February 1, 2006
Volume 8, Issue 3
Midwifery Today E-News
“Waterbirth”
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Can We Have Liberty in Hospital Birth?

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In This Week’s Issue:


Quote of the Week

"The overwhelming dominance of the obstetric paradigm has ensured the virtual silencing of dissent."

Henci Goer


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The Art of Midwifery

Dropping a waterproof flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during a waterbirth. It also helps you spot floating debris so it can be removed from the water.

Barbara Harper, Midwifery Today Issue 54


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


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Botanical Medicine in Midwifery, by Susan Perri
Learn about the use of extracts and the differences between standard, alcohol and water-based preparations. Explore a glossary of plant categories and a comprehensive list of herbal resources, products and supplies. This treasure chest of remedies is perfect for students and others who are just beginning to learn about herbs. Get the book.

Research to Remember

A University of North Carolina-Chapel Hill study of 1900 pregnant women examined the effects of the women's work schedules on pregnancy outcome. The women described work conditions such as number of hours a day they worked, how much of that time was spent standing, what shift they worked, and how often they lifted objects that weighed 25 pounds or more. The study found that pregnant women who worked a night shift at any time during their pregnancy had an increased risk of preterm birth compared with those who worked the same number of hours during the day. Those women who had worked a night shift during their first trimester increased their risk of premature birth by 50%. The researchers noted, however, that few of the women in the study had worked a night shift during their seventh or eighth month of pregnancy. The researchers speculated that working during the night may disturb the body's internal rhythm and therefore affect the usual activity of the uterus. The study also concluded that women who spend more than 30 hours a week standing or those who perform heavy lifting at least 13 times per week are at no increased risk for preterm labor or small-for-gestational-age babies.

Obstetrics & Gynecology, December 1, 2005


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Waterbirth

Waterbirth Tool Bag

In my tool bag as a water labor or birth labor assistant, I include extra equipment besides the standard labor assistant accoutrements:

  • Rubberized thong slippers
  • A one-piece swimsuit or body leotard (in case I have to get into the water; first I take a shower)
  • Short terrycloth robe
  • Water bottle for me filled with part juice or tea mixed with honey and water
  • Underwater watch to check a second hand during contractions
  • Rescue Remedy (a Bach flower remedy) for all those attending the birth
  • One or two sterilized small inflatable pillows for the mother to lean against in the water
  • Infusion of raspberry leaf tea, a spoon and honey
  • Bag of bendable straws for the mother in the shower or tub
  • Extra set of clothing in case something gets wet
  • Green 65 cm birthing ball for birth attendants to sit on while the mother is in the tub or for the mother to use while in the shower
  • Two rolls of soft toilet paper wrapped in a clean plastic bag
  • Small box of soft tissues
  • Lavender essential oil (5–10 drops in the tub, a great antiseptic). I also like to keep on hand a spray bottle of lavender: using a small spritzer bottle filled with purified, filtered or distilled water, I add 10 drops of lavender essential oil, ice chips to make it cool, and spray on the mother when she's in the waterbirth tub. (I make sure ahead of time that lavender does not make the woman nauseous.)
  • Hand lotion that is not greasy
  • Lip balm because the water tends to dry out my lips and hands
  • Three books: Water Birth, A Midwife's Perspective, by Susanna Napierala; The Waterbirth Handbook, The Gentle Art of Waterbirthing, by Dr. Roger Lichy and Eileen Herberg; and Water Birth, The Concise Guide to Using Water during Pregnancy Birth and Infancy, by Janet Balaskas and Yehudi Gordon
  • Thermometer. If I am attending a homebirth, I usually include a thermometer to check temperature of the mother if I suspect she might have a fever. It is amazing how many people do not have a thermometer in their homes.
  • Scooper: I also suggest to the parents that if the pool rental does not supply a scooper for scooping out fecal and birth matter released in the water during labor or birth, they purchase one from a local pet store, sterilize it and wrap it in a plastic lock-strip bag. Urinating in the water is fine—urine is sterile and clearing the bladder will make room for the baby's head to dip down. All labor attendants, however, should use the bathroom facilities.
  • Large stainless steel or plastic bowl: birthing the placenta under the water is medically safe. A small bowl floating on the water will sink with a good-sized placenta.

Judith Elaine Halek, excerpted from "Aquadurals and Douladurals Replace the Epidurals," Midwifery Today Issue 54


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Recommendations

The main recommendations are based on the fact that immersion in water at the temperature of the body tends to facilitate the birth process during a limited length of time (in the region of an hour or two). This simple fact is confirmed by clinical observation and by the results of a Swedish randomized controlled study suggesting that women who enter the bath at 5 cm dilation or after ("late bath group") have a short labour and a reduced need for oxytocin administration and epidural analgesia. Physiologies can offer interpretations. The common response to immersion is a redistribution of blood volume (more blood in the chest) that stimulates the release by specialized heart cells of the atrial natriuretic peptide (ANP). The inhibitory effect of ANP on the activity of the posterior pituitary gland is slow, in the region of one to two hours. When a woman is in labour this inhibitory effect is preceded by an analgesic effect that is associated with lower levels of stress hormones and increased release of oxytocin. Furthermore, it is partly via a release of oxytocin that the redistribution of blood volume stimulates the specialized heart cells.

