photo courtesy Allison Kuznia Photography
The use of warm water during labor is a great comfort measure. It is safe, widely available, inexpensive, and effective. Warm water immersion in labor can diminish stress hormones (called catecholamines) which increase pain and slow labor; it also directly reduces pain by increasing the body’s production of natural pain relievers (endorphins), can ease involuntary muscular tension, and enhance relaxation during and between contractions. It can also lower blood pressure within minutes and decrease edema (swelling), and the buoyancy can promote better circulation and increase the efficiency of uterine contractions. In addition, use of a large tub increases mobility so that it is easier to change positions to aid the progress of labor, especially when a woman is becoming tired. Research suggests that birth into water can reduce the incidence and severity of perineal tearing - the water encourages relaxation of the pelvic floor and provides natural support to the perineum.
Waterbirth may have benefits for the baby as well, and often provides a gentler transition to life outside the womb.
Many pregnant women are drawn to water, especially during labor, and women all over the world give birth in labor tubs, tide pools or natural springs. There are several ways to use water during labor. Some area hospitals have installed their own tubs for this purpose (be sure to ask about a backup plan in case it's already in use when you arrive). Rented tubs can be used in the hospital or at home, and might be just what you need for a more comfortable labor. The emphasis on technology and monitoring in hospitals sometimes makes this a controversial request, but be persistent - in this setting the reintroduction of natural elements such as water can be a real lifesaver. Some women choosing hospital birth use labor tubs at home, often with the services of a doula, to help them comfortably delay admission; this enables them to enter the hospital when labor is well established, which can often help them avoid unwanted interventions. If you are planning to birth at home, most traditional midwives are experienced and comfortable with waterbirth and will welcome your decision to use a tub. A bathtub or shower can also provide pain relief and relaxation, and should be available wherever you choose to give birth. Since it has no undesirable side effects, water should be offered before drugs for pain relief; many women may then go on to birth without medication, reducing risk to both mother and baby. The benefits of water are enhanced by other birth helpers such as massage, hypnotherapy, and emotional support.
A woman can enter the pool whenever she wants; however, if a mother chooses to get into the water in early labor, before her contractions are strong and close together, the water may relax her enough to slow or stop them altogether. If this happens it was most likely prodromal or “false” labor. That is why some care providers limit the use of the pool until a regular pattern of strong contractions is established and the dilation of the cervix is at least 5 centimeters. In fact, the tub is ideal to have at home for women who experience lots of preparatory contractions, since it can sometimes help them stop long enough to get some rest. On the other hand, some women have found that entering the pool helps them relax enough to really get labor going! Most of the time, it is helpful to wait until active labor so the mother has something in reserve for when coping with contractions becomes more difficult. According to Barbara Harper of Waterbirth International, the first hour of relaxation in the pool is usually the best and can sometimes help a woman achieve complete dilation even in that short amount of time. Alternating time spent in the water with time out, changing every hour and a half or so, can prolong the beneficial effects of water and provide renewed pain relief each time it is used.
photo courtesy Allison Kuznia Photography
There are some practical considerations to using water as a comfort measure. The advantage of tubs specifically designed for birth is that they are portable, heated, and large enough to accommodate movement and a variety of labor positions, as well as keep the baby's entire body underwater during the birth. This is important because it keeps the baby from being stimulated to take a breath before it is completely born. If a mother is using it for pain relief or reduction of blood pressure and edema, it is important to have enough depth to be fully immersed - her whole body should be under the surface. Less water than this will still be helpful, but not as effective. Be sure to fill the tub with water that is close to body temperature, 96 to 99 degrees Fahrenheit. Once filled, a heated tub will maintain this temperature as long as needed, even if the labor is lengthy. Be attentive to temperature - water above 100 degrees can promote excessive blood loss after the birth or cause the mother to become overheated, flushed or dizzy. If it is too cold she could become chilled and waste energy shivering - energy better used for labor! For this reason, have plenty of towels and blankets handy, since many women will be in and out of the tub several times before the baby is born. During any labor it is important to keep drinking liquids, but especially while in the tub, to avoid dehydration. Have a non-slip surface (bath mat or similar item) nearby for when the mother gets out, and a person or two ready to assist if necessary. It's useful to have a place nearby where the mother can rest after she gets out, such as large sofa or a mattress on the floor, covered with a waterproof sheet or shower curtain liner.
The question of safety needs to be addressed. There are no known hazards to laboring in water, whether or not the bag of waters has broken, and waterbirth is completely safe as well, as long as some basic precautions are used. First, there are several factors that prevent the baby from beginning to breathe underwater after birth. The water temperature is close to that of the amniotic fluid in the womb, so there is no shock of a temperature change. The baby is also receiving oxygen from the umbilical cord just as it has for the previous nine months. In addition, the baby has an autonomic reflex, called the dive reflex, which prevents it from inhaling any substance that is in the throat and causes it instead to swallow. (This reflex disappears after about six months.) There is a complex chain reaction of hormones and chemicals that cause the breathing process to begin; just know that it is impossible for a newborn to breathe until up in the air. The water should be deep enough that the mother can easily keep her bottom under the surface until the birth is complete. Once born, the baby should not be left under the water for an extended period of time (longer than half a minute). There are several waterbirth videos that show babies under water longer than this who do just fine, since the placenta is still supplying the baby with oxygen; but it can’t be predicted when the placenta will begin to separate and stop the flow of oxygen. The safest approach is to remove the baby unhurriedly within the minute after birth, face down so excess water drains from the nose and mouth. The mother may birth the placenta into the tub or into a bowl held under her while she stands up out of the water; sometimes she will be asked to leave the tub for this.
A note about waterbirth; the use of water during labor always works best when there is no expectation that the birth will happen in the tub. Although the water can be a valuable tool, some women need more assistance from gravity or find that contractions slow down in the tub. The best approach is to be flexible. Michel Odent, French waterbirth expert and author of Birth Reborn, says that “The baby can be born underwater when there are suddenly irresistible powerful contractions and the mother does not feel like getting out of the pool: it should not be the objective... Often women need to get out of the pool for the very last contractions, at a phase when paradoxically a short rush of adrenaline can help. Women who are prisoners of the project of giving birth under water may be tempted to stay too long in the bath.”
However you choose to use it, water can have significant benefits for you and your labor. Finding a setting that will allow you to incorporate it will be well worth your time. Currently there are several hospitals that allow women to labor in water, although certain restrictions will apply; be sure to ask your care provider about these. Abbott Northwestern has hydrotherapy pools available for labor, but will ask you to get out for the birth; waterbirth options and a tub are available through the nurse-midwifery programs at St. Joseph’s Hospital (St. Paul), Woodwinds Health Campus (Woodbury), and Hennepin County Medical Center (Minneapolis). Regina Medical Center in Hastings, St. Francis Hospital in Shakopee and Lakeview Hospital in Stillwater also offer waterbirth. Labor tubs can be rented from Waterbirth Resources, (612) 822-3263; you can also call for a list of homebirth practitioners. As this option becomes well-known and more women request it, expect more caregivers to offer water immersion for labor and birth.