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Waterbirth International desperately needs Your financial support.!

The best way to donate is to send a check to Waterbirth International
PO Box 1400    Wilsonville, OR 97070    USA

or Donate online today so they can continue to advocate for safe, gentle birth for mothers and babies everywhere.

  ~DONATE any amount you can
  ~Become a MEMBER of Waterbirth International
  ~Buy a birth pool for your local midwives
  ~Buy a birth pool for yourself
  ~Buy a birth video and donate it to your local library

THANK YOU! from all those lucky waterbirth moms and babies, past, present and future.

Waterbirth Mirror - Major Innovation!

The 'Howes Birth Mirror' is a new design by midwife Virginia Howes that provides the visibility you need without the hazards of glass or the sterilization challenges of plastic mirrors.

Interview with Waterbirth Advocate

11/27/05 :  To Quote Barbara Harper, RN, "The pendulum, we hope, has swung as far as it can in the direction of the medicalization of birth and is now swinging back to a more sensible friendly approach.."  When the 1st edition of Gentle Birth Choices was published in 1994, Barbara was already an educated, experienced and outspoken advocate for mothers and babies and families.  Her nonprofit, Global Maternal/Child Health Association, has been going strong since 1990. Find more information on our guest by clicking here.

Listen to this program from Tributaries Radio

Five-Minute Activism to Support Waterbirth - Let Your Waterborn Baby Be Counted!

The AAP published an article that was very belittling of waterbirth, and here's one response:

"Waterbirth International wants to hear from mothers and fathers who have chosen this gentle, peaceful way to give birth.  List your babies' birthdates and their first name on our "I WAS BORN IN WATER" page.

You don't have to list your baby's full name, so there's no invasion of privacy. 

Waterbirth Database - For the first time, an opportunity for midwives and doctors world-wide to collaborate to collect consistent data, and contribute to the evidence concerning water immersion during labour and birth.

This site also offers the Waterbirth Guidelines - an evidence-based set of practical guidelines for midwives on using water in labour and birth, as well as many other resources.  A must-read for midwives attending waterbirth.

WARNING!!!  If you have Aetna health insurance, you may want to change at the next opportunity
, when your employer has their annual "open enrollment".  Aetna doesn't cover homebirth, citing a single study based in rural Australia which shows that high-risk births far away from a hospital are high risk.  They further cite the policies of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, both business competitors to homebirth providers. Their policy statement ignores a mountain of evidence that homebirth is as safe as or safer than hospital birth for normal, healthy pregnancies..  If their policymakers have any integrity, this logic will soon lead to cessation of coverage for planned VBAC's . . . there's no dearth of studies and AAP and ACOG policies proclaiming the danger of VBAC's . . . and then they'll stop coverage for any woman who declines standard ACOG/AAP recommendations regarding routine ultrasound, routine induction, routine IV's, routine use of continuous electronic fetal monitoring, routine administration of antibiotics for all GBS positive women (up to 40% of birthing women), and prompt cesareans for any woman who fails to progress in a timely fashion during labor and pushing.  They may also stop coverage for children who are not vaccinated according to the full schedule of vaccinations recommended by the AAP, even though many intelligent parents decline the newborn hepatitis B vaccine and practice selective vaccination according to their child's own needs.

If this is troubling to you, as it should be, let them know.  You can easily send e-mail to Aetna's National Media Relations Contacts and simply tell them that they should not be in the business of denying coverage for reasonable healthcare choices, such as homebirth, waterbirth and VBAC.  They will especially want to know if you are choosing another healthcare provider because of this unreasonable policy.  You might also suggest that they expand their research beyond ACOG and AAP recommendations.  They could start at:  http://www.gentlebirth.org/archives/homsafty.html#References


Even if you can't arrange to have a special birthing tub set up in your home for labor, you can still increase your own bathtub's capacity with an overflow drain cover.

Online Waterbirth Videos

Using Water for Labour and Birth - why people use birthing pools - excellent YouTube video featuring Amy Maclean, childbirth educator.

Wow! She really does a great job of explaining all this!  The only point she missed is that the increased warmth around the belly increases the blood flow to the uterus and so increases oxygentation of the baby during labor.  And I think it's always important to note that women can labor in the tub and then get out for the final pushes if she doesn't want to have a waterbirth.  Great video!

Birth Through Water (click on the video icon on the left bottom) - lovely tribute to waterbirth.  [Notice how erect the nipples are!  This is a key sign to help you distinguish between the "real" contractions of active labor, where the oxytocin levels cause nipples to become erect.]

YouTube.com has some waterbirth and homebirth and unassisted birth videos.

Blaze's home birth - a nice one from an Australian doula - although this may look like an unassisted birth, there was a midwife providing hands-poised care.

Waterbirth Baby Born Underwater in the Sac - YouTube video

Here's a great whale birth.  Note that in the absence of the natural whale midwives, they had aquarium staff to make sure baby made it to the surface for that first breath!

Waterbirth Organizations

These organizations are focused on waterbirth:

Waterbirth International - host of the International Waterbirth Conferences (Barbara Harper's Web page).  They have a large set of resources, including articles and protocols.  Barbara is available to come to your facility to present a workshop about waterbirth.
Waterbirth International also maintains a practitioner referral directory.
And they have a collection of waterbirth birth stories.

Notes from the Gentle Birth World Congress, 2007, in Portland, Oregon

The Waterbirth Website (Karil Daniels' site, including information Learn About Waterbirth, The Benefits of Water for Labor and/or Birth, How to Prepare for a Joyous Waterbirth, and her video, "WATER BABY: Experiences of Water Birth")

About Waterbirth

See also: Responses to Waterbirth Critics

Waterbirth Basics - from Newborn Breathing to Hospital Protocols by Barbara Harper, RN

Mama, Talk About When Max Was Born by Toni Olson - A water birth book for children!

Waterbirth Discussion - http://groups.google.com/group/waterbirth - a Google group started by Barbara Harper to get around the Spam problem on the Yahoo! group at http://groups.yahoo.com/group/waterbirth

Waterbirth: The Power of Water, by Sarah J. Buckley, MD

Use of water birthing pools in labour - Find out about water birth and using a birthing pool during labour. Read about what happens when a baby is born in water, when you may need to get out and tips on safety.

I was surprised that they talk about bringing the baby out of the water face first.  Yes, moms are very eager to see their baby's face.  But this seems like you're begging for the baby to get water in the mouth, instead of draining out the fluids.  Water in the mouth isn't a big deal, but it's a lot better to take a second or two to drain secretions out of the baby's mouth a bit.  This is how Michel Odent did it, and I find it works much better.

