A Blueprint for Waterbirth: ACNM's Practice Template

Midwife Firen Jones (Nightingale Birth founder) supporting a mother in the tub

Midwife Firen Jones (Nightingale Birth founder) supporting a mother in the tub

Water is delightfully therapeutic whether you are swimming in the ocean, taking a hot bath, icing a sore muscle or floating in a pool.  It is only sensible that women in labor can benefit from showers and submersion in a warm tub of water; it relaxes tense muscles and eases the weight of pregnancy as gravity lessens, and you are able to rest more comfortably. 

Families in the Bay Area are discovering the benefits of hydrotherapy for pain relief during labor and to help them have a natural, unmedicated birth. And while some hospitals may allow their patients to labor in the shower for a short while, they do not have birth tubs to labor in or offer waterbirth as an option.  This is one of the many reasons families are turning midwives for their care.  Using water for therapy throughout the labor process is so ingrained into the education and practice of midwives that it is offered by every home birth midwife I know.  

While most of our clients use water at some point during their labor and birth, whether they actually deliver in the water is about 50/50 and completely up to their preference in the moment.  But I can say that water is an important therapeutic option in labor; it offers a whole different environment to labor in.  

In November 2016, representatives from American Association of Birth Centers, American College of Nurse Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives and other birth experts developed a model template for safely using hydrotherapy during labor and for water birth.  

Personally, I think this was a smart move by the ACNM. It provides information and direction in how to approach waterbirth for providers who are less familiar with the practice.  It also creates a standard of care (born from the midwifery model of care) that hospitals can adopt if they are considering offering waterbirth.  

Lets take a look at the basics they’ve outlined: 

Pool Rules:

  1. Baby is head down
  2. There is only one baby
  3. Pregnancy has reached term (37 weeks gestation)
  4. Baby’s heart rate has been evaluated.  Their baseline, heart rate and rhythm appear to be normal.

Golden Rules of Hydrotherapy:

  1. If she might have trouble getting herself out of the tub, maybe she shouldn’t be in there.  Basically if she has a musculoskeletal condition or reduced mobility, has taken any sedative medications, had an epidural or abnormal blood loss (hemorrhage) she may not have the strength or wherewithal to remove herself from the water.  Makes sense.
  2. Keep the water warm, but not too hot.  Use a thermometer to monitor the water temp – it really shouldn’t be over 100F.  And it is likely your client will be letting you know it's too hot.  Body temperature or a little warmer is ideal.
  3. Keep it clean.  No one wants to see a turd floating by as they are trying to relax, plus it smells and is gross.  Sure lots of people poo a little when giving birth, but one of the many magic tricks of midwives is for our clients to never realize they poo during labor. Let's keep it that way.  A disposable fish net or even using a gloved hand to remove debris works just fine. 
  4. Empty and refresh the tub.  We definitely want to avoid mini science experiments during these labors so regularly emptying, rinsing and refilling the birth tub not only provides an opportunity for your client to get out, walk around and change her position (which is good during longer labors), but it also helps avoid bacterial contamination that can result from prolonged heating of water.
  5. Slip and slides have no place in labor.  Make sure she can get in and out without slipping. Labor is hard enough and slipping on a wet floor will only make it worse.  Have able-bodied support available if she needs help, as leg-lifts are ten times more difficult in labor.
  6. Use your clinical judgment.   This probably isn’t your first rodeo with a waterbirth.  Listen to your laboring client and follow your intuition about whether she should stay in or get out.

Facilitating a Safe Waterbirth:

  1. Monitoring is as normal.  On this note, definitely get a waterproof doppler probe and keep the other end well protected from water!
  2. Support spontaneous physiologic pushing.  Since the baby will be born into the water there is no need to “catch” them so you can take a hands-off approach or help your client catch their baby. 
  3. Gently bring baby up and out of water immediately following birth.  We’ve all seen that video where the OB is allowing baby to stay submerged for several moments following birth.  Don’t do that, evidence doesn’t support that practice.  Help your client bring her baby up into the lovely fresh air.
  4. Do not submerge baby’s face once it has been exposed to air.  If just their head is born into the air (client suddenly stands up), assist your client in a supported position where baby is born avoiding re-submersion into water.  Likewise, once baby is brought to the surface of the water, support your client in holding their baby to prevent submersion of baby’s airway following birth.
  5. Maintain newborn's temperature. This is best done by drying their head and keeping them skin-to-skin.  They can stay partially submerged in the tub or covered with warm dry blankets in the immediate postpartum.
  6. Monitor third stage per normal.  This is greatly based on comfort level and experience of the midwife, but barring excessive bleeding the placenta can be delivered normally in the tub.  Just be sure to grab a bowl!

