Is Waterbirth Right for Me?
Natural pain relief, shorter active labour, and a more satisfying birthing experience are some of the benefits promised by this widespread practice, but what exactly happens at a waterbirth? Is this a good choice for your birthing journey?
Many people find taking a bath relaxing and, indeed, doctors often recommend that pregnant women take baths to help relieve pressure and soothe muscle pain. But a waterbirth is more involved than that. Preparations need to be made beforehand to ensure the health, safety, and wellbeing of mother and child. This article discusses many different aspects of waterbirth to help you decide what you want for yourself.
Waterbirth is likely an ancient practice. Old legends from Crete, the South Pacific islands, and elsewhere tell of women going to special pools or shallow inlets to bring their children into the world. In modern times, the first recorded waterbirth took place in France in 1803, when a midwife sought to help a mother who had been labouring for almost two days; but the medical community first began studying the practice only in the 1960s. Since then, waterbirths have slowly gained acceptance as a safe and effective practice worldwide.
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At first blush, the thought of your baby being born in water may seem dangerous, but there is a deep logic to this practice. The warm water of a specialized tub or birthing pool provides a more familiar, less shocking environment for a baby’s first moments outside the womb. What’s more, the warmth and buoyancy of the water make it easier for the labouring mother to relax and to shift position, and immersion hydrotherapy is an excellent method of pain relief that does not rely on medication.
However, this is not to say that there are no drawbacks to consider. Doctors recommend against waterbirth in some cases, especially if your pregnancy is considered high risk and medical intervention is anticipated. More about that below.
What will the water be like?
The temperature of the birthing pool
The temperature of the birthing pool should be close to body temperature—37°C (98.6°F). Your baby will have spent nine months floating in amniotic fluid at body temperature, and one of the main reasons parents choose waterbirth is to ease their baby’s transition into the world. Some temperature fluctuation is fine; water cools over time and your pool may have to be reheated now and then.
Most practitioners recommend temps of 35–38°C (95–100.4°F) for birthing pools. For comparison, jacuzzis generally have a maximum temp of 40°C (104°F). If you don’t enjoy that type of environment, waterbirth may not be the best option for you.
The water should be clean with no additives. Most facilities use regular or filtered tap water. City water in Europe, North America, and much of Asia passes through several different steps at a treatment centre before it reaches the public. The final step typically involves adding low levels of a chemical disinfectant such as chlorine to ensure that any remaining viruses, bacteria, or parasites are neutralised. UV light or ozone may also be used. This is the water people the developed world drink and bathe in; it is generally considered safe for waterbirths. If you have questions about water quality in your area, these should be discussed with the responsible practitioner as local conditions and water sources differ.
Waterbirth and Hygiene
Hygiene is one of the most important considerations for all births, and this is no less true for waterbirths.
Some people dislike baths because they don’t like the idea of sitting in the grime they have just washed off their bodies. While it is important to keep your tub clean, dirt suspended in water settles away from your skin and a bath will get you just as clean as a shower. But of course, birth is a messy business, and it is only logical to wonder about the hygiene of it all.
The water in a birthing pool or tub will not be perfectly sterile, but this is not harmful for your baby. However, the surrounding environment can pose some risks. Any birthing facility must be cleaned thoroughly and systematically before and after each use and the people assisting at your birth must also follow a high standard of hygiene, including no outside shoes and no unwashed hands.
Many hospitals and birthing centres have special facilities for waterbirths to ensure they are clean and safe. Make sure the facility you choose is licensed, uses up-to-date equipment, and complies with the highest standards of cleanliness and hygiene. An OB or midwife should be present to help you though the labour and ensure the safety of yourself and your child.
What about other by-products of birth?
If the environment is clean and well managed, a waterbirth can be perfectly safe.
Research has shown that water is not able to travel upwards through the birth canal. Both mother and child are protected, and waterbirth does not pose any additional risk of uterine or birth canal infection. However, birth always involves fluids passing from the body—but even so, cases of infection resulting from waterbirth are very rare.