I just love that the British view it as normal for women to get back into the birth tub after the placenta is out.  This doubtless comes from their long tradition of the postpartum bath, which was normal since they often didn't have access to showers.

On the subject of keeping your bladder empty, I'll point out that moms really hate to leave the tub to go to the toilet, because it's almost certain that they'll have a contraction during the time away from the tub, and it will hurt a lot more.  It's also a pain to get them dried off and/or lay down waterproofing to the toilet.  I found that having the mom stand in the tub and pee into a large disposable plastic cup works really well; she just tucks it between her legs and pees; it's flexible enough that it fits pretty well.

Water Birth - Excellent Patient Education from Kent Midwifery Practice in the UK (Kay Hardie and Virginia Howes)

Birth into Being is available from the dealingwithgravity.com web site.  In 1982 - 89 Elena Tonetti was one of the leaders of the "conscious birth" movement in Russia.  She worked closely with Igor Charkovsky, organizing birth camps at the Black Sea where babies were delivered with wild dolphins. Elena is now in the Marin area, offering workshops for birth trauma release.  This is a fabulous video!

Gentle Birth Alternatives [unavailable as of 2/05, but here's a copy of an article - What Is A Gentle Birthing Experience?]

Birth Balance - A Resource Dedicated to Integrating Balance and Birth Since 1987

Aqua-baby - Labour and birth in water - About waterbirth in Holland - "Most Dutch midwives will be glad to help you have a natural birth in water."

Waterbirth/Tub Insurance Coverage and Reimbursement

"With Child Retreat" A watery weekend retreat for pregnant couples in Florida with Waterbirth midwife pioneer Marina Alzugaray. Experience paradise and learn about Gentle births, Waterbirths, and AquaNatal prenatal water exercises in the beautiful tropical waters of the Florida Keys.  This is a retreat for couples who love water, the ocean and want to treat themselves to a magical weekend during their pregnancy.

Contact Marina Alzugaray of the CoMadres Institute for more information.

Waterbirth section from Sheila Kitzinger's site.

THE WATER BIRTH EXPERIENCE from another Sheila Kitzinger site.

Water Birth from the HomeBirth Association of Ireland

Childbirth Methods - Water Birth - from Motherstuff

Water Babies - Your Waterbirth Resource on the Web

Under Water Child Birth - The Miracle of Water Babies  - from "The Marnie Ko Collection" on Nurturing Online 

Water Birth Resources -  at Robin Elise Weiss' pages at The Mining Co.

BirthWaves - Your resource for home and water birth information and products

Baths During Labor Reduce Pain, Don't Cause Infection

Waterbirth Figures Prominently in Nice Summary of Comfort Measures w/Focus on Avoiding Drugs

Home births increase when water tubs offered (UK, Mar., 2009)

EDLICH, R (and others) Bioengineering principles of hydrotherapy JBCR 8(6):580-584, 1987
DONIEC-ULMAN, I (and others) Water Immersion-induced endocrine alterations in women with EPH Gestosis Clin. Nephrol. 28(2):51-55, 1987

Report by Michael Rosenthal in "THE FEMALE PATIENT/vol.16/August 1991. [pg40]Warm-Water Immersion in Labor and Birth"....This article also includes their statistics for approximately 1400 women who labored in the water, and 679 births occurring in the tub. Super article!!!!

Water Birth: One Birthing Center's Observations by Linda Church in Journal Of Nurse-Midwifery Vol.34, No $. July/August 1989 and Jet Hydrotherapy for Labor and Postpartum Pain Relief by Kathleen Aderhold and Leslie Perry in MCN (Matrnal Child Nursing?) Vol 16, March/April 1991 Report of experiences at St. Lukes Hospital, Denver, Colorado.

Waterbirth Increases Safety of Breech Birth

There is a doctor in Ostend, Belgium who is experienced assisting delivery of both breech and twins in water.
This article contains a level of anxiety about birth that is unsettling. However, evaluated as an obstetrical document, it has a relatively non-interventive attitude.

Britain's National Childbirth Trust discusses the pros and cons of  waterbirth.

I'd like to find out about how people on this list view waterbirth. I have been hearing from lots of other women lately, and the same phrase keeps coming up. When I ask moms & birth care providers what they think of it, many say "I'd never want to have a baby any other way!"

I've been doing waterbirths since I started doing homebirths over a year ago - probably 50% of my clients now use the pool during labor, and most stay in the pool for birth. All who have birthed in water say that they wouldn't want to do it any other way. Those who have had previous babies out of water inevitably find waterbirth much more comfortable. I haven't had any client who felt otherwise, or who wouldn't do it again.

I enjoy waterbirths, but do find that the babies' lungs sound "wetter" than babies born out of water. This sometimes keeps their color from pinking up as fast, and tone is a bit diminished. However, this seems to have no detrimental effects - it's just different. Once the waterbabies nurse, their lungs clear up rapidly. They are much more relaxed, as a group, than babies born out of the water.

The pool we use is a 60" x 22" inflatable kids pool - works great, and very portable.

I am an Italian obstetrician and I have experienced with some midwives water birth in a small public hospital on the hills of Florence-Italy. We had about 600 deliveries a year and we had alternative obstetrics and also water birth in a small room at the second floor of the hospital. Three months ago administrators and politicians (even women) decided to close this hospital: to rationalize sanity in the city of Florence???

Any way water is the most wonderful element where to stay during labor. It does relax wonderfully (have you ever had a warm bath after a heavy and tiring day, may be even without sleeping since the night before?). It does reduce pain. Many urologist suggest a warm bath when a patient has terrible pain for a stone in the ureter that wants to come out (urinary colic).Water pushes you up so you feel very much relived. The warm water creates a relaxing atmosphere for the woman and for every body who is there. We have considered the water another possibility for the woman during labor. She can sit , walk, lay down, be hold by her partner, or stay in the pool with water. We had to fight hardly against other doctors, some midwives, administrators, politicians, architects (the water is heavy at the second floor). We wanted this pool against the general tendency to generalize epidural during labor. The water is very good against pain and with no problem. Even if rarely we used epidural if it was necessary for the woman. Some women spent a short or a long time in the pool and then they decided that they felt much better and decided to come out and walk or sit or whatever they wanted to do. But sometimes they decided to stay in the water and deliver the baby there. Water birth is a wonderful experience. Nothing happens to the child if you do not stimulate him. The baby starts breathing movements only if you stimulate touching, especially if you panic. Otherwise the baby starts breathing only for the change of temperature from the water to the air. Of course there is no need to keep the baby under water afterwards. Of course sometimes it is necessary to assist the birth but that is not a problem. Our pool was blue and made by an artisan that makes boats with resin and the design was made by the midwives.

