February 12, 1999
Volume 1, Issue 7
Midwifery Today E-News
“Waterbirth”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Waterbirth: Things to Think About
5) Inhalation of Water Suppressed
6) Women's Responses to Water
7) Birthing the Placenta
8) Commentary
9) Switchboard
10) Letters
11) Coming Themes

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1) Quote of the Week:

"Practice what you preach by collecting data, also known as 'walk your talk.'"

- Sharon Glass Jonquil, CNM

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2) The Art of Midwifery

Perineal massage is used very minimally during waterbirth because the warm water itself brings more blood to the mother's tissues.

It would seem ill advised to assist a breech birth underwater because gravity is a primary factor in getting the baby out without problems. Likewise, the normal birth of twins is greatly facilitated by the force of gravity which helps bring the second twin down into the pelvis. (Anne Frye, Holistic Midwifery, Vol. One)

After birth, the midwife or mother's partner should bring the baby up to the mother's chest. The baby must be kept warm with frequently changed warm, wet blankets. The baby's body can remain in the water as long as the head is covered and out of the water. (Wisdom of the Midwives: Tricks of the Trade Volume Two, Midwifery Today Books)

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3) News Flashes

Waterbirth Effective

A small retrospective study by two English midwives of the effects of laboring and birthing in water compared fifty waterbirths and fifty "bedbirths" (vaginal birth in any position). It showed that: Women who had bedbirths were much more likely to have artificial rupture of membranes than waterbirth mothers--31 percent vs. 23 percent for primips and 42 percent vs 17 percent for multips. The women who gave birth in water were more likely to have an intact perineum, and none of them had episiotomies. For first babies, 19 percent of waterbirth mothers had an intact perineum and there were no episiotomies. For bedbirths, 15 percent of the mothers had an intact perineum and there were 27 percent episiotomies. Tears were more common in waterbirths--81 percent compared with 58 percent--and second degree tears were 50 percent compared with 31 percent. For multips, 75 percent of waterbirth mothers had an intact perineum compared with 66 percent of bedbirth mothers. Tears were 25 percent and 26 percent respectively, and the waterbirth mothers had fewer second degree tears--8 percent vs. 13 percent, and no episiotomies compared with 8 percent of bedbirth mothers. Of the waterbirth multips, 21 percent used no pain relieving drugs compared with 4 percent of bedbirth mothres.

- AIMS Journal, Spring 1995

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4) Waterbirth: Things to Think About

Anne Frye, midwife and noted author of several textbooks for midwives, offers these guidelines to practitioners in Volume One of her book, Holistic Midwifery:

Some questions and topics you might wish to consider for yourself and then discuss with the women seeking waterbirth are:

  • Why do you want an underwater birth? Anne explains that some women think water will take all the pain away or think birth is difficult for the baby, both notions she disagrees with. She explains that it is important that the mother not percieve the labor as frightening, harmful or otherwise damaging to the baby.
  • Do you wish to keep the baby under water or bring it immediately to the surface? Anne, in her practice, brings the baby to the water's surface immediately upon delivery, but she advises midwives that they will have to decide what they feel most comfortable with as they gain experience.
  • What kind of tub does the birthing woman plan to use? Does she have an adequate water source? It's best to use a light colored or white tub with a light source inside the unit. Water should be fresh, and maintained at a constant body temperature of 99 to 100 degrees F. The room should be warm.
  • Discuss priorities for the birth. Assess whether the woman agrees to follow what seems right in the moment and not to press for a waterbirth regardless of the situation.
  • Consider universal precautions in terms of waterbirth. Think about blood born pathogens and fecal contamination from the mother.
  • Be prepared for emergencies and changes of plans.

Order Holistic Midwifery from Midwifery Today. Just $69 plus shipping. email inquiries@midwiferytoday.com for information on how to order. Please mention code 940.

