Adding Water Birth to your Midwifery Business
Many women search for a midwife, because they want a water birth and their doctor doesn’t offer that service at the local hospital. Midwives are known for water births and the peacefulness this type of birth offers. Many hospital midwives aren’t familiar with water birth and tend to find the unknown skill a bit overwhelming. I am here to tell you as a hospital midwife, home birth, and birth center midwife that did two water births with my kids, it is AMAZING!!!
ACOG (organization that runs OB providers) tried scaring women away from water births with position statement that water births aren’t safe. This position statement really dropped the options in hospitals and malpractice insurance coverage that would continue to support this option of birth. Most women need to do out of hospital births to find a water birth option.
Over the past decade, immersion in water for delivering the baby is becoming more popular in many countries. Benefits of water immersion include increased relaxation, mobility, and pain relief. The safety of water immersion during labor has been established by research, and does not result in reduced APGAR scores, increased neonatal or maternal infections, or increased NICU admissions (Cluett and Burns 2009). Several studies have shown that water births do not pose increased risks to mother or baby if properly planned and attended by a licensed care provider (Deckker 2014, Young 2013, Demirel 2013).
If you haven’t been trained in doing water biths (common for CNM schools), find a mentor or clinical rotation that does water biths regularly. I was blessed to have a clinical rotation with Amish birth center that regularly did water births. The knowledge and skills I gained during that rotation set the framework for how I took care of msot of my out of hospital births. Water birth became second nature. There are subtle differences in assessing a women in the water and supporting birth that need to be taught.
Women that choose a midwife for care are categorized as low risk and healthy based on midwifery scope of practice (varies by each state). Not all women are good candidates for water birth. Here are some examples of national guidelines to use for writing policies for your practice.
Recommended Criteria for the Use of Water Immersion
¬ Mother has elected and made an informed choice regarding water birth
¬ Single gestation at or >37 weeks who is low risk and within the midwife’s scope of
Contraindications for Birthing in the Pool
¬ Presence of thick meconium
¬ Excessive intrapartum bleeding
¬ Elevated maternal temperature greater than 100.4° F (38° C)
¬ Non-reassuring fetal heart rate patterns
¬ The midwife’s ability to manage complications
¬ Active herpes, carrier of MRSA, or untreated skin infection should not enter the pool
¬ Rupture of membranes without active labor
¬ Use of agents producing sedation
It is best if the mother is in active labor, as assessed by the midwife, before the mother enters the water. If used during latent stage, pool should be disinfected and a new liner should be used for active labor. If a birth center tub is used for inflatable home tub, clean using sterilization solution in between clients.
Keep a close eye on mother and baby’s vital signs. I typically did mother’s vital signs (BP, HR, and temp) within 30min of arrival at home unless she was close to delivering. I would do them again every 4-6 hours depending on how mother was doing. Baby was monitored based on AWHONN’s guidlines: 30min in active labor and 5-15min during pushing during and after contraction ended. Did around 1-2min of heart tones depending on how active mother was. As long I could determine baby’s baseline and no late decelerations were present, baby was doing well during labor.
Waterproof dopplers are a must. Knowing how to angle a doppler to listen to a baby close to coming into the world while a mother is squatting is a talent. There are training programs available for water birth skills. Water Birth International has a great course to help midwives acclimate to this new skill set.
Since sitting in the pool can be dehydrating, the mother should be encouraged to remain hydrated, drinking water and electrolytes. The mother should be encouraged to empty her bladder regularly on the toilet. Fecal matter or other contamination should be removed from the water immediately. If the water becomes significantly contaminated, the mother should leave the pool unless birth is imminent.
The midwife should prepare a safe birth environment outside the pool in case evacuation of the birth pool is necessary, such as having towels and a blanket or mattress near the pool. Special attention should be provided to prevent slipping, and towels and/or a mop should be nearby. Have plastic under the inflatable birth pool and place towels all over the floor to prevent slipping. Having partner and midwife on both sides of laboring when getting in and out of the pool helps prevent falling. I always kept lots of extra blankets around my heating pad for mother and baby when birth occurred.