In addition to all the other benefits of waterbirth, it seems also to reduce postpartum perineal pain; this is in keeping with Chinese medicine theory that heat applied to the perineum after birth helps with healing.

Minnesota women embrace the gentle option of water birth
by Darlene Pfister, Star Tribune
Published Oct 1, 2002
[Local copy]

A continuation of the work of Igor TYcharkovsky in water research and exploration with babies water and dolphins.

Basia Barbara Szpak DEC,LMT
Aalbersestraat 14
1814 RH, Alkmaar, NL

tel/fax: 31 (0)72 540-1920

My practice is geared around waterbirth as the cornerstone to support particular values in my practice. There seems to be three main feelings about waterbirth among practitioners. Love it, it's an option, and  not really comfortable with it. As would follow,  midwives that are "into" waterbirth have a vastly higher rate of waterbirths.

My prenatals last approx. 2 to 2 1/2 hrs. for firsts time clients, not just first time parents. I prefer my clients to NOT take "prenatal classes" because they are ultimately geared to an institutional based paradigm of birthing behavior rather than of an undisturbed spiritual or ritual nature.
 It ALWAYS goes back to empowerment and waterbirth, and not just  facts about waterbirth .

"Transition" as described in childbirth classes does not exist in homebirth as we practice it. The hall marks of transition with the the "Third Emotional Sign Post: Self Doubt" as labeled by Bradley just don't exist at home. "Transition" happens in a hospital because the staff starts to change their behavior, i.e.. flipping on the warmer, rolling in the instrument table, more staff in and out as they perceive the intensity in her labor. This activity registers in the brain as danger to the birthing environment causing distress to the laboring woman. As well,  most childbirth education classes are very outdated in presenting that somehow a woman is in a place of self doubt because she is not able to verbalize what she wants or needs. Rather the model should be constructed that she is in the deepest part of her work. Are men in a place of self doubt because if you were to ask whether they want chicken or fish for dinner in the most intense moments before they orgasm during sex they might fumble for an answer?  So I feel like we are teaching a whole lot of women that when they are in the deep mystical night so to speak of their labor,  they are in the land of self doubt. How utterly disempowering!" Transition" has become a buzz word that I have to de-program out of my clients birth view.

So that brings us back to the tub.... it becomes the sacred ritual circle where a woman can go to be in that intense dark night of her labor protected from even me. Water becomes, in my practice, not just a medium but a psychic location if you will. I encourage my women to decorate the tub with prayers or mantras and during the set up of the tub, and usually again in early labor if I am there, I tell many of the names of the children who were born in the tub, and that I have never transported a baby that was born in that tub, which is wonderfully true.

So really in the wonderful way of things, my clients chose me because of my emphasis of waterbirth, but soon discover that waterbirth is much more than simply giving birth in the water, it is  the underpinnings of a birth experience that values the strength and empowerment of the family as well as the spiritual and ritual nature of birth. 

The Birthing Pool Test by Michel Odent - this is an interesting discussion of the hormonal changes associated with deep water immersion.  " . . . we need to remember that the immediate peak of oxytocin following immersion in warm water will induce a feedback mechanism and eventually the uterine contractions will become less effective after an hour or two."

Responses to Waterbirth Critics

There are some classes of healthcare providers who are critical of waterbirth.  My best guess is that they're concerned that attending waterbirth doesn't allow them to be plopped on their comfortable OB stools with the woman in a "controlled" position.  Midwifery is generally supportive of birthing positions that are safest and best for the mom and baby rather than the healthcare provider.  This includes giving birth in the comfort and safety of warm water.

Water Birth Option Returns to CHI Health St. Elizabeth [4/9/15] - After the American College of Obstetricians and Gynecologists claimed water births posed risks to mom and baby, the hospital went to work.

"All of the water birth charts, babies who had had water births were audited by neonatal intensive care," Schumacher said. "We've never had an adverse outcome, so at that point they decided that it was safe for us to reinstate water birth."


Immersion in Water during Labor and Birth
- Position Statement from the American Association of Birth Centers [pdf version]

They say, "According to the ACOG/AAP statement, potential problems associated with underwater delivery include an increased risk of infection in the mother and baby, difficulty controlling the baby's body temperature, greater risk of umbilical cord damage, breathing problems caused by the baby inhaling water and possible seizures or asphyxiation of the baby after birth. "

Studies show neonatal GBS colonization is lower in babies born in water; one might guess that this applies to other infections as well.  In fact, research does show that overall infection rates are lower in waterbirth babies.

How hard is it to control a baby's temperature in a tub that's 100 degrees?  It's way easier than in a room that's 60 degrees!

Greater risk of umbilical cord damage than dropping the baby on the floor?  I don't think so.

Breathing problems from inhaling water?  Babies are BORN through amniotic fluid, and nobody seems to worry that they're going to inhale that.  In fact, we know that sometimes they do, and the only problem is if there's meconium in it.  Yes, I know there are significant differences in the content of amniotic fluid and tap water, but they're propagating the fear of fluid, in and of itself.

From the waterbirth study done in the UK: "There were five perinatal deaths among the 4029 babies born in water in England and Wales, giving a perinatal mortality of 1.2 per 1000 live births (95% CI 0.4-2.9). This compares with a perinatal mortality of 1.4 (95% CI 0.7-2.3) for a comparable group of low-risk primiparous women having a conventional birth (relative risk 0.9; 95% CI 0.2-3.6). "

And I'll point out that even though they don't like having the birth in water, they speak well of providing facilities for women to labor in water.  So why don't we see this in more hospitals?

Many critics of waterbirth seem disdainful of waterbirth because it's just for the mom's comfort.  I would think that maternity care providers would be overwhelmingly concerned about the mom's comfort, right after the baby's safety and comfort.  Why do they think the mom's comfort isn't important?  Giving birth is an important part of her journey to motherhood, and the more positive her birth experience, the more positive her mothering will be.

Sometimes disdain for waterbirth is expressed as "Yes, maybe it's good for the mother, but it's not good for the baby." even though there is no evidence to support this.

In fact, I would argue that laboring in a warm tub (100 degrees) actually *IS* good for the baby in that it increases the blood supply to the uterus, thus increasing baby's oxygenation.

Some people are concerned that the baby might inhale water; this concern is easily addressed.   When a baby's head is born underwater, you can look at their face to see if they're unconscious, gasping or with a normal facial expression. (When a mom's on hands and knees, you get a really great view, and you can use a mirror for other positions.) With the chest compressed in the pelvis, baby can't take a breath until the chest is out. If you're not confident about the expression on the baby's face, you can get the mom standing before the baby's chest comes out, thus avoiding any possibility of inhalation of tub water.