 Signs that it is time to get out of the tub:

  1. Client’s temperature is above 100.4 degrees Fahrenheit
  2. Tight nuchal cord that cannot be reduced
  3. Apparent shoulder dystocia
  4. Excessive bleeding
  5. Client loses consciousness… obviously…

This work of the ACNM and collaborators provides an evidence-based template for larger institutions to develop guidelines so birthing families can have the option for laboring and birthing in water.  Quite honestly, I am a midwife who recognizes the importance of evidence-based practice and appreciate having this kind of information available to guide my practice.  I also respect the unique needs of each birthing family and know to be judicious with how I use guidelines for each individual.

Interested in reading the full article?  Find it HERE

What are your thoughts?  How might this inform your choice to use hydrotherapy in labor or have a waterbirth?  If you are a provider, how might this inform your practice?



Labor Is Not A Straight Line

We live in world of logic, rationale and cause and effect. While labor does produce effects, it is rarely a straight path. You may have to make many loops and turns to get to your destination - the baby! Examine your view of what labor should or will be. Is your vision realistic?


During a normal unmedicated labor, you may experience any of the following:

  • Surges that start up for several hours and then stop. This may happen over hours, days or even weeks.
  • A labor that speeds up and then slows down.
  • A plateau at 4cm, 6 cm or 9cm where you suddenly aren’t making the same amount of progress as before. 
  • You get to full dilation and then labor stops for several hours before the urge to push comes (this is a great time to take a nap!)
  • A labor that stops completely if you feel scared, vulnerable, or like you’re being watched.
  • Pushing really hard for an hour or more without being able to see or feel any descent of the baby (this is because what is happening is internal — baby’s head is molding and your tissues are stretching — a lot of work is being done that you can’t see).

Cell Phones, Computers, Microwaves... And Your Baby

Photo by Randy Sloan 

Many pregnant moms worry about the effect of electromagnetic waves on their unborn baby. Frequent causes of worry are computers, laptops, cell phones, microwaves, and wireless internet routers.

Here's what we know and what we don't know about these devices and how they affect your baby.

Cell phones emit low levels of radio waves, called non-ionising electromagnetic radiation. Lots of everyday items do. Televisions, computers and microwaves all give out this type of radiation. Non-ionising radiation is much milder than ionising radiation, which is emitted by X-rays, radiation therapy machines and CT scans. The electromagnetic fields produced by mobile phones are classified by the International Agency for Research on Cancer as possibly carcinogenic to humans.

A large number of studies have been performed over the last two decades to assess whether mobile phones pose a potential health risk. To date, no adverse health effects have been established as being caused by cell phone use.

However, many of these items have only been used since the 1990s, and in research terms, that is not a long enough time to know whether they can have long term effects on health. Further, there are few studies on the specific effects on the unborn fetus, so we are forced to rely on evidence from animal studies or human studies that may not include pregnant women. Several studies are ongoing to more fully assess potential long-term effects of cell phone use.

So basically, we don’t know exactly how electromagnetic fields affect us or if they will affect your baby in the long-term. Therefore, it may be wise to reduce your exposure while pregnant. Here are some ways you can do that:

  • Check your phone’s specific absorption rate (SAR) rating: Every mobile phone has a SAR value, which tells you the maximum amount of radiation, or energy, absorbed by your body when you're using your phone. The higher your phone's SAR, the more radiation you absorb. Check your SAR rating in your phone instructions, on the manufacturer's website or at www.sarvalues.com
  • Use a hands-free device or headset. The power (and hence the radiofrequency exposure to a user) falls off rapidly with increasing distance from the handset. A person using a mobile phone 30–40 cm away from their body – for example when text messaging, accessing the Internet, or using a “hands free” device – will therefore have a much lower exposure to radiofrequency fields than someone holding the handset against their head.
  • Limit the number and length of calls or use text message. Using the phone in areas of good reception also decreases exposure as it allows the phone to transmit at reduced power, therefore reducing radiofrequency exposure.
  • Get rid of your microwave. Or replace an old or broken microwave that can leak radiation.
  • Do not use your laptop on your lap. Put it on a table or a lap desk (you can get a cheap computer lap desk at Target). Sit as far away from your computer as is reasonably comfortable. Do not use it while it is charging as it emits more radiation at this time. 
  • Use an EMF shield for your computer. Even if you use an EMF shield, don’t put your laptop directly on your lap. Here is one EMF shield that has good reviews: http://harapad.com/ 
  • Go wired. WiFi emits electromagnetic frequency as well and some EMF shields don’t protect against this. 

Information from http://www.who.int/mediacentre/factsheets/fs193/en/
Photo by Randy Sloan