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5) Inhalation of Water Suppressed

Breathing is inhibited through natural physiological processes, including hormones (prostaglandins, progesterone and endorphins) released from the placenta, and a low metabolic rate. This process is further supported by the large number of chemoreceptors found in the larynx of the newborn, which is said to facilitate the baby's recognition of which fluids can be swallowed and which inhaled. In other words, the baby recognizes that it should not inhale water but that it can be swallowed. This reflex is seen by many practitioners who undertake waterbirths and have not seen inhalation of water. The one caution is in the case of severe intrapartum hypoxia (not the normal physiological hypoxia of labor but severe) where the fetus may be compromised and this mechanism can be overriden.

- Dr. Paul Johnson, cited in "Waterbirth: An Attitude to Care" by Dianne Garland, Books for Midwives Press, 1995

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6) Women's Responses to Water

"From the first mention of the word [water], many women forget about drugs and are much more concerned with how long it will take to fill the bath. As a general rule we advise the woman not to enter the bath before it is full so that we can do a last-minute check of the baby's heart and the temperature of the water. However, when women don't listen to these recommendations, it is a goood sign. It means that they have already dramatically reduced their neocortical control and are already on their way 'to another planet.' It is probable that the delivery will be easy and fast. Any 'irrational' behaviour is a positive sign. For example, I have seen women who could not wait and entered the bath while there was still not more than an inch of cool water at the bottom of it. I have also seen women start to shout and have strong contractions as soon as they saw and heard the running water: they grasped the edge of the pool and the baby was born on the floor before the bath was ready.

However, a majority of women enter the bath when it is full and when the water is at the right temperature. As soon as they are in the bath, most women give a great sigh, expressing relief and even well-being. From that time on, if the lights have been dimmed, if the baby's father does not behave like an observer, if the midwife keeps a low profile and if there is no camera around, it is probable that the cervix will dilate quickly. (We Are All Water Babies, by Jessican Johnson & Michel Odent, Celestial Arts Publishing, Berkeley, CA)

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Mark your calendars!! Global Maternal Child Health Association (GMCHA) along with several other organizations, including Midwifery Today magazine, are planning the next world waterbirth conference. Waterbirth 2000 will be held September 21-24, 2000, in the downtown Portland, Oregon, Marriott Hotel. So write the date down and make your reservation early.

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7) Birthing the Placenta

Childbirth practitioners are divided on the issue of delivery of the placenta in water. Physicians and midwives who allow women to deliver the placenta in the water report that it is safe and without side effects. Using this method, the umbilical cord is not cut or clamped until the placenta is out of the woman's body. Doctors and midwives have observed that there is less bleeding and that the babies almost always start nursing immediatly after birth, which helps with the expulsion of the placenta. Some midwives state that the time allowed for the passage of the placenta increases slightly with birth in water. It is their general feeling that the water relaxes the uterus and that the contractions for birthing the placenta are less effective when a woman stays in the water after the baby's birth. When some women stand up to get out of the tub, however, the placenta virtually falls out.

- Barbara Harper, RN, "Gentle Birth Choices," Healing Arts Press, 1994

Order "Gentle Birth Choices" book ($16.95) or video ($39.95) from Midwifery Today. email inquiries@midwiferytoday.com for information on how to order. Please mention code 940. Shipping will be added to all orders.

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Global Maternal/Child Health Association

If you are a midwife and not yet listed with our referral service, then you are losing business. Write to us at waterbirth@aol.com to receive a Professional Survey. You'll also find the widest selection of books and videos on waterbirth. And don't forget to register for the next World Waterbirth Conference that will take place in Portland, Oregon, at the Downtown Marriott, September 21-24, 2000.

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6) Commentary: by Jill Cohen, midwife

It was late in the evening. I sat staring into the fire, waiting as I often do for the phone to ring. Midwives frequently have a sixth sense about birth and on this particular evening, my senses proved true--at 10:30 pm the phone indeed rang. At first all I heard was the echo of deep breaths and water running. I knew this was labor.

Water and labor fit hand in hand for most laboring women. The shower or bath warms, secludes and relaxes a woman so she can open more easily at her own pace. It creates a womb-like environment in which a woman can feel safe. It may not take the pain away, but it enables a woman to cope through her intense sensations, relaxed and with least resistance, creating more comfort. Water forms a warm, wet buffer around her, keeping outside forces and interventions at bay. Yet if the woman should need assistance or monitoring it can be accomplished easily in her watery environment.