Personally, I find that there is a lot of extra work for everyone in planning a waterbirth. And it's a lot harder on my back, and I sometimes get soaked. I am also theoretically exposed to more pathogens. However, I rarely see any decelerations when mom is in the tub, for whatever reason. I think the buoyancy helps prevent cord compression, and the warmth increases oxygenation. So I actually feel that waterbirth is safer for the babies.

I have a small volume practice, but I've attended about 100 waterbirths. None of the babies born underwater has needed transport for respiratory issues.

Babies born out of water are three times more likely to develop early onset GBS than babies born under water, and this is among women who were screened as GBS negative. For homebirth midwives who don't screen their clients for GBS or who have GBS positive clients who decline antibiotics, then waterbirth is significantly protective.

The numbers here were quite small, as in 1 out of 1500 babies. But it does mean that a baby with respiratory issues is more likely to be incubating a GBS infection if they were born out of water than if they were born under water.

So I'd be more vigilant about a baby born out of water than a baby born under water.

There's a set of web pages about birth that include articles that talk about the Toxic Effects of Water Birth on Mom and Baby and offer Water Birth Cautions.  I spent a while rebutting her comments, and then it occurred to me that she was perhaps trying to stir up controversy just to increase traffic to her web pages, as she does carry advertising.  So I didn't want to leave my comments on her web pages, and I'm not including any links to her web pages, and I discourage people from patronizing web pages that are just written for sensational effect.

Having spent some time writing up my rebuttal notes, I'm including them here for posterity.

This woman seems to know little about birth.

The paragraph about jaundice makes no sense.

She goes on and on about the effects of chlorine in the water but doesn't seem to know that it can be neutralized by vitamin C. She also seems to ignore the reality that many people swim, bathe and shower in chlorinated water and don't worry too much about it.

Any thinking person knows that untreated well water is not suitable for waterbirth.

She writes:
"A study in 2004 of the water in a birth pool that had been filtered and thoroughly cleaned found high concentrations of the pathogens E. coli, coliform, staph, and P. aeruginosa (7)"
Unfortunately, the footnote link she gives for this goes to "The Nourishing Traditions" book on Amazon.  They are one of her advertisers, so who knows if this redirection is intentional?

She doesn't seem to know much about vaginal flora.  In particular, E. coli (which is a coliform bacteria) and a friendly form  of staph are part of the vaginal flora.  These are the very bacteria that she purports to WANT to pass along to the baby. Indeed, a baby could not live without e. coli, and the mother's strain of e. coli is the ideal seed for the baby's gut colonization.  Obviously, even a freshly showered mother is going to shed some e. coli into the tub, and it makes no difference whether the baby picks it up from the mother's vaginal fluids or the tub water.

The P. aeruginosa is notably a bacteria found in stagnant pools of water, such as in the inner workings of whirlpools.  Again, without knowing which study she's referring to, it's hard to know exactly what she meant by that statement.  But experienced water birth midwives know to avoid whirpool tubs unless they can be sterilized.  The AquaDoula people have an elegant solution to this--a tub with no jets of any kind and with a heater that works by conduction through a plastic liner that is fresh for each new client.

She says that babies born out of water are born dry, so they don't need to be dried off, which she further claims preserves the vernix until it flakes off.  This is patently ludicrous.

There is no such thing as a dry birth.  All babies are born damp, which is why drying them is the first step in all newborn care for most hospital births.  In watebirths, we simply drape a baby blanket over the baby so the baby doesn't lose heat, and the blanket can be used as a sort of wet suit as we pour the hot water from the tub over it.

Vernix is not water soluble and is not affected by being born in water.  And it doesn't "flake off".  It's absorbed by the skin, just as any emollient.

Now that I think of it, the vernix would retain the vaginal flora from the birth.  New information is coming out about the qualities of vernix.  It's known to be bacteriostatic, meaning that it doesn't support the growth of pathogenic bacteria.  But it doesn't seem to impede the colonization of the newborn's skin with healthy skin flora.

Michel Odent, MD, writes that "The first germs on the baby's skin will rule the kingdom." . (Read more about Colonization of Baby's Skin Flora)

He has also been head of the Primal Health Institute, dedicated to studying the long-term effects of birth on a child's health. I'm sure he knows more about newborn colonization than this author.
He is also a pioneer and champion of waterbirth.

I find myself wondering if she wrote this web page to be controversial  and generate traffic to her site.  It does look like a semi-commercial site, and she did generate a lot of traffic.

There have been actual studies (ref: "The Vagina is Not a Straw") to show that water does not go all the way up the vagina and into the cervix when a woman is sitting in a bath tub.  Yes, they really did a study about this.

The beneficial bacteria are in the upper two thirds of the vagina, and the pathogenic bacteria are in the outer third.  If anything, waterbirth selectively affects the pathogenic bacteria while not affecting the beneficial bacteria.

And, of course, her argument assumes that there is active chlorine in the water.

She expresses concern that baby might possibly be contaminated by bacteria from the mom's gut.  Well, where better to get bacteria for the baby's gut than from her own mother's gut?  The baby will already be immune to those particular strains of bacteria because the mother is already immune to them.  The baby cannot survive without getting e. coli into the gut, and the mother's strain is the safest source.

She gave birth in a birth center but doesn't write anything about the effect of birth center germs on her baby.

Really, it's hard to imagine why this woman considers herself an expert on waterbirth since she lacks both experience and knowledge.

Comparison of Birthing Tubs

Is there really that much difference between a rigid-sided birthing pool and the kiddie pools or paddling pools?

Why Kiddie Pools Don't Work - You can find comparative photos of a Gentle Birth Pool and a 22-inch high kiddie pool at - www.waterbirth.org  (The GBPool is exactly like the AquaDoula in size and similar construction.)

This is written by Barbara Harper, Director and Founder, Waterbirth International

"Having started the first waterbirth pool rental service in this country, we tried every pool available before creating our current pools.  The photos on our site tell you everything.  I am not telling women they can't have waterbirths in kiddie pools - they do and it happens every day.  But from a physiology stand point alone - they have missed one of the biggest benefits of water labor - buoyancy.

"Janet Balaskas of the Active Birth Center, Jayn Lee-Miller who created SplashDown Waterbirth Pools in 1989, Michel Odent, and myself are creating a paper statement telling the facts about how disappointing the experience is with kiddie pools or paddling pools as they are called in the UK.

"I know many women will have their own opinions about this and my purpose is not to "sell" pools - we give free rentals to women every single month - but to have women understand the true benefits of immersion and what we fought hard and long to win over the past 25 years.

"Please have a look at our website and decide for yourself.  As a midwife for the past 20 years, also, I have attended births in kiddie pools, horse troughs, swimming pools and lots of Gentle Birth Pools and I would prefer over and over our Gentle Birth Pool or a horse trough  - not a kiddie pool."

