're in water, they won't try to breathe because they know that they're in water and their body knows they're in water because they have this dive reflex and these sensors on their skin. They won't attempt to take a breath usually if they're well. But I should say here that one contraindication for water birth is the event that you suspect a baby is distressed. If you think that baby is going to come out and it's currently oxygen deprived in utero where it's hypoxic, if it's deprived of oxygen for some reason, it might override that dive reflex and try to take a breath immediately after being born, whether it's in water or not. And this can happen in utero as well.
[25:59] So a baby that is genuinely distressed might try and take a breath as soon as it's born. So really the only contraindication for water birth is if you think the baby might be distressed and you can ask the woman to exit the pool just in case or just stand up so the baby's not born in water. And this can be the case for things like brand new meconium stain like or if it's creating a picture and showing you, yes, this baby is definitely not coping with labor and birth. And the same goes if you think the baby will need assistance to be born you know shoulder dystocia breech births maybe somebody out there is doing twin births in water and you might think that the next twin needs help I mean you can do them in water but it's hard to get a sturdy position for yourself and good visualization specifically for if you need to do any hands-on maneuvers things are really slippery and the water provides so much movement that you can't get sort of a solid stance to maneuver the baby.
[26:58] And then if you think the baby's going to need assistance or some kind of resuscitation, that's a lot easier to do outside of the pool. I'm saying this, but these are pretty rare circumstances, but those would be one reason why you would get out of the water. They don't happen very often. It's just as two things you should know. If you're planning on being a midwife caring for women who are having water births is if you think you're going to need to maneuver the baby or if you think the baby needs resuscitation, do that outside of the pool.
[27:27] Also, a lot of touching and maneuvering of the baby under the water can also stimulate the baby to breathe. So as a general rule of thumb, We don't touch or handle the baby underwater unnecessarily because we want to avoid stimulating it. If it starts to feel lots of touching and poking and pulling and grabbing, you might think, oh, maybe I'm born and be stimulated to breathe. So generally, we keep our hands off the baby as it's being born into water. And if you're watching birth videos, and I've seen the same, I've seen some water birth videos where the mum or another parent themselves are patting or stroking the baby's head while they wait for the next contraction to be born. And I would advise against overstimulating the baby and also keeping the baby underwater unnecessarily. I've seen that too, where the sort of parents think it's cool to kind of swim the baby in the water before bringing it out. There's no need for that. And overstimulating the baby in the water can stimulate them to breathe.
[28:31] The other thing is that water should be close to body temperature or warmer
[28:35] so the baby doesn't feel cold when it's born. So cold water can be enough stimulus for the baby to take a sudden breath. And so that's the other reason why I advise against things like ocean and river births. It's not dissimilar. If you plunged yourself into cold water, you go, babies do the same thing. So ocean and river births, I don't recommend them, mostly because of the cold but also bacteria anyway warm body temperature water that's clean out of the tap so drinking water is what you would use so another thing to remember is that the water should be high enough to cover the woman's whole belly right up to under her boobs and again approximately body temperature or a bit warmer so that the whole baby's head and the whole body is born into water so that they stay under the water for the entire birth and don't expose them to the air partially. So the baby needs to be fully born in water, not half-half.
[29:37] That way you know that the dive reflex is going to stay in place. And if the head is born and the baby is exposed to air for any reason, maybe the water isn't high enough or the woman suddenly comes out of the water, don't submerge it again. The baby now should be born in air and not water. So they can go from water to air, but not air to water. So when the baby's head is born underwater, the very, very worst thing that you can do for that baby is... And for the woman is to suddenly change the environment by doing things like pulling the plug of the bath. And I've heard of places who don't have robust training for their staff or really strict rules around who can give birth in water. And they will tell their staff that if a woman gives birth in water, you've got to pull the plug.