Until very recently, amniotic fluid and urine were thought to be sterile. Research has shown that both can contain very small amounts of specialized bacteria, but this poses no danger to the newborn. Both blood and stool can carry pathogens, but the amount of chlorine generally found in tap water, the heat of the birthing pool, and the fact that a small number of germs will be dispersed in a large tub of water make it highly unlikely that they can cause infection.
The thought of urine, blood, and even faeces getting into the water around you might seem confronting at first, but when you are in labour your mind and energy will be elsewhere.
In the early stages of labour your midwife will likely encourage you to get out of the pool to pee. But once labour is in full swing you won’t be worrying about anything else. And yes, it’s true, you will probably poop a little while giving birth, regardless of where you are. This is completely normal and nothing to be ashamed of.
A professional birthing team will be prepared to quickly remove any unwanted birthing by-products with a special sieve, including poop. It’s a natural part of the experience and no big deal. If there is time, some women prefer to have an enema before getting into the tub, which pretty much solves the problem.
The fallout from Covid
Unfortunately, Covid-19 is a high-risk infection we all have to live with now. Birthing facilities around the world have adopted additional safety precautions to avoid cross-contamination between parents, babies, and practitioners, and in some places, such as Iran and the UK, waterbirths were suspended for a while. In places where waterbirths continued, only the mother was allowed to be in the birthing pool, whereas before the pandemic partners could choose to lend their support in the water.
However, the pandemic also led to an increase in home births and births at alternative facilities to reduce potential exposure. Covid-19 has not been detected in treated drinking water, which means that standard water treatment methods are sufficient to remove or inactivate the virus. Protocols continue to change and improve as we gain information, so Covid should be added to your list of topics to discuss when planning your birth journey.
The Benefits of Waterbirth
Again, each pregnancy is different. However, many women are attracted to the idea of labouring in water. Some of the most common reasons include:
Pain relief and other physiological advantages
Immersing your body in warm water does a number of things: your blood vessels dilate increasing blood circulation throughout the body, the buoyancy of the water reduces the effect of gravity on your bones and tissues (by about 65% if you are in up to your chest) so you feel lighter; these two effects combined with warmth help your muscles relax, which reduces any pain or soreness you might feel.
Hydrotherapy also stimulates the production of endorphins, the body’s “natural pain killers”, and oxytocin, which helps synchronize contractions and therefore shorten labour, and can help regulate glucose in the blood, which may give your endurance a boost.
Women who spend at least part of their labour in water are less likely to use additional pain medications.
Reduced trauma to the perineum
The uterus is the most powerful muscle in a woman’s body. The small balloon expands from the size of a pear to the size of a watermelon during pregnancy, and the three layers of muscles inside have to get that watermelon out through the birth canal, the passage from the cervical opening through the vagina and out the vulva.
The muscles of the perineum make up a small triangle surrounding the vulva and the anus. During birth, a great deal of pressure is exerted on this area. The evidence suggests that women who choose waterbirth suffer less trauma to this area, likely due to the physiological benefits mentioned above.
In "land births", if the perineum is likely to tear, the OB or midwife will perform an episiotomy. In other words the muscles are cut cleanly so they can be easily stitched back together, which is preferrable to a deep, ragged tear. Statistically, waterbirths result in a higher incidence of 1st and 2nd degree perineal tears and a lower incidence of 3rd and 4th degree perineal tears. The accepted explanation is that because pressure is reduced and significant tears are avoided, fewer episiotomies are performed, so there is a higher number of women who experience light tearing.
With everything else going on, most women don’t even notice a perineal tear until afterwards when it is healing. 1st degree tears can heal on their own, while 2nd degree tears may require a few dissolvable stiches. Such tears are usually healed completely within a few weeks.