Research, Studies and Safety

Barbara Harper's web pages have an excellent collection of Articles/Protocols.

American-College of Nurse-Midwives - A Model Practice Template for Hydrotherapy in Labor and Birth [11/24/16]

No evidence that water birth poses harm to newborns [1/21/16] - There is no evidence that water births, where a baby is intentionally born under water in a tub or pool, poses any increased harm to the child, researchers have found. Researchers examined outcome data for more than 6,500 midwife-attended water births in the United States and found that newborns born in water were no more likely to experience low Apgar scores, require transfer to the hospital after birth or be hospitalized in their first six weeks of life, than newborns who were not born in water.

Maternal and Newborn Outcomes Following Waterbirth: The Midwives Alliance of North America Statistics Project, 2004 to 2009 Cohort.  [full text]
Bovbjerg ML, Cheyney M, Everson C.
J Midwifery Womens Health. 2016 Jan 20. doi: 10.1111/jmwh.12394. [Epub ahead of print]

RESULTS: Waterbirth neonates experienced fewer negative outcomes than nonwaterbirth neonates: the adjusted odds ratio (aOR) for hospital transfer was 0.46 (95% confidence interval [CI], 0.32-0.68; P < .001); the aOR for infant hospitalization in the first 6 weeks was 0.75 (95% CI, 0.63-0.88; P < .001); and the aOR for NICU admission was 0.59 (95% CI, 0.46-0.76; P < .001). By comparison, neonates in the intended waterbirth group experienced more negative outcomes than the nonwaterbirth group, although only 5-minute Apgar score was significant (aOR, 2.02; 95% CI, 1.40-2.93; P < 0001). For women, waterbirth (compared to nonwaterbirth) was associated with fewer postpartum transfers (aOR, 0.65; 95% CI, 0.50-0.84; P = .001) and hospitalizations in the first 6 weeks (aOR, 0.72; 95% CI, 0.59-0.87; P < 0.001) but with an increased odds of genital tract trauma (aOR, 1.11; 95% CI, 1.04-1.18; P = .002). Waterbirth was not associated with maternal infection. Women in the intended waterbirth group had increased odds for all maternal outcomes compared to women in the nonwaterbirth group, although only genital tract trauma was significant (aOR, 1.67; 95% CI, 1.49-1.87; P < .001).
DISCUSSION: Waterbirth confers no additional risk to neonates; however, waterbirth may be associated with increased risk of genital tract trauma for women. [Ed: In general, midwives are so good about preventing perineal tearing because they've had lots of relevant training.  It may take a while to bring the same low rates of genital tract trauma just because midwives are still in the learning phase.  Personally, I found that the warm water was like a nice, warm compress on the perineum and did a lot to prevent tearing.  It's also possible that many hospital waterbirth tubs are shallow and put the women in positions where they're essentially lying on their back, which puts all the baby's weight on the perineum and is known to increase damage.  Personally, I found that a kneeling position worked really well, and I saw less damage in birthing tubs than out.]

MANA and CFM Position Statement on Water Immersion During Labor and Birth [2016] - support ongoing access to water immersion during labor and birth across all birth settings.

This has an impressive list of references--83 citations.

Neonatal GBS colonization is lower in babies born in water.

Neonatal group B streptococcus colonization in water births.
Zanetti-Dällenbach RA, Holzgreve W, Hösli I.
Int J Gynaecol Obstet. 2007 Jul;98(1):54-5. Epub 2007 May 1.

Is CDC GBS Protocol for Performing Rectovaginal Culture for GBS at 35-37 Weeks of Pregnancy and Subsequent Antibiotic Prophylaxis for Full Term GBS Positive Women Biased? Critical Analysis of: Centers for Disease Control and Prevention of Perinatal Group B Streptococcal Disease. [free full text from webmedcentral.com]

Ms. Judy S Cohain

A review of the literature shows that birthing the fetus into water has the lowest rates of Early Onset Newborn GBS (EOGBS). A single case of early onset newborn GBS was reported among 4,432 hospital births into water in the absence of antibiotic prophylaxis (1,2) suggesting a 300% lower rate of EOS among low risk women giving birth into water compared to 1/1,450 currently for hospital births into air where CDC protocols are adhered to (3). Possible theories to explain this might be:
1) Inoculating the baby with mother’s intestinal flora at birth is protective;
2) Bath water dilutes GBS acquired during the descent among a multitude of competitive intestinal bacteria;
3) EOS is prevented by lower level of interventions and kangaroo care at water birth promoting maternal/fetal immune function.
From the data in hand, the most effective way to prevent EOS is to deliver a baby into very warm water.

Just Cool It - Athletes, and patients, know that overheating hurts a body’s performance.  A new device, called at various times the RTX, Core Control or simply The Glove, cools the body's core so that blood isn't diverted from the muscles to the surface for cooling. Mammals have specialized blood vessels in their palms and other hairless skin surfaces—ears, nose, cheeks and soles of the feet—that are designed to dissipate heat.  (Maybe this is why a cool cloth on the face and forehead feels so good during pushing!)  Heller and Grahn theorize that more blood, and thus, oxygen, is available to the muscles when the body doesn’t have to route extra blood to the radiators for cooling.  Cooling allows an athlete to recover from intense exertion quickly, allowing someone to do more work in a shorter period of time.  They now believe that the reason why pushing IV fluids can help with exhaustion isn't the minerals or the rehydrating, but rather the invasive cooling; they had noticed that if the IVs were kept on ice, they worked better.

Immersion in water in pregnancy, labour and birth (Cochrane Review)

The Cochrane Collaboration is an international committee of specialty-specific physicians who evaluate all known research in their area.  They conclude:

"Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth."

Try doing a search on "Related Articles" for some of these citations to get the newest studies!

Water births 'ease slow labours - 26 January, 2004 - BMJ article discusses benefits of the "birthing pool".

Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour.  [PDF text]
Cluett ER, Pickering RM, Getliffe K, St George Saunders NJ.
BMJ. 2004 Feb 7;328(7435):314. Epub 2004 Jan 26.

CONCLUSIONS: Labouring in water under midwifery care may be an option for slow progress in labour, reducing the need for obstetric intervention, and offering an alternative pain management strategy.

Study Shows Benefits of Underwater Birth By Hannah Cleaver

BERLIN (Reuters Health) Jan 22, 2003 - Giving birth in water should no longer be considered an "alternative" method restricted to specialist centres, according to European researchers who evaluated the outcome of more than 1500 births.

Drs. Albin Thni and Konrad Mussner, from the regional hospital in Sterzing in the South Tyrol region of northern Italy, compared data from 969 water births, 515 births in bed and 172 using a birthing stool.