[30:30] And that is the worst, most dangerous thing that you could do in that scenario. So all of a sudden, you've created the most dangerous situation you possibly could in water by having the baby be part in water, part out of water. And it sort of shocks the woman as well, who's just pushed the baby out in the water or maybe just the head out in the water. And now all of a sudden, the whole bath is draining. So the safest scenario is to complete the birth, not stress the woman out in that moment or change the height of the water. It's the worst possible thing you can do in that scenario. Complete the birth in water. That's the safest option. So I mentioned a few things here which are general rules of thumb for water. The pool should be body temperature or a bit warmer to the comfort of the woman. If the water's too cold, it could stimulate the baby to breathe prematurely. The pool should be filled up high to cover the woman's belly all the way up to her boobs so that if the baby's born underwater, the dive reflex will prevent the baby from breathing. And, you know, once it fills air, you can't rely on the dive reflex. If the head's born and the woman is out of the water, don't resubmerge her.
[31:46] If you suspect the baby's in distress or experiencing a shoulder dystocia, a breech position, or there's a surprise twin, it's clinically easier to manage this with the woman outside of the pool and, you know, And also if the baby's distressed, it might override that dive reflex and attempt to take a breath in the water.
[32:06] So with babies who were born in water, try not to touch them unnecessarily. You want to minimize stimulation to the baby until after it's surfaced from the water to avoid premature breathing. And it's normal and okay for the baby's head to be out and then wait for the next contraction for the body to be born. The baby will not drown in that process if everything is normal.
[32:36] So as far as water birth goes, those are the general rules of thumb. And as I talk now about the benefits and risks of water birth, I'll share a few more tips on how to stay safe during water birth. So the other thing I'll mention about babies born in water is because their first breath is delayed by their transition through the water, the use of APGAR scoring for babies in water, I believe it should be a little bit different to being born on land. I haven't found any research on this, but theoretically, if they're still in an intrauterine scenario when they're born, then really the, I think the APGAR scoring should start once they surface the water. Because the APGAR score is usually timed when you, from the point of the baby being born. But midwives who attend a lot of water births will tell you that typically babies born in water seem to take longer to respond to being born. It's kind of less of a dramatic entrance, which is completely okay because the cord is still pulsing. The baby's still getting all the nutrients and oxygen and everything it needs. It's all provided.
[33:44] But at the very least, I would suggest starting APGAR clock at the time that the baby surfaces. I mean, APGAR scoring is thwart with controversy anyway. So if you have a look at episode 97, if you're interested in APGARs, but yeah. What I know from attending water births and what other midwives have also shared is that when babies are born in water, they do seem to be a lot more chilled out, a little bit more relaxed. It's a lot more of a kind of gentle entry and they don't all cry all the time. They just kind of slowly come in and wake up. So some people suggest that maybe water birth babies need to have a different APGAR scoring method. But anyway, just to let you know, not to be alarmed necessarily
[34:31] if the baby takes a little bit more time to come in. But I mean, yeah, obviously you're the clinician. If you're a midwife listening to this, be aware. But the APGAs might look a little bit different for water birth babies. So let's look now at what the evidence and research says about water birth.
[34:51] So let's look at what the evidence and research says about water birth. And I'll start with the Cochrane Database of Systematic Reviews, which was published in 2018. And then I'll also cover some other studies that match their findings and some more recent research that was released after the Cochrane Review. So fortunately for me, this is an easy one because all the research is pretty much in agreement with each other. And water birth isn't particularly a controversial topic in the research literature. There's not a lot of people anti-campaigning for water birth. In fact, the Ranskog Royal College of Obstetricians for Australia and New Zealand has a whole water birth policy. They don't discourage it, which is encouraging. And so, yeah, there's not a lot of controversy around water birth. And on the whole, the research agrees that women find the use of water immersion in labour and birth a helpful comfort strategy.
[35:54] And it seems to assist with pain management, increases women's satisfaction, and is helpful to their labour process overall. And Michel Audond comments in his work that water was an effective tool to help calm the woman if she's feeling overwhelmed by labour. And so if she's tired or overwhelmed, the water would allow her to rest.
