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?