Many families plan to use water in labour, especially if they are planning to give birth at home. Many women share their birth stories, either in person or on social media, and you may come across personal experiences that involve a pool. So, what are the benefits of water birth and are there any downsides?
Alongside personal experiences of women and the Midwives supporting them, there has been some research looking at this area. And there are some practical considerations too! Here is the inside guide to using water in labour, which can be in the hospital or home setting. Many of our clients who plan a home birth with our care, choose to have a birth pool.
Use of water in Labour, how does it work?
Water has historically been used for comfort in Labour in many ways and at different stages of labour. The French Obstetrician Michel Odent, a keen supporter of and advocate for natural unmedicated birth, often recommended using water for women experiencing a prolonged early labour to assist them with discomfort and to aid relaxation. In recent times, water has been promoted as a safe and effective means of helping with labour sensations, providing we are aware of and managing safety considerations. It is popular for use in home births.
Some women in labour may choose to use a shower as the sensations of the water moving on their back can be helpful. The way nerves conduct sensory information from the uterus in labour is that signals are transmitted via the spine and then being received and interpreted in the brain. A competing sensory input, such as massage, TENS (transcutaneous electrical nerve stimulation) or water, will interfere with and reduce these signals from being conducted through to the spine, and therefore the woman in labour will often feel that her labour sensations are more manageable. (TENS is electrical so of course cannot be used in the pool, it can be used in early labour and then removed prior to entering a pool or shower)
Immersion in water also has this effect of reducing sensory information from the uterus being perceived in the brain, along with enhanced freedom of movement due to the buoyancy of the water (remember, you are heavily pregnant at this time!). Water also for many people helps them to relax, it’s a bit like a massage all over your body from the movement of the water. It can also provide a sense of privacy and having your own personal space bubble (aka pool!) around you. Relaxation and feeling safe, calm, supported and undisturbed can enhance oxytocin production, and thereby promote and protect a natural labour to proceed and progress in a healthy and straightforward manner. Take a look at our information leaflet on water births here
Listening to your baby’s heartbeat in Labour, why do we do it?
Physiologically the baby prior to birth receives oxygenated blood via their umbilical cord (oxygenation takes place at the placenta with oxygen as well as nutrients diffusing from the mother’s circulation into baby’s blood). While there is some temporary intermittent interruption of blood flow to the placenta in labour due to contractions, in most healthy pregnancies with a healthy well grown baby (implying a placenta and maternal blood circulation that is functioning well), this does not cause the baby any difficulties and the baby is well adapted to cope with labour.
This is the reason that we as Midwives want to listen to your baby’s heartbeat when labour is well established, usually every 15 minutes after a surge, and every 5 minutes when in the second stage of labour, as we expect to hear changes in the baby’s heart rate if baby is experiencing some stress due to some disruption to their supply. A normal baby’s heartbeat is between 110-160 beats per minute, does not show an upwards trend or have decelerations (a slowing of the heart rate which persists for 15 seconds or more). We would discuss monitoring your baby’s wellbeing with you as part of your birth planning conversations to agree a plan together.
We are able to listen to baby’s heartbeat in the Pool using an underwater Doppler so there is no need for you to move.
Water Births, special considerations
In recent years Waterbirth (giving birth immersed in water) has been reintroduced and become popular. Women can choose immersion in labour simply as an aid to managing labour sensations and may wish to exit the pool for the birth, and many women choose to remain in the pool and give birth in water.
Our professional understanding of the rationale for safety during birth is that babies have a diving reflex (as do all air breathing mammals) which suppresses their breathing under water. Cold is known to stimulate a baby to breathe, so the baby must be born completely under the water and the water should be at body temperature. If the baby had experienced any significant reduction in their oxygen levels prior to birth (which is rare) this could also stimulate the baby to gasp. We as Midwives are therefore watchful during a birth occurring in water that the pool water temperature is maintained at body temperature (around 37’C), and if there are concerns around baby’s heartbeat (explained further above) we would advise you to exit the pool and give birth in air. We do not recommend delaying bringing baby to the surface following birth as their physiological need to initiate breathing soon after birth is strong.