[36:16] And women do find water soothing, and it offers them a reset. So if there is a time in labor where you feel like everything is too much and you feel like you need a kill switch and sort of reset and start again water can be a great leveler to help calm the situation and the research on outcomes is slightly varied but on the whole if by having a water birth you introduce no new and unusual risks when choosing to birth in water and in fact I'll demonstrate the outcomes don't vary much but you do experience a reduction in birth interventions owing to being in water so we'll have a look at that as well. So let's start with the Cochrane Database of Systematic Reviews piece on water births and you can read it in the resource folder so if you're on the mailing list for the podcast you can get access to that. If you're not on the mailing list and you want to see all these research papers go to melanethemidwife.com join the mailing list you'll get immediate access to the resource folder and forevermore you can see the rest of the podcast episodes resources.
[37:20] So in the Cochrane database, in that paper, they found 15 trials. And all of those trials, this is the catch because the Cochrane database for systematic reviews uses randomized control trials. They found 15, except there was only a total of 3,663 women across all those studies.
[37:42] And we've already spoken about doing a randomized control trial on water birth is not feasible. So our best chance is to look at observational studies. So I won't go through all the details of the Cochrane review except to share the conclusion because I have some better and more recent studies. But Cochrane says, in healthy women at low risk of complications, there is a moderate to low quality evidence that water immersion during the first stage of labor probably has little effect on the mode of birth or perineal trauma, but it may reduce the use of regional analgesia, so pain medication in labour. The evidence for immersion during the second stage of labour is limited and does not show clear differences on maternal or neonatal outcomes or the need for intensive care. There is no evidence of increased adverse events to the baby or the woman from labouring or giving birth in water. Available evidence is limited by clinical variability and no trial is being conducted in a midwifery-led setting. Now that's the biggest part that I want to talk about. Of all of those studies, the 15 that Cochrane used for their 2018 look into water birth, none of the births happened in a midwife-led setting. So up until 2018, we only understood water birth from the perspective of obstetric management.
[39:08] So it doesn't make sense that there would be no study at that point.
[39:16] So what they concluded is as though there was 15 studies, there wasn't really high volume of women. It's hard to make strong conclusions.
[39:24] But there are other papers that have been done, research that's been done since 2018. So let's look at some of the more recent papers published after 2018, which did focus on midwifery-led care and on midwifery-led units. And we'll start with this next paper, which was published in 2022, and it's called Maternal and Neonatal Outcomes Following Water Births. And this was a cohort study of 17,530 water births, and they compared that to 17,530 land births. So they got two groups that were approximately equivalent, as closely as you can possibly get it with research. they were matched 17,500 in one and 17,500 in another. And that's a good number of women to be able to make more clear conclusions on the outcomes of water birth. But again, the problem here, they solved one problem, it was midwifery-led unit, but, you know, this was done on low-risk women. So there's a massive gap in the research for women who were considered to have risk factors. But I'll talk about water birth for women who were thought to have risk factors a little bit later.
[40:35] Nonetheless, it's solved a few of our problems and they have a large data set. So this study, 17,530 women, and they were cared for by community midwives, either at home or community birth centers. And so they collected data from 2012 to 2018 and they compared the two groups, water birth and land birth.
[41:01] And we call it a retrospective study. So they didn't actually recruit any women. They just had collected data on outcomes. And then they looked back and said, well, what happened to all these women? Who did that? And what this study was looking at, they looked at maternal and baby outcomes. So for maternal outcomes, they asked, did they have a postpartum hemorrhage of greater than 1,000 mils? Separately, they asked, was the woman diagnosed to have had a postpartum hemorrhage, even though she didn't lose 1,000 mils? I like that type of questioning. They looked at the perineum and if there was any trauma to the vulva or vagina and to the anus. And they looked at if women had to transfer to hospital within six hours after the birth. They also had to look at if the woman had to be hospitalized up to six weeks after the birth. So those are the outcomes they checked for women. And then for babies, they looked at something that's called cord avulsion. And we'll talk about that. It's going to become a significant. Again, you'll know what chord avulsion is by the end of this episode. So they looked at chord avulsion where the chord snaps.
[42:08] Soon after birth, not during the birth.