I waited for the contraction to pass as I listened intently for the mystery woman on the other end of the phone to finally identify herself. I could tell by the echo that she was in her bathroom, and could tell by the sound of running water that she was in the bath. The tempo of her breath told me I would be heading over soon... as soon as I could ascertain who she was! After her breathing slowed and she paused to collect herself, I heard her giggle a "Sorry!" I knew right away it was my dear friend Hazel. This was her fourth child--I was out the door!

I walked in to find her children sound asleep and her partner sitting at the edge of their large tub, a glass of cold water and bendable straw in hand to help keep Hazel well hydrated. Before she could utter a word another contraction arrived and she went deep into herself. Because water can speed labor along once the woman is over 5 centimeters dilated, and I guessed that Hazel was at least that, I busied myself preparing her birthing room. I then settled into the bathroom with my water Doppler and monitored our little friend. All was well. Hazel needed to pee, so she got out and onto the toilet. Another big contraction, wide eyes and pop went the bag of waters. They were clear and smelled sweetly of baby.

It was time to decide where this child would be born. Without hesitation, Hazel chose the tub. As soon as she was situated I heard the familiar sound of relief I hear so often when women sink into warm water. It is music to a midwife's ears, as is the steady heart rate of a baby about to be born. Hazel pushed with the next contraction as she pulled her legs back and sang that magical birth song, low and deep. With that push we saw the baby's head. Two more pushes and the head was born. As we waited for the next contraction we had time to see this little child and appreciate the peacefulness of his/or her entrance.

Water is vital to life--we cannot live without it. Its ability to nourish, nurture, propagate and promote life fits so well in the birthing world. I believe that because babies come from a watery environment, when they are born into water it feels familiar to them. Under normal circumstances babies will not breathe until they hit air. When they emerge into water their house gets bigger, but they still think they are in the womb.

This little one was wide eyed and waiting. It is always amazing to see such peaceful passage. Within a few moments another contraction came and the baby was gently born. Hazel instinctively reached down and brought her baby to the surface. There was no need to suction--this little boy flexed, stretched, yawned and pinked up without even crying.

Misunderstandings abound about the use of water in birth, such as risk of infection, risk to the baby, and lack of ability to monitor effectively. There is now much research-based evidence to indicate that with proper preparation and protocol the risks are no more than for air birth. So for those women and practitioners who choose water to facilitate birth, go for it! But first, be informed. Investigate what standards should be used. Plan what kind of tub you will use, where to put it, and find your water source. Remember that water is a different medium to work with. Familiarize yourself with it; think about its potentials; imagine its relation to birth. Merge with it and feel its effects. For me, the rewards of using water in labor and birth is summed up in that magic sound of relief in a woman's moan as she enters the warm water, and the magic moment as baby comes forth with that peaceful look that tells me the passage has been safe and gentle.

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9) Switchboard

Breech Feedback

The latest issue was oppulently enjoyed this morning. What luxury. I agree with all the good tips re breech and wanted to add another element. There is a real difference between a nulliparous breech birth (first full term pregnancy and birth for the woman) and multiparous breech birth. Here in Canada, midwives tend to transport for breech and in the twenty-three years I have been doing birth work, there have been two breech deaths with women who really wanted to have their first vaginal birth at home. One was a first baby and the other was a VBAC. I would think that these two deaths were out of about twenty breech births attempted at home but I can't be sure. I think a really important guideline to have with breeches is that the birth should be progressing with good strong contractions that are increasing--you don't want the uterus to run out of steam at the end when you need some good piston effect from the upper uterine segment to bring the head down naturally. Most OBs, in hospital, want Pitocin running during breech births to make sure there is no stalling at the end.

Preventing breeches is another important part of midwifery. I believe a lot of breeches happen in second and subsequent pregnancies because the mother is carrying a thirty-pound two year old on her "bump" for the entire pregnancy. If the baby is breech, that weight on his head every day can predispose him to settle into the pelvis in that position. Warn the mother of a toddler not to use their pregnant bellies as a platform for heavy objects of any kind. Dad can carry the two year old more often or she can use her hip as a support.

