For thousands of years women have been using water to ease labour and facilitate birth. Wherever there has been even slightly warm water, there have been women bathing in it, using it ritually, and finding great comfort in it, especially in labour.
Soaking in a tub of water to ease labour sounds inviting to most women. If the water is where a woman wants to be and there are no complications, then in the water is where she will feel the most comfortable. When it is time to birth the baby, there is no reason to ask the mother to get out of the water.
When a woman in labour relaxes in a warm tub, free from gravity’s pull on her body, with sensory stimulation reduced, her body is less likely to secrete stress-related hormones. This allows her body to produce the pain inhibitors ‘endorphins’ that complement labour. Noradrenaline and catecholamines, the hormones that are released during stress, actually raise the blood pressure and can inhibit or slow labour.
What is waterbirth?
The act of giving birth in water is so incredibly simple. A mother submerges herself in warm, body temperature water during her labor. If she feels like giving birth in that warm buoyant state, there is no need to ask her to leave the water.
The baby has grown in a fluid environment for the past 9 months. Babies adjust very well to being born in a birth pool. Waterbirth is miraculous.
How long is baby in the water after the birth?
Practicioners usually bring the baby out of the water within the first ten seconds after birth. There is no physiological reason to leave the baby under the water for any length of time. There are several water birth videos that depict leaving the baby under the water for several moments after birth and the babies are just fine.
Physiologically, the placenta is supporting the baby with oxygen during this time though it can never be predicted when the placenta will begin to separate causing the flow of oxygen to baby to stop. The umbilical cord pulsating is not a guarantee that the baby is receiving enough oxygen. The safe approach is to remove the baby, without hurrying, and gently place him into his mother’s arms.
What is the temperature of the water?
Water should be monitored at a temperature that is comfortable for the mother, usually between 95-100 Fahrenheit (35C-37.7C). Water temperature should not exceed 101F (or 38C) as it could lead to an increase in the mother’s body temperature which could cause the baby’s heart rate to increase. It is a good idea to have plenty of water to drink and cold cloths for the mother’s face and neck. A cool facial mist from a spray bottle is a welcome relief for some mothers as well.
What prevents baby from breathing under water?
Waterbirth is simple. Within the simplicity of water labor and birth lies a complexity of questions, choices, opinions, research data, women's experience and practitioner observations.
Over the past five years as more hospitals within the United States examine waterbirth and create programs to support the use of water for labour and birth, newspaper reporters latch onto the sensationalism of this simple option and publish stories of successful waterbirths in local publications. Each reporter does their best to simplify waterbirth and at the same time answer the most common questions. Each story shows a happy beaming mother, a quiet peaceful baby and a proud father, who usually successfully set up a portable birth pool. The surprise headlines like, "œwatery birth" or 'baby's birth goes swimmingly” or "junior makes a splashy entrance,” are countered with the simple stories of couples who have made this decision for themselves and are proud of it.
The first and foremost question in everyone's mind and the lead in all of these newspaper accounts is simple:
How does the baby breathe during a waterbirth?
There are several factors that prevent a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns. The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his intercostal muscles and diaphragm in a regular and rhythmic pattern from about 10 weeks gestation on. The lung fluids that are present are produced in the lungs and similar chemically to gastric fluids. These fluids come out into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero. 24-48 hours before the onset of spontaneous labour the fetus experiences a notable increase in the Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements (FBM). With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain. You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about forty percent of the time. When the baby is born and the Prostaglandin level is still high, the baby’s muscles for breathing simply don't work, thus engaging the first inhibitory response.
A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping. If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs. If the baby were in trouble during the labour, there would be wide variabilities noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby's birth.
Another factor which is thought by many to inhibit the newborn from initiating the breathing response while in water, is the temperature differential. The temperature of the water is so close to that of the maternal temperature that it prevents any detection of change within the newborn. This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature and yet the babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed.
One more factor that most people do not consider, but is vital to the whole waterbirth and aspiration issue, is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.
