Friday, March 21, 2014

Water Labor/Water Birth: The latest weigh in by ACOG and AAP and What You Should Know

The latest issue (3/2014) of the journal Pediatrics features a report assessing the use of water as a part of labor and birth, relieving or shortening labor and adding to maternal satisfaction.

The American Academy of Pediatrics (AAP) Committee on Fetusand Newborn and the American College of Obstetricians and Gynecologists (ACOG)Committee on Obstetric Practice examined the available data on water births, distinguishing between early and late stage labor.  According to a Time Magazine e-Zine article 10, the committees concluded that waterbirth should be considered an experimental procedure, since the studies looking at “safety and benefits were not large and robust enough” to make a decision pro or con.

However, a Cochrane Review2 of the literature included 12 trials (3243 women).  Water immersion during the First Stage of Labor significantly reduced epidural/spinal analgesia without adversely affecting labor duration, operative delivery rates or neonatal well-being.  One trial showed that immersion in water during the Second Stage of Labor increased women’s reported satisfaction with their birth experience.

ACOG and AAP say that delivering in water provides no health benefits for the baby or mom, can be dangerous, and even fatal.  In an interview with friend and colleague Barbara Harper RN, and Director of Waterbirth International, Barbara staged that “once you look at the anatomy and physiology of the newborn breathing mechanism – this prevents babies from taking their first breath until their faces come in contact with air.”

On Harper’s website, she has published the scientific explanation of why babies will not drown in water:

What prevents a baby from taking a breath under the water? 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 labor 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).7   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.5  If the baby were in trouble during the labor, 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.6  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.

A study in the Sao Paulo Medical Journal3 concluded that evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth.”  Several more studies substantiate this.

To say that birthing in water provides no health benefits for the baby or mom, is erroneous at best.  One study in particular sites the positive physiological effects of hydrotherapy can facilitate the neurohormonal interactions of labor, reducing pain and facilitation of the progress of labor8.  Results show that the pain felt by the women were lowest among women having water birth, even lower than the women laboring with analgesia.  This reduces the need for pain medication and analgesia.  Additionally, laboring in a tub has been found to reduce stress hormones and catecholamines which inhibit oxytocin and therefore, labor progress.  Several studies have found the duration of the Second Stage of Labor to be shorter due to the baby more likely adopting more relaxed and flexed positions and the mother more easily assuming positions to maximize the diameters of her pelvis.1,9 The length of the Third Stage of Labor is also reduced, minimizing the amount of blood loss due to the reduced duration and the hydrostatic pressure in the tub.

Both the Royal College of Obstetricians and Gynecologists and the Royal College ofMidwives believe that to achieve best practice with waterbirth, it is necessary for organization to provide systems and structures to support this service to women. The RCOG and RCM have outlined parameters to safely meet the needs of women requesting this birthing option.

Hopefully, the U.S. organizations can come together to focus on the needs of the laboring mother who desires waterbirth, in the same way they have done with many other maternity practices with the similar research data outcomes.


  1. Chaichian, al. (2009)  Experience of water birth delivery in Iran. Archives of Iran Medicine. 12:468–71.
  2. Cochrane Review
  3. Cordioli, E. (2013) Immersion in water in labour and birth.  Sao Paulo Medical Journal, 212(5):364.
  4. Dahlen, H.G., et al. (2013)  Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on labor.  A descriptive cross sectional study in a birth centre over 12 years.  Midwifery. 29:759-64.
  5. Fewell, J.E., Johnson, P. (1983) Upper airway dynamics during breathing and during apnea in fetal lambs. Journal of Physiology Vol 339, pp 495-504
  6. Harding, R., Johnson, P., McClelland, M. (1978) Liquid sensitive laryngeal receptors in the developing sheep, cat, and monkey. Journal of Physiology, Vol 277, pp 409-422
  7. Johnson, Paul (1996) Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynecology, Vol. 103, pp.202-208
  8. Mollamahmutoglu, L. et al. (2012) The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery.  Journal of the Turkish-German Gynecological Association. 13(1): 45-49.
  9. Otigbah, C.M. et al. (2000) A retrospective comparison of water births and conventional vaginal deliveries. European  Journal of  Obstetrical and Gynecological Reproductive Biology.91:15–20. 
  10. Time Magazine

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