After removing complicated births that required vacuum extraction, other manual help or epidural anaesthetic, the results show a clear advantage for water births, they report in the December issue of the German-language journal Geburtshilfe und Frauenheilkunde (Obstetrics and Gynaecology).

"Our results suggest that water birth is associated with a significantly shorter first stage of labour, a lower episiotomy rate, fewer perineal lacerations and reduced analgesic requirements compared with other delivery positions. Water birth appears to be safe for the mother and the foetus-neonate if candidates are selected appropriately," they write.

Average duration of first-stage labour was 381 minutes for women in water compared with 473 minutes for those using the other delivery methods. There was no difference in the duration of the second stage of labour.

The rate of episiotomy was significantly lower when the women were in water (0.52%) compared with 17.2% of those in traditional beds and 7.6% on stools.

Water births were not associated with an increase in perineal tears, which remained at 23% in all groups.

Of women having their first child, 58% experienced no lacerations during a water birth compared with 36% of those on traditional beds and 48% of those on a stool. None of the women giving birth in a pool needed analgesics.

Other factors examined included arterial cord blood pH, and maternal haemoglobin levels at baseline and postpartum. No differences among the three groups were found.

The researchers report that much criticism of water births has been based on ideas that are no longer valid, such as that the child might aspirate water and drown.

This can be ruled out, they wrote, as the reflex to breathe air is only activated once the child's head comes into contact with air.

"We believe that the water birth will lose its 'outsider' status and will, in the next few years, will take up a fixed place in obstetrics. It leads to minimal intervention and is a woman-friendly method and thus results in higher satisfaction of the mother," they conclude.

Geburtshilfe und Frauenheilkunde 2002;62:977.

Waterbirth Abstracts

Waterbirths: a comparative study. A prospective study on more than 2,000 waterbirths.
 Geissbuhler V, Eberhard J.
Fetal Diagn Ther 2000 Sep-Oct;15(5):291-300

CONCLUSION: Waterbirths and other alternative forms of birthing such as Maia-birthing stool do not demonstrate higher birth risks for the mother or the child than bedbirths if the same medical criteria are used in the monitoring as well as in the management of birth.

Effects of intrapartum hydrotherapy on labour related parameters.
Aird IA, Luckas MJ, Buckett WM, Bousfield P
Aust N Z J Obstet Gynaecol 1997 May;37(2):137-42

The results showed that nulliparas [first-time mothers] who used the birthing pool had significantly reduced operative delivery rates, a shorter second stage of labour, reduced analgesic requirements and a lower incidence of perineal trauma. In multiparas [repeat birthers] there were significant reductions in analgesic requirements.

 Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. [Medline entry]
Gilbert RE, Tookey PA
BMJ 1999 Aug 21;319(7208):483-7

"The risk of perinatal mortality for babies delivered in water is similar to the risk for babies born by normal vaginal delivery to women at low risk of adverse outcome"

The above article references a single case of a baby born with "waterlogged lungs".  I am wondering how they knew the water was from the birth tub rather than amniotic fluid?  Many babies are born with amniotic fluid in the lungs; clearing this is a normal part of respiratory initiation and happens uneventfully in a healthy newborn.

What the research says about waterbirth from the UK

They address the issue of babies who "drowned" or died from waterlogged lungs:  "Although there have been one or two reports of babies who have died of waterlogged lungs, this seems to have been because they were kept underwater for a long time after birth, rather than being brought to the surface immediately. "

For an excellent collection of research about pain relief provided by laboring in water, follow the "Related Articles" link from this abstract.

In 1987, women in a Copenhagen hospital were offered the choice of taking a warm bath in their first stage of labour.  Over half the women accepted the offer and found that they dilated at twice the rate of women who stayed dry.
[Warm tub bath during delivery.
Lenstrup C, Schantz A, Berget A, Feder E, Roseno H, Hertel J
Acta Obstet Gynecol Scand 1987;66(8):709-12 ]

Harper and Odent both offer an enormous amount of experience with waterbirth from all over the world. Odent is meticulous in his physiologic explanation of the initial breath, and they both offer research as well. Please read this stuff before you set your head on this option (birth in the water). It has proven to be extremely safe and is a wonderful choice to have available.

Birth under water.
Odent M
Lancet 1983 Dec 24-31;2(8365-66):1476-7

Unfortunately, even the abstract is not available online.

[Water births and the exposure to HIV].  [Article in German]
Colombo C, Pei P, Jost J
Pflege 2000 Jun;13(3):152-9

Because of the diluting effect of the poolwater, we estimate the potential risk for a HIV-exposure to intact skin as minimal and, therefore a potential HIV-infection as "low level" and to be unlikely. However, a risk for nosocomial HBV-infection is significantly

Enning Modified APGAR Scoring for Babies Born in Water

Enning Modified APGAR- Scoring for Babies Born in Water

Pretty cool huh?? Now you have babies in the 9 & 10 range again instead of 6 or 7.

Waterbirth Videos

I bought "A Clear Road to Birth", "Birth into Being: The Russian Waterbirth Experience", "Waterborn", and "Birth Joy and Raspberry Leaves" from this website.  My favorites are "Birth into Being" and "Waterborn".  "A Clear Road to Birth" shows a few empowering births.  The "Birth Joy" video footage is quite poor, but it's still good to see.

I bought "Born in Water: A Sacred Journey" from this website, the Andaluz Waterbirth Center.  Seven wonderful births!  This is another of my favorites.  This video helped empower me a great deal!  As I watched these women confidently give birth, the feeling that "I can do this!" grew and grew inside me.

This webpage is where you can order the wonderful "Waterbaby: Experiences of Waterbirth".  I don't own this one but was fortunate enough to be able to borrow it from another home/waterbirthing mom in my area.  I watched it by myself and then watched it again with my husband when he came home.  I would have watched it again, but I had to return it that same day I got it.  I rank this one right up with "Birth into Being".  This "Waterbaby" video is just about an hour with about half of it spent talking with Dr. Michel Odent, hearing his experiences with waterbirth and learning about his waterbirthing maternity section.  This video shows at least three births in water, two with Michel Odent.  It also has a section with Dr. Michael Rosenthal in California at the Family Birthing Center.  He shares some of his knowledge, and a few mothers talk about their experiences at the Family Birthing Center, comparing "land" hospital births with their wonderful "waterbirths".  This video is just about $70 (shipping included) but definitely worth it!

There is an Australian waterbirth video called "The Art of Birth: The story of four gentle births in water". It shows 2 waterbirths in a birth centre and 2 at home. One of the midwives involved is Shea Caplice, an independent midwife working in New South Wales.