The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled. God built this autonomic reflex into all newborns to assist with breastfeeding and it is present until about the age of six to eight months when it mysteriously disappears. The newborn is very intelligent and can detect what substance is in its throat. It can differentiate between amniotic fluid, water, cow's milk or human milk. The human infant will swallow and breathe differently when feeding on cow's milk or breast milk due to the Dive Reflex.
All of these factors combine to prevent a newborn who is born into water from taking a breath until he is lifted up into the air.
So, what does happen to initiate the breath in the newborn? As soon as the newborn senses a change in the environment from the water into the air, there is a complex chain of chemical, hormonal and physical responses, all resulting in the baby breathing. Water born babies are slower to initiate this response due to the fact that their whole body is exposed to the air at the same time, not just the caput or head as in a dry birth. Many midwives report that water babies stay just a little bit bluer longer, but their tone and alertness are just fine. It has even been suggested that water born babies be given the first APGAR scoring at one minute thirty seconds, not at one minute, due to this adjustment.
There are several things that happen all at once for the baby. The shunts in the heart are closed; fetal circulation turns to newborn circulation; the lungs experience oxygen for the first time; and the umbilical cord is stretched causing the umbilical arteries to close down. Nursing and medical schools taught their students for years that the first breath was dependent on the pressure of the passage through the birth canal and then a reflexive opening of the compressed chest creating a vacuum. That action has no bearing on newborn breathing whatsoever. There is no vacuum created. The newborn who is born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted up out of the water and into mother's waiting arms.
All the fluids that are present in the lung alveoli are automatically pushed out into the vascular system from the pressure of pulmonary circulation, thus increasing blood volume for the newborn by 1/5th or 20%. The lymphatic system absorbs the rest of the fluids through the interstitial spaces in the lung tissue. The increase of blood volume is vital for the baby’s health. It takes about six hours for all the lung fluids to disappear.
When we look back at the analysis of the statistics of babies born in water it proves that these inhibitory factors are more than theories. A study conducted in England between 1994 and 1996, and published in 1999, reports on the outcomes of 4032 births in water. Perinatal mortality was 1.2 per 1000, but no deaths were attributed to birth in the water. Two babies were admitted to special care for possible water aspiration. From 1985 to 1999, it is estimated that there have been well over 150,000 cases of waterbirth worldwide. There are no valid reports of infant deaths due to water aspiration or inhalation. In the early days of waterbirth a baby was reported as dying from being born in the water. This particular newborn death was caused not by aspiration, but by asphyxiation due to leaving the baby under the water for more than fifteen minutes after the full body was born. At some point the placenta detached from the wall of the uterus and stopped the flow of oxygen to the baby. When the baby was taken out of the water, it did not begin breathing and could not be revived. On autopsy the baby was reported to have no water in the lungs and its death was attributed to asphyxia.
This is the reason that we bring babies up out of the water within the first few moments after birth. Some people have commented on the long time that some babies remain in the water in the film, “Water Babies: The Aquanatal Experience in Ostend.‿ Video tape is deceiving, but so are our senses. When timed, the film sequence is only forty-seven seconds, but when viewers are asked to judge how long the sequence of immersion for the baby really is, reports range anywhere from one minute to five minutes.
Bringing a baby out of the water too quickly can be just as traumatic but it can also lead to either torn or broken cords. This has been reported by a number of midwives and doctors. If the practitioner is not looking for a torn cord the possibility of the baby needing a transfusion increases. Torn or broken cords can be avoided by bringing baby out of the water slowly and gently. Mothers who desire to pick up their own babies need to be reminded to not do it too quickly, either.
The inability to accurately assess blood loss in the water is a reason that some midwives have stated for either not 'allowing' the birth to take place in the water or asking mother to get out right away after the baby is born. Blood loss assessment is easy to judge after a few births. Garland and Jones report in a review of waterbirths at Maidstone Hospital in Kent, England, that the midwives are much better at judging and reporting blood loss in the water after experiencing over 500 births. A useful key to judge postpartum hemorrhage is how dark is the water getting? Can you still assess skin color of the mother's thighs even though there is blood in the water? A few drops of water in a birth pool diffuses and causes it to change color. A waterproof flashlight comes in handy at this point. Dropping a flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during the birth. It also helps you spot floating debris and remove it.
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