Hospitals are corporations with set policies, but those policies can be amended, changed or new policies put into place. Knowing how and who to approach within the hospital is one of the keys to success. The sooner you start the process, the more opportunity there will be to use water immersion for both labor and birth in a hospital.
Begin your inquiries early and be persistent. Consult with your maternity care provider, first, and assess their experience, knowledge and if they have taken any courses or read research articles about labor and birth in water. Enlist their support for your birth care plan. State that you have chosen to use water as a comfort measure and would like to have a waterbirth if it is appropriate at the time of birth. The birth in water is not, yet, the biggest issue. Setting up the circumstances to allow a waterbirth always come first. That usually means the ability to bring a portable tub into the hospital. If your provider refuses to even consider using water for labor or birth, find a new provider. Nurse-midwives in hospital practices are usually open to accommodating your desires for an undisturbed birth.
The next person to enlist is the nurse manager of labor and delivery at the hospital. The manager is the most influential person to assist in all the policy changes that need to happen. You can call the hospital directly and ask to speak to the nurse manager. If she is able to talk to you, make an appointment. Before your appointment gather all supporting material and have the consent and cooperation of your provider, first. That’s the first question the nurse manager will ask: “have you spoken to your doctor/midwife?” Put together a packet of materials which includes a letter from your provider, a sample policy and some research articles. (It might be a good idea to bring a food item or self-care gift like bath products.) You can give her a list of resources, including our website. Once there is an agreement that a policy needs to be put into place, she will coordinate all the necessary meetings with department heads who all need to agree to a system wide policy change. This process can take up to six months, but sometimes it happens more quickly.
Your job during the implementation of the policy is to continue to advocate for change. You can to talk to other mothers who are pregnant around the same time, or those considering getting pregnant and educate them with the research on water labor and birth that you have done. You might also contact a local birth center or home birth midwife to educate yourself more about childbirth options in your local community.
Discuss other options for comfort management with your partner, your provider and know which of those options are available if the policy does not change quickly enough. Showers, walking, rocking, doulas, dancing, music, soft lights can all be done with or without the availability of a soaking tub. Ask for all those at the same time you are advocating to use a birth pool.
If your hospital offers waterbirth as an option, there is usually no extra cost. Sometimes a hospital will charge a fee for the use of a portable birth pool. You can also purchase your own birth pool for home or hospital use through many different sources. We recommend Waterbirth Solutions.com. The cost for a complete portable birth pool kit is now under $250. Midwives will often provide a birth pool for a small rental fee or they may refer you to a local doula or rental company who provide a number of birth pools for hire within the community.
Some insurance companies do reimburse for the expense of the pool rental or purchase. Parents who have been successful in receiving a reimbursement have asked their provider to write a prescription for the birth pool or to make an order in the chart. Insurance companies view the use of the tub as a “pain management” treatment and are more likely to cover the cost if there is a code associated with the order. If the hospital has permanent birth pool equipment, there is no reason to inform your insurance company that you have had a waterbirth. It doesn’t matter if the baby was born in the bath or on the bed – it is still a vaginal birth.
A woman should be encouraged to use the labor pool whenever she wants. Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started. If contractions are strong and regular, no matter how dilated the cervix is, a bath might help the mother relax enough to facilitate dilation.
It has been suggested that the bath be used as a “trial of water” for at least one hour and allow the mother to judge its effectiveness. Midwives report that some women can go from 1 cm to complete dilation within the first hour or two of immersion. Research studies have demonstrated that water is an effective tool to assist irregular contractions to become more consistent or to use water immersion instead of Pitocin for a stalled labor. This reaction is due to an increase in Oxytocin levels and a reduction of stress hormones.
Water should be maintained and monitored at a temperature that is comfortable for the mother, usually between 92-100 degrees Fahrenheit (32-38 degrees Celsius). Water temperature should not exceed 101 degrees Fahrenheit (38 degrees Celsius) as it may lead to an increase in the mother’s core body temperature, which in turn may cause the baby’s heart rate to increase. It is a good idea to have plenty of water to drink to prevent dehydration 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. If the mother is exhibiting signs of overheating, such as facial sweating or flushing, she should get out of the tub for a short period of time and the water should be cooled. The water does not need to be body temperature when the baby is born. Babies are more vigorous at cooler temperatures (92F/32C).
There are four main factors that prevent the baby from inhaling water at the time of birth:
1. The fetus moves the muscles of the chest wall during pregnancy about 40% of the time. Close to the time of labor, the Prostaglandin E2 levels from the placenta rise, which cause a slowing down or stopping of those fetal breathing movements. As the baby is born, the Prostaglandin levels remain high, disabling the baby’s muscles for breathing. The muscles simply don’t work, thus engaging the first inhibitory response.
2. All babies are born experiencing mild hypoxia or low oxygen levels. Hypoxia causes apnea (absence of breathing) and swallowing, not breathing or gasping. The first reflex after a baby is born is to swallow, not breath. The swallowing will allow the fluids that are in the mouth to enter to stomach.
3. Fetal lungs are already filled with fluid. That fluid is there to protect the lungs, and keep the spaces open that will eventually exchange carbon dioxide and oxygen. It is very difficult, if not improbable, for fluids from the birth tub to pass into those spaces that are already filled with fluid. One physiologist states that “the viscosity of the fluid naturally occurring in the lungs is so thick that it would be nearly impossible for any other fluids to enter.” The blood supply to the lungs is also very low during pregnancy and birth. This causes a high pressure within the lungs, thus keeping everything out.