Pain Relief in Waterbirths

Water Immersion and Pain Control in Labor

Effects of intrapartum hydrotherapy on labour related parameters.
Aird IA, Luckas MJ, Buckett WM, Bousfield P
Aust N Z J Obstet Gynaecol 1997 May;37(2):137-42

The results showed that nulliparas [first-time mothers] who used the birthing pool had significantly reduced operative delivery rates, a shorter second stage of labour, reduced analgesic requirements and a lower incidence of perineal trauma. In multiparas [repeat birthers] there were significant reductions in analgesic requirements.

From The Waterbirth Handbook by Dr. Roger Lichy & Eileen Herzberg:

When asked what was their most successful form of pain relief, women at West London Hospital who had had three or more children said that a warm bath was more effective than drugs.

In 1987, women in a Copenhagen hospital were offered the choice of taking a warm bath in their first stage of labour.  Over half the women accepted the offer and found that they dilated at twice the rate of women who stayed dry.
[Warm tub bath during delivery.
Lenstrup C, Schantz A, Berget A, Feder E, Roseno H, Hertel J
Acta Obstet Gynecol Scand 1987;66(8):709-12 ]

The John Radcliffe Hospital has just published some research that shows that women who have laboured and given birth in water were less likely to need drugs for pain relief.  [Water birth. Pooling information.- Select "Related Articles" for lots more references.] It seems likely that bathing in warm water is helpful in relieving pain during labour an may even encourage labour to progress more rapidly because of its soothing effect on stress hormones.

Heat Halts Pain Inside The Body - 7/5/06

The old wives’ tale that heat relieves abdominal pain, such as colic or menstrual pain, has been scientifically proven by a UCL (University College London) scientist, who will present the findings today at the Physiological Society’s annual conference hosted by UCL.

Dr Brian King, of the UCL Department of Physiology, led the research that found the molecular basis for the long-standing theory that heat, such as that from a hot-water bottle applied to the skin, provides relief from internal pains, such as stomach aches, for up to an hour.

Dr King said: “The pain of colic, cystitis and period pain is caused by a temporary reduction in blood flow to or over-distension of hollow organs such as the bowel or uterus, causing local tissue damage and activating pain receptors.

WBAC - Water Labor and Waterbirth for VBAC

OK, people, it's time for a new acronym - WBAC - Water Birth After Cesarean!

Some hospitals prohibit laboring in water for women having a VBAC.  This is not based on any particular evidence.  If the hospital requires continuous monitoring, they should have a waterproof continuous monitoring device.

Water is by far the safest place to have a VBAC.  The support of the water allows for 3 key safety supports for VBAC/;

  1.  the woman can tune in to what her body is telling her about her uterine scar
  2. the woman needs no other pain relief that would obscure her own ability to tell if her uterus was rupturing.  Not having an epidural also means she won't likely need a dangerous augmentation agent.
  3. water can slow down the action of the uterus allowing a gentler progression of the birth process

Water Immersion Increases Amniotic Fluid

Deep water immersion increased amniotic fluid volume by squeezing fluid from the mother's interstitial space in to her vessels, increasing the mother's intravascular volume and thereby increasing perfusion of the uterus and placenta, so the baby gets hydrated.

Water Immersion Reduces Blood Pressure

See also: Oligohydramnios

Deep water immersion reduces both peripheral edema and blood pressure in pregnant and non-pregnant individuals. The water pressure pushes extracellular fluid back into blood vessels, and peripheral vasodilation drops the blood pressure (obviously this part doesn't work if the water is too cold.) The effect lasts for some hours after the immersion. Tom Strong in Phoenix published data showing an increase in amniotic fluid volume after deep water immersion (at least shoulder deep).

There's a reference in Susanna Napierala's "Waterbirth a midwifes perspective" of an Unpublished abstract of Myra Smith, Effect of Warm Tub Bathing During Labor, Grady Memorial Hospital Atlanta, Georgia, 1987. "After studying thirty-one low-risk women, Myra Smith found that the mean arterial pressure and anxiety level significantly decreased after fifteen minutes in the tub and remained reduced (1987)".

WaterBirth for Large Women

I would be grateful if any body could help on the following:  There are a set of criteria for women being able to use the water birth.  Is there any reason to be concerned about maternal BMI and consider it as an inclusion /exclusion criteria? If yes, what cut off point is reasonable (BMI 30 or 35) and is there any evidence for it?   If NICE Antenatal guideline suggest women with BMI  more than 35 to be referred to consultant care (as high risk), can we assume the same basis for waterbirth?

I think it's fairly unlikely that there is any evidence for large BMI being contraindicated f r labouring and/or giving birth in water. Personally I feel it's extremely restrictive to exclude a woman with a large BMI from having this resource in labour, after all even large woman can have normal births! In fact anything that makes it more likely that an overweight woman has a normal birth the better- that way she is more likely to avoid the problems/complications she will be more at risk of if she has a surgical intervention. I can imagine that labouring in water would offer a 'large' woman definite advantages: buoyancy and support and easier mobility being several. Hopefully guidelines are only ever that and aren't translated into absolute 'allowed' and 'not allowed' which don't always appear to facilitate maternal choice.

At Maidstone, a DGH with a medium sized consultant unit, we offer waterbirth to almost all women, regardless of their BMI.  We also "permit" women with a uterine scar to use the pool, although we ask that they are first "risk assessed" by their consultant and our senior midwife, who is a waterbirth researcher. In reality, only a very few women are not "allowed" to use the pool. Our only real criteria for inclusion is that women are able to enter and leave the pool independently, they have a "normal" blood pressure and that they have not had pethidine within 3 hours.  They also should be in established labour.

I wholeheartedly agree that the mobility which the pool facilitates and the increased likelihood of a normal birth outcome, makes larger women ideal candidates for the pool, and that they should not be excluded unless there are other reasons for doing so.

I have also found that women with body image issues (which applies to some but not all women with high BMI) often feel more at ease in the water - they may feel a little less "vulnerable" in their bodies with the security of water. Fitness instructors often find the same thing with women who are much more comfortable going into the pool for exercise than working out on the gym floor.

 I have had lots of experience with women labouring in water, it
certainly is easier for larger women to move in the tub. A number of women have chosen to wear sports bras or t-shirts for modesty reasons.

So many thanks to all who responded to my query on water birth and BMI.  From your responses, there is no evidence against offering water birth to women of high BMI. I should say obviously, some of us seem to have more clinical freedom than the others.  In our unit we are fighting to keep the option open at least for women of BMI less than 35 not just under 30s.  We are told bigger ladies may be more at risk of collapsing in the pool!

I was having a look at the discussion and in the hospital where I was a  member of a Midwifery Led Unit, the exit criteria for weight was (and is) a BMI of 40 at booking.  Anyone below that BMI who is booked in the MLU has automatic access to waterbirth and in any case, weight is not part of the waterbirth policy in either the Midwifery Unit or the Obstetric Unit.