[42:13] Respiratory distress as a result of having been in water. Did the baby need to be transferred to hospital within six hours? Or if they had to be admitted to the knee or natal intensive care unit. And they also had a look at if the baby needed to be hospitalized for anything. And they checked if the babies had any infections. They also looked at deaths of babies. So in this research, they found that no woman died, which is what we would expect from sort of a small data set like that, 17,500 women, we would not expect a death. So if we have a look at the results, let's have a look. If we look at maternal outcomes from this, this was published in 2022.
[42:56] Postpartum hemorrhage of greater than 1,000 mLs. For the women who had water birth, the stats were 2.38%. So 2.38% of the 17,500 had a postpartum hemorrhage of over 1,000 mLs. If you gave birth on land, the stat was 2.99%, so very close to 3%. So 2.4% compared to, 3%. So the women who gave birth in water appeared to have less of a chance of having a postpartum hemorrhage of over a thousand mils. Next, genital tract trauma. So tears to vulva, vagina, anus, first degree, second degree, labial tears, grazers, anything. Your chances of having a tear is 49.3%. If you're on land, 49.2. So pretty much identical, basically the same. You're at no increased risk of a worse or better outcome for your perineum if you give birth in water, according to this study.
[44:00] And they had a look at the third and fourth degree tears. And this is something that came up when people were emailing me, asking me for research, that their obstetricians were worried about them birthing in water because they believed that there would be an increased chance of third or fourth degree tears if they had their babies in water. So this study specifically picked out that stat. If you're in water, you have a 0.75% chance of a third or fourth degree tear that starts to involve the anus. If you're on land, 0.84%. So this study, although it was 0.75% compared to 0.84%, they considered that statistically significant. So in fact, based on this study, you've got less of a chance of a third or fourth degree tear if you give birth in water.
[44:49] But also here, these women gave birth at home or in a birth centre. So there's no chance of vacuum or forcep delivery, which is something that can really predispose women to a third or fourth degree tear from either an episiotomy or the actual procedure of the vacuum forceps, So that risk is eliminated if you're birthing in water because people simply don't have access to give you an episiotomy or vacuum or forceps if that's the plan. So now let's look at maternal hospitalization in the first six weeks. And that is 1.9% if you give birth in water, 2.2% if you give birth on land. So that was considered, again, statistically significant. So if you give birth on land, there's a statistically significant, more likely chance that you'll need to be admitted to hospital in the first six weeks after your birth. But again, we're talking 2.2 versus 1.9. So because the other thing that people worry about is uterine infection for the woman. Sometimes they'll say your waters are broken. You can't get in the pool. Your waters are broken. You're at risk of an infection. Or like what happens? Does the water actually get up there?
[46:03] Unlikely. but people do worry about maternal uterine infection as a result of having given birth in water. So this, there was also a statistically significant difference, but not in favour of water birth. So maternal uterine infection in the first six weeks, if you give birth in water, 0.31%. If you gave birth on land, it's 0.25%. So statistically more likely to get a uterine infection if you give birth in water, so 0.31% versus 0.25. So there was an increase in maternal infection. But interestingly, in terms of the women who had to be hospitalized for uterine infection, they were the same. So the same number of women had to go to hospital for uterine infection than those who gave birth on land. So even though some women were diagnosed with a uterine infection after water birth, but also after land birth, only half of them actually needed to go to hospital. So the hospitalization rate for infection was the same for any woman. And that tells us that it wasn't particularly serious that they had to be hospitalized and that it was managed at home under the care of their midwife.
[47:23] So those are the stats. And if we look at outcome for babies now. Now, the first thing, this umbilical cord avulsion. So cord avulsion is when the umbilical cord snaps off from the placenta. So either it can happen close to the baby or further up the cord. And it happens once the baby is born. And if it happens, the midwife has to notice it. You should notice it. So in the water birth group, there was a cord avulsion rate of 0.57%, so about half a percent. On land, it was 0.37%. So there was an increase in quarter voltion as a result of water births. And if I'm honest, I've seen two cord avulsions at home in water and one on land. And the two water birth ones were pretty much a result of the dad catching the baby and kind of forgetting about the cord and placenta and kind of pulling the baby too far away from the mum and snapping the cord by sheer force just by the fact, just lifting a part of the water and handing the baby to mum. So this could kind of happen if there was a short cord and the baby's born and the mum goes to lift the baby up out of the water, not noticing that the cord is short, and then it snaps. So this is generally how it happens.
