Photo by Fox Valley Birth and Baby—

Cultural Differences in Waterbirth Practices

Editor’s note: This article first appeared in Midwifery Today, Issue 124, Winter 2017.
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Many US practitioners are unaware that we do waterbirth differently than our European colleagues who developed it. Many of these European doctors and midwives are upset at that difference and would like US midwives to change the way we do waterbirths. There are two crucial differences in the way waterbirth is taught on the two continents.

Temperature of Water

First, most US births occur in water that is far too warm. Most of us were taught that the water should be close to womb temperature, or internal body temperature—near 100F°. Most US waterbirth photos show steam coming from the water, moms with red cheeks needing cold washcloths to cool off, etc. As a result, the typical American water-born baby is pretty relaxed at birth.

As a result, some water-born babies seem a bit slow to come around. They aren’t stressed—they seem well-oxygenated, but they sometimes seem a bit slow to begin the transition to breathing air. They may be alert and have good tone and the heart rate is fine or a little slow—100 or so (or sometimes they may almost seem to be asleep). They just don’t seem interested in breathing for a while.

Some midwives carefully watch that transition for 15–30 seconds or so, and as long as all is improving, they wait and watch. Some midwives grab these babies and start working on them—stimulating them to start breathing because they seem to be in no hurry to begin. Almost all of these babies (all healthy ones) will begin taking breaths and will breathe well, and I think all of them would do it without the extra stimulation we give them; but I totally understand the agitation of the midwife who just wants to see that baby become responsive.

Some believe that this slow transition is normal in water babies—and many propose using a modified Apgar for waterborn babies because they are “just slower to start,” although we know they are going to be fine.

The Europeans believe this US temperature is not “physiologic” and that mothers are “enervated.” They believe that babies are born “non-vigorous” because of the relaxant effect of the heat. They also believe that the overly warm water interferes with the signals the baby should be receiving during second stage, which will trigger him to breathe when he is fully exposed to air. They believe that cooler water on the scalp plays the same role as air on the scalp during crowning. The Europeans believe that water in second stage or birth should be at a comfortable “swimming pool temperature,” not at “bath temperature” or “body temperature.” They recommend tepid-to-cool water and are a bit horrified that US births take place at bath temperature.

Transition from Water to Air

The other major difference in waterbirth teaching is that most US practitioners remove the baby from the water very rapidly after birth and bring the whole baby out of the water. European practitioners recommend letting the baby “acclimatize” under the water for a moment—a few seconds to as long as 10 or 15 seconds. They also strongly insist that the baby be lifted slowly from the water.

Transition is different for water and air—unless baby is brought up slowly.
What causes a baby to breathe? It is not emergence from the womb; it is emergence into air, which permits oxygen to contact the skin, sending signals to the placenta, which then raises the CO2 level. The rise in CO2 is the trigger to begin to breathe. Any rise in CO2 (whether a response to decrease in O2 or not) can trigger the reflex breathing response—which is why fetal distress in the womb can result in aspiration.

The baby in a land birth gets those signals to breathe, with a drop in oxygen and rise in CO2, all the way down the birth canal as soon as scalp is close to the introitus, all the time the head is emerging and then during the moments or minutes it takes for rotation and birth of the body. A baby being born is well into the transition process and might even be breathing while still on the perineum.

A baby who is born under water does not get this signal. The baby born under water has a higher oxygen blood level (yes, this is proven fact) and thus has a lower CO2 level. These babies have not been getting exposure to air on their skin on the way down the birth canal or after head immersion in the water and will not be exposed until they emerge from the water and into the air. Water-born babies are usually still in intrauterine circulation when they come out of the water.

They are very well-oxygenated, in wonderful condition, but in a sense they are still “in the womb.” A few moments to minute or two of exposure to air will start transition to air-breathing life. This is especially true for the babies who are brought out in one move—as most babies are—with either the birth attendant or the mother snatching them out of the water quickly. This slower transition is normal and natural and may be beneficial as well, because the baby’s lungs may be nicely emptied of fluid before attempting to breathe. (The change in fetal circulation empties and opens the lungs from the entrance of air—not sucking them out or draining them. We can drain the bronchial tree, trachea, and throat. We can suction the nose and mouth and back of the throat. What happens in the lungs is a different process and is under control of the heart and placenta.)

Europeans recommend lifting the baby from the water face first. They also encourage moms to hold babies with just the face emerged for a while before lifting them fully from the water.

We can get a faster transition if we mimic air birth by bringing the baby into exposure to air in stages: First, bring the face out of the water and wait there … then the rest of the head and wait there … and when baby is responsive and breathing, then bring the rest of the body out of the water.

This is very different from what we do. (Most of us “snatch” the kids up as fast as we can get our hands on them! Baby is held by mom—often facing her chest—with the baby’s entire body exposed to air in almost a split second, rather than the gradual process we see during a land birth.)

I was exposed to this European teaching a few years back and was convinced by their data supporting both lower temperatures and slow/partial emergence. They’ve been doing waterbirths since around 1970, and I think they’ve worked out the best/safest methods. US practitioners were slow to adopt waterbirth and we gave our own twist to it when we did. I began to recommend lower temperatures for second stage—whatever was comfortable for mom. The moms seem to get a lot more pain relief from those lower temperatures than they did from our “bath temps.”

I talk with the moms about taking a moment to greet the baby, reminding them that they don’t have to snatch the baby up so rapidly. I advise them to just turn the baby toward them so they can see the face and then to bring just the face up into the air first—and then the head and body. We talk before birth about watching the baby emerge—and it’s very cool to see moms do this, rather than just scoop up the baby and scrunch it into their arms as is usually done.

I strongly believe the Europeans are correct. I believe that the babies are born more vigorous: Awake, alert, responsive, and fully ready to breathe. I don’t have to use any form of modified Apgar, either!

About Author: Gail Hart

Gail Hart graduated from a midwifery training program as a Certified Practical Midwife in 1977. She has held a variety of certifications over the years; she was a Certified Midwife through the Oregon Midwifery Council, and an LDEM in the state of Oregon. She is now semi-retired and no longer maintains her license, but keeps active with a small community practice. Gail is strongly interested in ways to holistically incorporate evidence-based medical knowledge with traditional midwifery understanding.

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