Birth should happen naturally without induction agents or herbs. Let the mother’s body have gaps in contractions that is normal before active pushing starts. Follow the instincts of her body for position changes and breathing techniques. If the mother is starting to breath fast or get anxious, calm her with birth affirmations and a hand to hold during peaks of contractions.
Birth should be allowed to happen spontaneously with minimal stimulation of the fetal head. Having a bright, focused light on a mirror in the water is really helpful to see what descent is occurring with baby without placing fingers in the vagina. It is an art to watch the sacrum spend from mother’s back. When the rectum would bulge, I knew birth was close (many times mother would have a unique vocalization when verge of crowning was happening). Let the baby slowly crown. Mother will instinctively grunt and push a little in between contractions. Try not to give any direction unless no descent is occurring or management is needed like bright red vaginal bleeding or concerning fetal heart rate is present. Midwives are life guards at the pool. We are literally there is mother and baby needs us (not manage them).
Let normal restitution happen. If a baby is in distress from a shoulder dystocia, face will turn purple and be tight to the mother’s perineum. If that case, STAY CALM. Ask the mother rotate to hands and knees or get out of the tub. Most of the time, position changes will resolve the shoulder dystocia for baby to be delivered. If the midwife gets nervous, mother tenses up and pelvic muscles don’t allow baby to rotate naturally.
Normal restitution will have a pause between contractions before shoulders rotate. I would take a gentle finger and feel when a mother was squatting if there was a loose gap on baby’s head. The cord should never be clamped or cut while the head is still under water. If a tight cord delays the birth, the mother must stand or step out of the pool. Once the head is above the water, it must not be allowed to go back under the water. Infant’s head should be brought to the surface immediately after birth, taking care to prevent cord avulsion. The rest of the infant’s body should remain submerged to promote temperature regulation.
If the cord is short, preventing the infant’s head from comfortably sitting above the water, the mother is asked to stand and hold her baby while tub is asked to get out of the tub. The nice part of a birth center tub versus inflatable tub at home was easy draining of the birth center if needed. I had plumbing put in a large drain purposely to empty tubs quickly if needed.
The placenta always made more watchful of concerns than delivering the baby did. I would keep a light closely watching the mother’s vagina for signs of placenta separation while she was snuggling her new baby. The baby’s color from a water birth will take a little longer to get pink than land birth. Apgar Score are typically slightly lower and that is normal. As long as baby getting oxygen from placenta (simple feeling of pulse from cord while watching for placenta to separate). Heart rate should be over 100bpm on cord. Baby’s chest will take a bit longer to turn pink. Just listen with stethoscope, keep mother and baby skin to skin, and watch for placenta separation.
A rule of thumb is as long as I could see the bottom of the birth pool near her vagina, there wasn’t too much active bleeding happening (minor bleeding from vaginal tear). Once I couldn’t see bottom of tub, I knew placenta was separating or she was actively bleeding from another source that needed to be assessed. Most of the time, there was a small burst of blood from placenta separation and would deliver placenta right in the water. We would stick placenta in a bowl and ask partner to cut cord when mother was ready.
Vital signs in the postpartum recovery are exactly the delivery outside of the water. Postpartum recoveries are very similar except making sure mother and baby don’t get too cold from skin being wet after leaving tub. I would have lots of warm blankets and towels ready for mother and baby to prevent that. Many times mother and baby would snuggle on a bed close to the tub. Partner would help birth assistant clean up tub while I paid attention to the mother and baby’s needs.
Water birth is an amazing service to offer families. There are some unique assessment skills and management differences to learn with water. It is all about training and having the right mentor to expose you to this style of birth. With time, I hope more hospitals provide water births. Until then, out of hospital midwives will continue to support families wanting to be mermaids for a day!