- Gloria Lemay

A question about breech babies: Is a woman with a family history of breeches genetically predisposed to having breeches as well?

- Monica

Waterbirth

I highly recommend having a waterbirth if you and your baby are healthy. I had my daughter in a five-person kiddy pool at home. It was the most incredible experience. Being in the water really helped cut down on the labor pain I was experiencing in my back. When she came out she wasn't in as much shock because she went from one watery environment to another. I really wouldn't have it any other way.

It was important to put salt in the water to make sure I didn't prune, and to keep the water at a comfortable temperature. I went into the pool during the last phase of the labor. Being relaxed in the warm water made for a relaxing labor.

I also attribute the fact that I had great midwife care, was at home in my own environment, and took good care of my baby and me with good nutrition and herbs. There is so much a midwife and mother-to-be can do to make sure a child comes into the world as nature intended. I encourage those of you who plan to have children to really look at who you are deep inside as you begin your travels to motherhood. How you have your children is certainly as important as how you raise them. I give great thanks to all of you midwives and doulas out there who facilitate the most important part of life--birth.

- Grace

Gestational Diabetes and Passover Food

I am in need of someone's expertise. I have a woman in my practice who has gestational diabetes and is also an Observant Jewish woman. With Passover quickly approaching, I would like to steer her in the right direction nutritionally while allowing her to practice her food selection within the confines of "Kosher for Passover." Historically, her diet is high in carbohydrates at this time of the year. Matzo is the staple, as are potatoes. An Observant Jew does not mix milk with meat within six hours so good nutrition is always a challenge. Failure to observe is not an option. Has anyone had any experience either first hand or professionally? Is anyone aware of anything in journals addressing these unique nutritional needs? I would appreciate any comments that might help in the care of this woman. Thank you for your kind assistance.

- Meg Stoyle-Corby, CNM

HIV and Breastfeeding

I'd like to see some information/research on HIV-positive moms and the risks of breastfeeding her HIV-negative baby, and prophylactic use of AZT on an HIV-negative baby.

In much appreciation of the manner in which Midwifery Today shares knowledge.

- Vi Sadhana, homebirth midwife

Readers, can you suggest resources for Vi and many other E-News readers?

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10) Letters

I just want to let you know how much I enjoy Midwifery Today E-News each week. Keep up the great work. I look forward to upcoming bulletin boards and chats.

- MJ Lovett

I anxiously await Midwifery Today E-News each week! I have received them from the beginning and have learned from each one of them. Since I work primarily in a hospital setting as a doula it is wonderful to hear about "normal" birth and the great information I can use to help my clients have normal births. Your last issue on breech birth was fantastic. I was devastated when one of my clients and I arrived at the hospital with her baby "rumping," only to be sectioned by a very frightened doctor who was never taught how to deliver a breech.

- Connie Banack
Alberta, Canada

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11) Coming Themes

- smoking and pregnancy
- placenta previa
- infections
- ultrasound
- epidurals
- breastfeeding
- education
- posterior labor
- postpartum depression
- meconium aspiration
- tear prevention

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"Normalizing the Breech Delivery"--36 minute video

This internationally acclaimed video by midwives Valerie El Halta and Rahima Baldwin Dancy, CPM is designed for teaching midwifery and medical students. It is also an outstanding educational tool for clients if you do breech deliveries.

It includes: a Breech Scoring System to help evaluate risk for a vaginal delivery; detailed consideration of the normal breech labor and delivery through sensitve footage of the birth of a first baby in the frank breech position; review of the key points using a doll and pelvis; what to do if there are complicaitons; and footage of a second twin born footling.

To order, send $59.95 plus $3 shipping to Informed Birth & Parenting, PO Box 1733, Fair Oaks, CA 95628. Money back guarantee. Call (916) 961-6923 to charge Visa or MC.


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Midwifery Today, Inc., does not assume liability for the use of this information in any jurisdiction or for the contents of any external Internet sites referenced, nor does it endorse any commercial product or service mentioned or advertised in this publication. Always seek the advice of your midwife, physician, nurse or other qualified health care provider before you undergo any treatment or for answers to any questions you may have regarding any medical condition.

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