[48:47] In my circumstances, everyone was fine. I noticed what happened, that the cord had snapped, and then you need to quickly clamp it because the blood that's coming out of the cord is the baby's blood. Any blood that's in the placenta also is the baby. so it belongs in the baby, and now the cord's been immediately severed. So it's important that you collect the cord straight away if you notice that the cord has been snapped. So it's slightly more likely to happen in a water birth, which makes sense. There's less visibility, and if the cord is short, then the woman's less able to manoeuvre the baby and sometimes can accidentally snap the cord or the midwife, whoever's catching the baby. So now that we know this about water birth, that cordavulsion is slightly more likely in a water birth.
[49:38] Incorporate that knowledge into your practice and I always do remind the women to be careful when bringing their baby up do it slowly and notice what the cord is doing if the cord's a bit short they might need to actually bring their body up with the baby so that it can surface but also sometimes the cord can be wrapped around the baby under their arm around the neck whatever it is so I if you see that if a baby's born underwater and you can see that there's a lot of cord coiled around the baby I would suggest gently unwrapping the cord in the water and you know you'd have to be kind of swift with it but loop it over it's a lot easier to untangle the baby when it comes to the surface all the cord is very tight and it's hard to loop it over and you know it's all a bit the baby's slippery and you've got to maneuver it so try and do that quickly under the water before letting it surface so now that we know that cord avulsion is more likely to occur in water for the reasons I just mentioned, instead of saying, oh, we shouldn't do water birth because it increases the risk of cord evulsion, just adapt your practice and educate.
[50:44] Yourselves, your staff and the women who are in your care, just to ensure that
[50:48] there are precautions and strategies in place to prevent it from happening in the first place. So have a clamp within reach just in case there is an evulsion, be aware that it can happen and careful when you lift the baby up so that there's no sudden movement of the baby away from the mother that the cord might snap. And that's what research is good for. It's really to point to things that need our attention so that we can come up with some solutions and strategies. So use caution around moving the baby away from its mother after it's born in water because there is a slightly increased risk of cord avulsion. Now we know. Okay, now continuing on in this study, let's look for the more concerning outcomes that people would have for the baby. So we'll look at the neonatal death rate, so the death of the baby.
[51:36] If you give birth in water, 0.28 babies per 1,000, so that's 2.8 babies per 10,000, will unfortunately not survive. If you give birth on land, it's 0.51, so half a baby per 1,000, so five babies per 10,000. So it's more on land, 2.8 per 10,000 in water, five babies per 10,000 on land. So although there's an increased risk of cord avulsion, it doesn't seem to be such a serious circumstance. If managed quickly, it doesn't increase the risk of the baby dying. In fact, according to this study, there's more risk to the baby dying after birth if it's born out of water than in water. And just quickly, with the other stats, there was respiratory distress was lower for babies having water birth than babies born on land. Everything else was lower that they checked. Neonatal infections in the first six weeks were the same, whether or not you were born on water or land. Neonatal admissions to hospital were lower if you gave birth in water. So the findings of this study, what they said, I'm just going to use their words because they're actually so beautiful. So the researchers said that for every 10,000 women who have a water birth.
[52:59] Six will develop a postpartum uterine infraction. On the other hand, those 10,000 water births would have simultaneously been associated with 60 fewer hemorrhages over 1,000 mLs, 74 fewer diagnoses of postpartum hemorrhage, 44 fewer instances of maternal transfer to hospital in the postpartum period, 28 fewer hospitalizations in the first six weeks, 8 fewer third or fourth degree tears.