4. The mammalian diving reflex is an inhibitory factor that is present at birth in all humans as well as all mammals. It lasts in humans up to six to eight months. When the face comes into contact with water, the glottis at the back of the throat automatically closes and prevents water from entering the lungs. Any solution that enters the throat is swallowed, not inhaled. This allows babies to also breastfeed without aspiring the fluid into the lungs.
The initiation of breathing is a complex system which allows the newborn to switch from fetal life in the womb, where the placenta supplies all the oxygen needs, to a newborn that activates its respiratory system for breathing. All babies continue to receive oxygen from the placenta via the umbilical cord, if it is left unclamped and not cut. The timing of the clamping of the umbilical cord affects the quality and ease of newborn respirations. The stimulation to breathe and switch from being an aquatic mammal in the womb to an air breathing mammal in the room, is also a combination of factors which begin with room air and gravity on the baby’s face. Water babies sometimes show a short delay taking their first breath only because they have not had the stimulation from gravity and room air while their head is being born, as opposed to babies born on land. Only after baby’s face greets the warm room air for the first time do they begin the miraculous switch from fetus to newborn. Water babies are gently lifted out of the water and placed on their mother’s chest where they immediately receive signals from their mother’s presence. Her skin keeps them warm while the baby’s heart begins pumping a large volume of blood into the lungs for the first time. It is only after the blood volume increases that the lungs become cleared of fetal fluid and the respiratory centers in the brain are stimulated. This process may take a full minute, so be patient. The baby’s color will gradually change and sometimes the baby will cry. Water babies are often very still and quiet, although extremely alert, eyes open and arms and legs moving. Those are all signs of a healthy normal newborn. A trained waterbirth provider will know to give the baby plenty of time to gently transition into newborn life.
Babies should be gently lifted out of the water without hurrying or rushing. Anyone can do this, including the mother herself. It is beneficial for the provider to allow the baby to emerge completely into the water, examine for a cord entanglement and unwind or remove the cord before lifting the baby up out of the water. This can be accomplished in a few seconds. Remind the mother to lift the baby up slowly if she is the one reaching down, because you don’t know how long the cord is. Research studies indicate that there are more cord ruptures or breaking of the cord, caused by quickly jerking the baby out of the water.
Remember that physiologically, the placenta is still supporting the baby with oxygen throughout the birth and immediately afterwards. It can never be predicted when the placenta will begin to separate causing the flow of oxygen 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 upright onto the mother’s chest or hold the baby, suspended with the head out of the water, until the mother reaches down to lift the baby up. Waiting for the mother to return to her conscious brain after her birth journey, allows her to becomes fully present with an overwhelming desire to meet her new baby.
Umbilical cord snapping or tearing is a risk in any birth. Our objective is to delay cord clamping and cutting for a minimum of three minutes for every baby, but it has been standard practice for decades to clamp and cut the cord immediately in every birth. Water adds an interesting dimension to this issue. The pediatric and obstetric community have stated their concern that cord snapping may be a problem based on the observation of some researchers.
This is quoted from Evidence Based Birth, by Rebecca Dekker, RN, PhD:
“In 2014, Schafer reviewed all published cases of waterbirth umbilical cord tearing. An umbilical cord tear is also called umbilical cord “snap,” “rupture,”or “avulsion.” Based on their review, they estimated that there are about 3.1 umbilical cord snaps per 1,000 waterbirths. Out of all the cases of umbilical cord snap, about 23% lead to NICU admission, 13% lead to the need for a newborn blood transfusion, and there have been no reports of any long-term harmful effects. Burns et al. (2012) reported 20 umbilical cord snaps in a study with 5,192 waterbirths and 3,732 land births where women left the tub before giving birth. Eighteen out of these twenty snaps occurred during waterbirth. Unfortunately we cannot compare the overall numbers of umbilical cord snap between waterbirths and land births, because other than the Burns et al. (2012) study, there have been no studies that describe how frequently umbilical cord snaps happen on land.”
My conclusion, after interviewing some of the researchers, is that umbilical cord rupture at birth is generally caused by rushing the baby out of the water very quickly. This is precisely why I recommend a slower delivery with a pause to look for cord entanglement and resolving that, insuring that there is enough cord to slowly raise the baby up out of the water and to wait for a few seconds (with the baby’s head out of the water) before lifting the baby or having the mother lift the baby up onto her chest. The safe approach to preventing umbilical cord snapping during a waterbirth is to allow the baby to do the majority of the work of second stage with the mother breathing through the contraction and only bearing down in the last moments. If she bears down continuously, and expells the baby forcefully, that increases the risk of what I describe as “torpedo babies,” who have the increased risk of also snapping their cords if those babies are entangled. Slow the second stage down, bring the baby up slowly and untangle a baby in the water–if there is an entanglement–before raising them up to the surface.
The majority of the babies who have encountered cord rupture do just fine, but a few are put in NICU for observation and even fewer need transfusion. The ideal for every baby is delayed cord clamping, but it is not always possible. Just consider a cord snap an early cord clamping, which is easily preventable by slowing the birth down just a bit.