Occasionally a baby may have the cord around their shoulder or body which may need to be untangled before or while lifting baby out of the water, so care is needed. Usually baby would then be received into their mother’s arms and be in close bodily (skin to skin) contact. Some birthing parents may like to lift their baby out of the water themselves. Many babies who are born in water may take a moment to realise they are out of the water and initiate breathing, and all babies (whether they are born in water or in air) appear blue at birth before they take their first breaths. As Midwives we are always watchful to observe a baby’s transition to extra-uterine life and expect babies to initiate and establish regular breathing usually within the first minute. We are also equipped at home births to provide urgent assistance (newborn resuscitation) if baby should require it. Most babies born at home are born in good condition and do not require intervention.
Third stage of Labour, what are the options when using a Pool?
After the baby has been born labour is not completed yet! The third stage of labour involved further contractions of the uterus to assist the placenta to detach from the wall of the uterus, become completely expelled and to control bleeding from the former site of the placenta. All this happens naturally, dependent on oxytocin hormones (so a calm and quiet environment is important at this stage). This natural process may take anything between 10 minutes or upto an hour (occasionally longer) and is called a Physiological third stage.
In the minutes following birth some of the baby’s blood in the umbilical cord and placenta is returning to the baby’s own circulation, some being used for the lungs which are now expanding and requiring a blood supply. This is known as ‘delayed or deferred cord clamping’ and has many benefits. In a physiological third stage your baby will receive more of their blood naturally transfused back into their circulation.
Alternatively a woman may choose a managed third stage, where an injection of synthetic oxytocin is given and the placenta can be drawn out using controlled traction on the umbilical cord. Normally a few minutes of delayed cord clamping can be facilitated. Active management is believed to result in a lower risk of having heavy bleeding occur and may be recommended for you depending on your history (heavy bleeding at previous births) or progress in labour.
During a physiological third stage the new Mama and her newborn baby can remain together undisturbed in the pool in skin to skin contact. We take care to top up the water and keep you both warm. Cramps are expected intermittently and we are watchful for some blood loss which is expected to occur during this process. You can exit the pool any time you decide during this process.
If there are concerns around bleeding we would advise and assist you to exit the pool and help dry you and your baby, and in this situation it is helpful to have somewhere in the same room where you can lie down together and we can provide medical assistance as needed.
For an actively managed third stage we would usually undertake this out of the pool.
Research evidence on women’s experience and safety for water births
There have been no large randomized controlled trials using water and therefore evidence from smaller studies may not be as robust, and rare events may not be demonstrated. Many of the trials were not conducted in a Midwifery led setting or at home so the outcomes seen may vary. Anecdotal evidence (people’s lived experiences) is mostly that women experience a reduction in their sensations when using water, and that any adverse events are rare when supported by experienced professionals (Midwives trained with safe use of water for labour and birth).
A Cochrane review of a number of small studies (Immersion in water during labour and birth – PMC (nih.gov) indicates that overall, women who use water in labour require fewer Epidurals (evidence that many women find it helpful), there is limited evidence on use in second stage (giving birth) and no evidence for adverse effects for mother and baby, a possible reduction in Caesarean birth associated with use of water, and no evidence for infection risk or need for resuscitation for newborn babies (although Paediatricians may occasionally see such cases they are not believed overall to represent an increased risk associated with use of water).
Key Safety or Practical Recommendations
(please also refer to our Home Birth Planning booklet for indivualised discussion with your Midwife)
- Use a new inflatable birth pool at home (with a single use liner) to eliminate infection risks. Inflatable pools are deep for buoyancy and freedom of movement, and have sufficient depth to give birth in (babies born under water have to be completely under the water so that cooler air does not stimulate their breathing), and facilitate ease of access and exit if needed.
- Pool placement ideally with space surrounding (or at least 3 sides) where a Midwife can access you if necessary. Pools cannot be moved when they are full of water!
- Environment: warm, space for a couch or mattress where you can rest with baby after the birth, or to exit pool if necessary at any stage, space for Midwife to attend and assist you within the area.
- Warm water, maintained at body temperature. At home, this will require a good supply of domestic hot water (or the use of kettles and pans), a brand new clean (never used before) bucket for emptying a few bucketfuls so that hot water can be added to maintain the temperature.
- Lots of towels to dry yourself and baby after the birth, and possibly during labour where you may get out for agreed or chosen examinations or to go to the toilet.
For further information take a look at our Water Birth – Frequently Asked Questions