[53:27] And what's most importantly is no increase in hospitalization for infection. So although they found a slight increase in uterine infection risk if you give birth in water, it doesn't increase the risk of you needing to go to hospital to manage that. And for every 10,000 babies born underwater, you would expect 20 cases of umbilical cord avulsion, but 12 fewer cases of respiratory distress, 26 fewer neonatal transports to hospital and 20 fewer hospitalizations in the first six weeks for the baby. And importantly, no increase in neonatal deaths. In fact, a decrease in neonatal deaths. So yes, cordivulsion increases, but this is a minor outcome compared to things like death and respiratory distress and admission to neonatal intensive care units. And I think what we have here is a beautiful baseline of what is possible for water birth because this study was done on low-risk women with midwives in a community setting. That's our baseline. That is what is possible. So as far as I can gather, this is our baseline to move on from. And if you started implementing water births in your hospital, we know that it's possible to have these amazing outcomes and these statistics.
[54:45] And if the stats in your hospital are different, then it's not what's happening with the women and it's not what's happening with water births, potentially it's what's happening in that setting with those care providers.
[54:59] Okay, so that was that one. That was 17,500 women compared to 17,500 women. Two big groups. And there's one more that I want to share with you and that's all I'm going to do because otherwise I will just be repeating myself. As I said, a lot of the research had very similar outcomes. So that last study that I just talked about covered births in the US and Canada. And this next one that I'm going to do is based in the UK. But there's nothing to suggest that the outcomes would be different in other countries that have established maternity care services and where care is provided by registered midwives. So I think this still is transferable information. So this next and even bigger and more recent study is called Maternal and Neonatal Outcomes Among Spontaneous Vaginal Births Occurring in or Out of Water Following Intrapartum Water Immersion. It's the POOL cohort study, P-O-O-L cohort study. And again, you'll find that in the resource folder. So the primary objective of this study was to answer a question that is commonly asked by women who are using water immersion for pain relief. And that is, is if everything remains okay during labor, should I stay in the water or should I get out for the birth? So the study was designed to establish.
[56:24] Among women who used intrapartum water immersion, so while they were in labour, and where their pregnancy and labour was uncomplicated again, is it safe to then give birth in water or should they leave to get out? So they included 26 sites or birthing units in the study from England and Wales, and they assessed births that happened between 2015-2022. And all the births were attended by midwives who were employed by the National Health Service, by the NHS, and who were registered with the Nursing Midwifery Council. So in the UK, midwifery is regulated and they're publicly employed. Many of them are. So this was done in units where the midwives were publicly employed and registered.
[57:10] And the births occurred in obstetric units, at home, and in midwifery-led units. They were all included. At births where the midwife was not in attendance, either because the woman chose to give birth without an assistant or because birth occurred at home before they could arrive, they excluded those. So this is midwife-attended water births. Now, the main thing they were looking for for women here was the anal sphincter injury, so third and fourth degree tears. And then the things they were looking for for the babies was a collection of outcomes including mortality so if any babies died if there was any stillbirths fetal death after the start of care in labor neonatal death before they were discharged home neonatal unit admission so if they were in intensive care if they needed respiratory support if they needed IV antibiotics so it sort of measured a whole range of the more complex outcomes for babies. And the other thing they were looking for were postpartum hemorrhoids. So there was some primary outcomes, the things like the big things they were really interested in, and then there was what we call secondary outcomes. So let's have a look at what they found.
[58:23] So they had a total of 869,000 records that they received from these 26 units and 90% of the women had no record of water immersion in birth. So only 10% of those women, so around 87,000 women had used water during labour and birth. That's 10% of the data they collected. A total of 60,000 births were relating to women without eternatal or intrapartum risk factors who used water and were eligible for the study. So in all, there was actually 39,600 water births. And 20,700 births outside of water on land. Now let's have a look at the findings. Now I've got here the chart where they explain the percentages of all the things that happened. So third and fourth degree tears for primates, women who have not had a baby before. If you give, in this study, if you gave birth in water, it was 4.8%. If you gave birth out of water, 5.3%. So higher if you gave birth out of water. If you had a baby before, the chances of a third or fourth degree tear were 1.1% if you were in water. If you were out of water, 1.7%. So again.