State of mind
Sana per aqua, or healing through water, as the Romans used to say. Water soothes us. Not only does hydrotherapy stimulate the production of oxytocin and endorphins, but it also suppresses the release of epinephrine-norepinephrine, which is responsible for the fight or flight response. The birthing pool becomes a safe, soothing, intimate space where the labouring mother can free her mind from worry and focus all her energies on the work at hand.
Other Considerations
Length of labour
We typically talk about four stages of labour:
- Early labour is when true contractions begin, and the cervix thins, or effaces, and opens, or dilates, from closed to a 6 cm opening. This stage is the least intense and can last for hours or sometimes even days for first timers.
- Active labour is when the contractions intensify as the cervix dilates from 6 to 10 cm. This stage typically lasts from 4 to 8 hours.
- Delivery—this is it, the urge to push, the panting, the crowning of the head! The actual birth can take a few minutes or a few hours.
- Once the hard part is over there is one final stage, the Delivery of the Placenta.
The placenta is another amazing piece of biological design—it has been the interface between you and your baby for many months and now it is no longer needed. Delivery usually takes thirty mins to an hour, but you will already be focused on other things. Once the placenta is safely out, the uterus can slowly return to its original size, closing off the blood vessels that have been nurturing the baby.
Reports about the effect of waterbirth in this context are mixed because the length of each stage depends on a multitude of factors. There is some agreement that using the tub during early labour might extend that stage because the mother is relaxing more than is helpful, while hydrotherapy can speed the active labour stage because the mother is able to relax more fully between contractions.
Limited pain relief options
Women who choose waterbirth tend to be those who want to go through labour naturally using natural methods of pain relief such as massage and breathing techniques. Gas and air—a mixture of air and nitrous oxide (laughing gas)—can be used safely to provide some relief if this option is available.
Epidural or spinal anaesthesia is not compatible with waterbirth
These methods require the insertion of a catheter, which usually performed by an anaesthesiologist in a hospital setting. The catheter acts as a port into the body for administering anaesthesia, so being immersed in water would put you at risk of infection.
Injectable drugs are too powerful as you might become too drowsy to take care of yourself the water, and a TENS (transcutaneous electrical nerve stimulation) machine has a small battery pack and sticky electrodes that can’t be submerged.
There is a window during labour in which a woman can change her mind, get out of the tub, and request additional medication, but it is limited by various factors and choices/consequences should be discussed thoroughly with the OB or midwife beforehand.
Water aspiration
A top-of-mind concern with waterbirth is often that first breath. There is no need to worry. All babies are born with certain involuntary reflexive behaviours including the dive reflex, which prevents them from breathing before they feel cool air on their nose and mouth for the first time. To ensure the baby’s face doesn’t encounter air before the birth is complete, the mother’s pelvis must be completely submerged at the moment of delivery.
Your newborn will be perfectly safe encountering the world through an extra tunnel of body-temperature water before the midwife guides the baby’s head into the air for its first breath or helps you do it yourself.
Nuchal cord
This is the clinical term for the umbilical cord being wrapped around the baby’s neck at birth. We’ve all heard the stories because it is a common occurrence—about 1 in 3 babies are born with a nuchal cord. However, only a very small percentage of these lead to poor outcomes. Usually, the midwife just slips the cord off as the baby’s head crowns and it’s no big deal.
The umbilical cord is weird and wonderful. It’s usually around 55 cm long, 2 cm thick, looped in about 11 coils, dense, elastic, fibrous, and filled with jelly. It contains two arteries and one vein that circulate blood and nutrients between mother and baby. (These are averages, but IRL there is a surprisingly wide range of variations that still result in healthy births.)
The jelly keeps the cord from compressing through labour contractions—even if it is tied in knots from baby activity in the womb—and blood passing through the cord continues to provide oxygen until the baby begins to breathe on its own.