The first practical recommendation is to give great importance to the time when the labouring woman enters the pool. Experienced midwives have many tricks at their disposal to help women be patient enough so that they can ideally wait until 5 cm dilation. A shower that more often than not implies complete privacy, is an example of what the midwife can suggest while waiting. The British Medical Journal survey (Aug 21, 1999) clearly indicates that many women stay too long in the bath (the average time was in the region of three hours for women who gave birth in water!). One reason is that many of them enter the bath long before 5 centimeters dilation.

The second recommendation is to avoid planning a birth under water. When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of long second and third stages. There are no such risks when a birth under water follows a short series of irresistible contractions.

The recommendations regarding the temperature should not be overlooked. It is easy to check that the water temperature is never above 37 degrees C (the temperature of the maternal body). Two cases of neonatal deaths nave been reported after immersion during labor in prolonged hot baths (39.7 degrees C in one case). The proposed interpretation was that the fetuses had reached high temperatures (the temperature of a fetus is 1 degree higher than the maternal temperature) and could not meet their increased needs in oxygen. The fetus has a problem of heat elimination.

One can anticipate that, if a small number of simple recommendations are taken into account, the use of water during labor will seriously compete with epidural anesthesia. Then helping women to be patient enough and enter the pool at the right time will appear as a new aspect of the art of midwifery.

Michel Odent, MD, excerpted from "A Landmark in the History of Birthing Pools," Midwifery Today Issue 54


The temperature of the water is very important; it must stay between 86 and 95 degrees F. Ideally, it should be between 92 and 94 degrees F for late labor, 86 degrees F for placental delivery, and then warmed back up to the low 90s for breastfeeding. Under these circumstances, the following benefits accrue:

  1. Neurotransmission of pain is reduced.
  2. Oxygen uptake via uterine vessels is increased.
  3. Muscle tone is normalized.
  4. Glucose metabolism is improved.
  5. Levels of stress hormones are lowered.
  6. Placental separation is facilitated.

The mother must be in the water for at least thirty minutes before maximum effects are realized. After two to three hours, benefits as per hormone stimulation diminish. Advise her to stay flexible, and see how she feels about being in the water as labor progresses. Never put a cold cloth on her forehead to cool her if she gets too hot: cool the water down or have her come out. If she gets claustrophobic in the tub, or feels like she cannot get enough leverage to bear down, she should get out immediately.

… It is best to avoid touching the baby as it is born. If the mother is undisturbed, she will touch the head herself, and the baby will spiral out (literally pushing itself out with its feet) and turn to face her. It may expel fluid from its lungs (seen getting into the water), and may reach one arm toward her with the other bent, as if swimming (the asymmetric tonic reflex). Mom and baby will then make eye contact, and she and her partner can lift it and bring it to her chest.

Elizabeth Davis, excerpted from Heart and Hands: A Midwife's Guide to Pregnancy and Birth,
chapter 2, pg 59, Celestial Arts: Berkeley, CA

MIDWIFERY TODAY Back Issues are available online: Issue 54


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About Physiology in Pregnancy and Childbirth

Learn about Waterbirth
The video "The Use of Water for Labor and Birth" by Marina Alzugaray illustrates the individuality of homebirths and provides an outline for the basic concepts of the use of water.


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Web Site Update

The entire program and registration form is now online for our conference in the spa town Bad Wilbad, Germany, October 2006.

The dates for the Eugene 2007 conference have changed to March 14–18, 2007. For our domestic conferences we are switching to the Wednesday–Sunday format of our International conferences. Watch for more information about upcoming conferences here.


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Forum Talk

[Two friends and I recently miscarried.] The hospitals here insist on a D&C. Is it necessary? Better? Some say if they want to get pregnant again it might be better if they start with a clean canvas? We are all very healthy young women, two of us were RH-, but did have RhoGAM after our first. Information?

Anon.


Share your thoughts and experience about this topic.
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Question of the Week

Q: What do you do to encourage women to trust birth?

E-News staff


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Think about It

When a midwife attends a birth, legally she is required to intervene. Although the law varies from state to state and country to country, generally it is safe to say that midwives must time contractions and measure dilation. If a labor is not progressing at the speed that some government officials have arbitrarily decided it should be, a midwife must choose between breaking the law and transporting the woman to the hospital. Even if a woman manages to give birth within the government's timeframe, there are restrictions on how soon after the birth the placenta must be delivered. … Most midwives will agree that the fear of prosecution is always in the back of their minds to at least some degree.

Laura Shanley, excerpted from "What Some Women Don't Want," Midwifery Today Issue 63

Lots of women say they want to be midwives to be advocates for women and their right to choose how, when, where and with whom they give birth—but are those rights really the first thing midwives are concerned with? In this litigious time, I think not. The bureaucracy stands in the way of pure attended birth. To me, it is not desirable to have someone present in my home who is ultimately concerned with preserving her license. Part of that motivation to preserve the license may mandate things like fetal monitoring, vaginal exams and time limits—all things that have proven disruptive to the process.

A.C., quoted from "What Some Women Don't Want," Midwifery Today Issue 63


Readers, what do you think? E-mail your thoughts to E-News at: mtensubmit@midwiferytoday.com Letters sent to ANY OTHER e-mail addresses will not be considered. Enter the words "Think about It" in the Subject line.

MIDWIFERY TODAY Back Issues are available online. Issue 63


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The Association of Texas Midwives annual conference "Trust in Birth" May 4–6, 2006 in San Antonio, TX. Presenting Marsden Wagner, Anne Frye, Barbara Harper, Penny Simkin and more! Visit www.texasmidwives.com for additional information.


48 Ways to Reduce the Fear of Childbirth


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