ACOG’s Committee Opinion on Water Birth

waterbirthhappy

Borealis client between contractions, waiting patiently for the tub to fill.

If memory serves, ACOG’s always had their undies in a bunch around water birth, but now it’s official: ACOG released its committee opinion about Immersion in Water During Labor and Delivery, stating, “The safety and efficacy of immersion in water during the second stage of labor have not been established.”  This assertion has been met with much scoffing, eye-rolling, and snappy, well-reasoned blogging to the contrary, from midwives, doctors, and mothers alike. Read great examples here, here, and here.

While I really can’t improve much upon what’s already been written refuting ACOG’s concerns and I believe water birth to be a safe option,  I found myself feeling that some of ACOG’s concerns aren’t really that outrageous.

Water birth deserves to be taken seriously enough to warrant a large, prospective trial, and conducting one doesn’t seem out of reach. MANA collects data from all over North America on out-of-hospital birth, and I’d love to see them tackle water birth outcomes. In addition, more hospitals (namely here and here), which will likely always be higher-volume than out-of-hospital birth – at least in this country – are offering water birth with both physicians and midwives in attendance. We are so lucky to have such a rich resource of potential data. Let’s gather it!

ACOG’s worried about babies aspirating water and cords breaking. I worry about that, too. So we put systems in place. The water needs to be high enough to cover mama’s whole bottom and uterus, so there’s little risk of a head being born out of the water as mama lifts her hips during a contraction, only for baby’s head to be plunged under again during the next break. This is a real risk in a too-shallow birth tub. On the other hand, water needs to be low enough to allow baby, once born, to travel to mama’s chest above the water, without yanking on the cord, which can cause discomfort for mama at best, and at worst, can cause cord breakage or even premature placental separation. We educate parents about this during prenatals when we talk about birth plans and the desire for water birth.

And ACOG’s infection control obsession isn’t that crazy, either. Germs cause infections. Which is why we take precautions: We require parents to buy a brand-new potable water hose, and require them to purchase a never-used, thick plastic liner for their birth tub.  We keep an eye on the water quality at all times. The rumor that moms poop when they give birth is actually true, and we use a fish net to scoop it out.  On very rare occasions, diarrhea happens. This, sadly, pretty much does require mama to get out of the tub, as the water is now saturated with fecal matter.  As far as baby’s exposure to small amounts of waste in the tub, when I was writing my graduation research project on GBS infections in babies, I happened upon a study I quote endlessly when I talk to parents about their birth choices:

The literature points to only one case of early-onset GBS disease of the newborn and no GBS-related deaths among 4,432 water births. This suggests that babies born into water have a lower risk of contracting GBS disease than those babies who have “dry births.” Three other studies analyzed by the Cochrane Review look at 402 additional babies born into water, none of whom contracted GBS.

A number of theories could explain the previous statistics. One, the tub water, which, by the time the baby is born is harboring many strains of intestinal bacteria, is inoculating the baby with beneficial intestinal flora, reducing the opportunity for GBS to take hold.  Two, the tub water may dilute the GBS bacteria. Finally, water birth, by nature, may reduce other interventions which predispose babies to infection, such as reducing mama’s exposure to repeated vaginal exams or artifical rupture of membranes.

Baby’s thermoregulation is a very  important concern with water birth.  We keep the room warm, make sure the water stays warm, and help mama to hold baby so that some of his little body stays under the water while his head is safely above the water. Though the temptation to wrap a blanket around baby is strong, in water birth this isn’t appropriate – it wicks up the water and chills the baby. I have employed a thermometer at water births a few times when I am concerned about baby’s temperature.

I am a proponent of water birth with midwives, doctors, and nurses who are trained in the finer points of water birth safety.

 

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