[59:48] Water birth protective for third or fourth degree tears. Overall, if you bunched them all together, there was a 2.5% chance of third or fourth degree tear if you gave birth in water, 3.8% if you were out of water.
[1:00:03] So that's already better. Then they had a look at the next primary outcome, the big major thing that they were looking at was adverse outcomes for the babies. If you bunched everything together, all the things they were looking for, the babies born in water, 2.7% of them had some major adverse outcome. If the baby was born out of water, it was 4.4%. So much higher in the out of water births. And they broke that up for us as well so we could see the breakup of the stats of the separate components. So neonatal admission that required respiratory support, 0.9% for the babies who were in water, 2% for the babies out of water. With regards to intrapartum or neonatal deaths, there were seven in the water birth group and six in the land birth group. But there was a few more babies in the water birth group. So in terms of the breakup, it's 0.18 per 1,000 births in water, 0.29 per 1,000 births out of water. So still lower intrapartum or neonatal death rate for the babies born in water.
[1:01:21] Babies who needed administration of antibiotics after birth, water 1.8%. Land, 2.9%. Again, better outcomes for the babies born in water. Now the secondary outcome, so kind of like the other things they were looking for, shoulder dystocia outcomes. For the women who gave birth in water, there was a 0.6% chance of shoulder dystocia. For those on land, 3.1%. So much higher on land. Postpartum hemorrhage with blood loss greater than a thousand mils, 2.9% if you gave birth in water, 3.8% on land. The next thing is they looked at cordavulsion for the babies, of course, and they found the same thing as the previous studies. 1% if you give birth in water, 0.3% on land, but we already know how to prevent that for next time.
[1:02:13] Neonatal resuscitation required at birth was lower if you gave birth in water, it was 4.1% versus 6.3% for those babies born on land. So the pool study is the largest UK-based study of water immersion during labour and birth. It's generated high quality evidence on maternal and neonatal outcomes that
[1:02:33] are associated with water birth. Now the study was consistent with other studies of water birth so now hopefully we can all at least agree that water birth for women that don't have complicating factors is at least equivalent to the outcomes for women who give birth on land, both for the women and for their babies, actually, if not better, in water. But we do just need to show caution with the possibility of the cord snapping and being aware of that. But from a physiology perspective, I know all these studies have been done on low-risk women. Yeah. But if we look at the physiology of labour and birth, I just can't see an increase in the risk for women who have things like diabetes or VBAC or a high BMI or a history of postpartum hemorrhage, for example. In fact, what we saw is that women who have had a history of postpartum hemorrhage are less likely to have one in water than on land.
[1:03:32] So for women with risk factors who've been told they cannot birth in water, and if that's you, please know that the water itself does not add a layer of risk to your birth. So sometimes, for example, bigger mamas are restricted from water birth because of the logistics of getting you in and out of the pool. Not because it's more dangerous, but it's just the logistics of getting in and out. And they're thinking always of the worst case scenario. What if the woman loses too much blood and we can't get her out of the pool? What if she loses consciousness? How are we going to get her out of the pool to care for her? It's really about logistics with the risk factors. And I could talk forever about water birth for women with risk factors, but I just want to encourage you mamas who have been told that you can't get into the water because of water. A risk factor. I would suggest that you work with your care providers to navigate
[1:04:30] creative solutions to overcome the barriers to you accessing water. Find out why and if you personally are at increased danger by getting in the water. It's likely that it's more of a logistical or workplace barrier and it's not actually more risky for you but your care team might have perceived challenges that relate to other things more than your particular safety.
[1:04:57] Now, that is all I'll say about that. That is this episode of Great Birth Rebellion podcast on water birth. I would encourage you to read and utilize all the papers in the resource folder. And if you are really keen to get through labor and birth without pain medication, I would suggest you incorporate the use of water into your pain management strategy and also consider getting the Guide to Giving Birth Without Pain Medication that I've created just for you based on everything that I've learned over the last 18 years of watching women do exactly that. You can do it too. The link is in the show notes and I will see you in the next episode of the Great Birth Rebellion podcast. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, Wear the Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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