Umbilical cord avulsion
In a waterbirth, if the umbilical cord snaps or ruptures before it can be clamped—this usually happens 15-20 seconds after birth—the baby could potentially loose a dangerous amount of blood in the water. This is a rare, but serious complication that might require a period of intensive care or in the most severe cases, a blood transfusion.
It takes about 13 lbs of pressure to break the average cord—that’s the weight of a mid-size women’s bowling ball. Of course, there is some variation in cord strength too. However, quite a few adverse conditions must align for the cord to rupture. Water labour is generally a little gentler on the body.
Temperature dysregulation
Mammals regulate their own body temperature, but it can take up to a few days before a newborn’s body adjusts to this task as they are used to momma doing it for them. All babies are born wet, even when born on dry land. The first order of business after making sure they are breathing is to wash and dry them. If a baby is too cold, it uses more oxygen but might breathe more slowly and have more difficulty nursing. If everything else is fine, skin-to-skin contact with mom is usually the best way to keep a newborn comfortable.
Monitoring the baby’s progress and foetal distress
Several times over the course of labour, the midwife will take a few moments to listen to the baby’s heartbeat with a stethoscope or handheld foetal monitor. A waterproof Sonicaid ultrasound transducer or old-fashioned Pinnard’s stethoscope can be used for waterbirth.
If the baby shows any signs of distress, such as an abnormality in the heartbeat or meconium (foetal faeces) in the amniotic fluid, the mother will be asked to get out of the tub so the problem can be assessed.
Limited gravitational assist
The overwhelming majority of women who choose waterbirths are satisfied with the experience and would choose it again. However, some women, especially first-time mothers, do better giving birth on dry land where they have the full effect of Earth’s gravity to help the baby emerge into the world.
It is important to remember that you can get out of the water at any time
Childbirth has stages. You can enjoy the water environment for the labouring phase but get out for the actual birth. Or stay in for the birth and get out to dry off and cuddle while you wait for the placenta to come out. Listen to your body and do let your OB or midwife advise you. She will know when it is important to get out or to just keep going and can share her experience to help you make good decisions when the time comes.
When you get out of the pool, the air will feel cold by comparison for a few minutes and your body will feel much heavier again, so you probably won’t be hopping in and out. Let your body sense and intuition guide you.
Risk of drowning
Although this always a possibility whenever water is present, such accidents are extremely rare. A competent birth team will remain aware of the environment to ensure the safety of mother and child. Choosing a waterbirth means relying on others, at least in part, for this aspect of your wellbeing.
Delays in the event of an emergency
Additional time and effort would be required to get out of the bath in the event of serious complications. No doctor can perform surgery in water. Waterbirth can be a very positive and satisfying experience as long as everything is alright.
Waterbirth is generally not recommended if:
- The baby is preterm
- The baby is breach
- Labour must be induced
- Twins or multiples are expected
- The mother has an active infection, including herpes
- The mother presents with fever
- The mother has pre-eclampsia
- The mother has diabetes
- Labour began more than 24 hours ago
- The mother has previously given birth by C-section
- Other high-risk health complications are involved
What about the baby’s experience?
Various studies comparing waterbirths to “land births” have found no statistical difference in Apgar scores, breathing difficulty, umbilical cord pH, shoulder dystocia (getting stuck), infections, hospitalizations, microbiome, or umbilical cord avulsions, and in the case of newborn hypothermia waterbirths have shown slightly better results. However, although these studies encompass many thousands of birth experiences, every birth is different and a great deal depends on resources, experience, and what happens in the moment.
The choice is down to you
For women who want to experience childbirth with little or no pharmaceutical assistance, waterbirth can provide many benefits. The majority of larger cities now have a number of alternative birthing centres, so you can visit a few places and choose to work with a midwife, and maybe also a doula, who inspire trust and can confidently support you through the process. If you have a partner who wants to be present at the birth, talk about the pros and cons to be sure you both feel comfortable and there won’t be any surprises.
Research nearby facilities, listen to your body, and make the choice that is right for you!
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