I have had several heavier than 250# moms who did wonderfully!! I find that it is the person's attitude, preparation, & general overall health that are the most affecting factors to a successful birth no matter where it takes place and weight is way down on the list of contributing factors.

Water laboring is very freeing, again for anyone, as you weigh 1/10 your 'land' weight. I have a Rubbermaid stock tank I loan to those who want to get into deeper water than their own bath-tubs. If you check at a farm store they will sometimes loan you one free of charge. Just attach a garden hose to the washing machine faucets. Clorox out the tub before and after use, fill with water to 95-99 degrees. Top it up with boiling water from the stove if it cools down before babe is born. Works GREAT!!! Your midwife/MD may want you to deliver out of the water so the decent of the babe can be controlled better. In water in a tub like mine, the best position for someone that is heavier is usually on their knees leaning forward against the end so the midwife can catch the babe behind you. This way gravity will work with you and the practitioner can reach the introitus better. (This having been said however--the best position is the one in which you can relax the best!!)

Leboyer Bath for Baby

Birth Without Violence by Frederick Leboyer (online version)

Well, if you can't arrange a waterbirth, you still might be able to arrange a Leboyer bath for the baby.

Purchase a plastic storage container the appropriate size. Then, if there aren't any complications and the nurses aren't busy, try the following:

The best place for the bath would be on the infant warmer/stabilet bed. It's got the heating unit over it so the baby won't chill. (a possible concern of the nurses) The "tub" can just be placed on the mattress and then the whole set-up is at a VERY convenient height for dad. The infant bed can be pushed up next to the mom's bed, which can be raised to an equally convenient height for mom so she can participate and still remain comfortable immediately post-birth. Put one of the blue chux from Mom's admit kit (bag in room) between the container and mattress so that any "sloshing" doesn't get the bed wet for baby. You can put one of the warmed baby blankets in the container as a "liner" and then use the edges of it as a soft washcloth. Once they've played in the water long enough, have Dad lift JUST the baby up out of the water, you can then whisk off the tub, wet blanket and chux and slide in fresh from the blanket warmer baby blankets and then baby is in a nice warm spot to get dried off.

As for the umbilical cord. Since at birth it is moist, there isn't any problem with cutting it short and clamping as usual before putting baby into the water. The reason we tell parent's NOT to tub bathe until after the cord has fallen off is, after the first 12-24hrs the cord has started to dry and re-immersing it in water can keep it from "healing" properly. But IMMEDIATELY at birth, there isn't any harm to immersing baby in the tub.

The "best" scenario for a hospital birth Leboyer bath is, at birth, have baby go directly up to mom on warm blankets. Let the labor nurse do her fussing (bulb suction, apgar assessing etc.) there while mom finishes delivering the placenta. If stitches are needed, you start setting up for the Leboyer bath while that is happening. If no stitches needed, hand baby off to dad, you set up the bath while the nurse is getting mom+bed put back together and then bath. Be sure to offer to take pictures while they're bathing the baby (especially ones where MOM + DAD are in the picture). You can get some GREAT shots of baby gazing up at dad and mom looking on.

AquaCranial(R) Therapy - An Exclusive Ocean Treatment Originated & Developed by Rebecca Goff & the Cetaceans. - what a lovely form of therapy!

Waterbirth Stories

This section has been moved to Birth Stories/Waterbirth Stories

Risk of Water Embolism

If the woman births on dry land, do you worry about water embolism if she wants to hop into the bath soon after the birth??? If not, why is this a different risk than staying in a waterbirth tub? Does it have something to do with time - if so, how long after birth does the risk of water embolism remain?

I think there probably is no real risk of water embolism; it was just something tossed out as a theoretical possibility (as in -- a meteor could come crashing through my roof today).

I think the idea is that the placenta could act like a plug and when it's lifted/pulled out of the vagina water could "rush back" inside and be pulled into the wide open placental bed.

Objections of course, are that the placenta doesn't usually "pop out', and the vagina and cervix are lax and well closed and the vessels at the placental bed should be tightly contracted by the time the placenta is expelled.

But -- I guess it could "theoretically" happen. It's also my understanding that it hasn't ever happened.

I find that most women are ready to get out of the tub/pool soon after birth - often before 3rd stage is complete and often these women are watered out by this time.

Yeah. This is our experience too.

In addition to the fact that water embolism is an imaginary concoction, which we seem to be in agreement hasn't ever happened, there's also the question of "what's the big deal if it happens?"

"Water embolism" is a contradiction in terms, because an embolus is a solid or viscous liquid. Water is neither. If a woman were to take on a volume of water per vaginum, it would pass right through the lungs without sticking there, and there would be no obstruction of bloodflow at all. Hence, no embolus effect.

It's conceivable that the "free water" in question could drop the plasma concentration of NaCl and thereby cause a degree of hemolysis, but this would not be life-threatening unless the volume of water were several liters.

I'd like to remind you all, from whom I draw inspiration, how much you sound like obstetricians when you say things like, "well, the risk may be very small, but might as well be safe," when dealing with imaginary threats.

Water embolism doesn't seem to happen with amnioinfusion, given the way everybody is going happy happy joy joy about that. I can't see why it should happen if you're just sitting in the bathtub but not if someone is actually pumping water into the uterus.

Amniotic fluid embolism is a recognized risk of amnioinfusion, but I don't see any OB's railing against its use because of the very low risk of AFE.  How comical it is that they rail against the theoretical risk of AFE in waterbirth but ignore the AFE risks inherent in standard OB interventions.

Respiratory failure associated with amnioinfusion during labor.
Dragich DA, Ross AF, Chestnut DH, Wenstrom K.
Anesth Analg 1991 Apr;72(4):549-51

Dibble LA, Elliott JP. Possible amniotic fluid embolism associated with amnioinfusion. J Matern Fetal Med 1992;1:263-6.

Just to add one more story to this wonderful discussion.  Michel Odent told me that when he wrote that 1983 article, the outcomes were so good that he was asked to put more medical risks in it.  So, he made up the whole "water embolism" thing.  He then went on to say that to get a water embolism, you would have to sit on a fire hydrant at full blast.

I have a midwife friend who allows all placentas to come out in the water, leaves them attached to the baby and then leaves some sterile scissors with the daddy. She tells him to cut the cord whenever they feel comfortable to do it.  She relates that is usually about 12 hours in every case.

I often conduct education sessions around waterbirth for midwives (and have done a presentation for obstetricians, neonatologists and others at one tertiary hospital considering the use of water for labour and birth following publication of articles related to near drowning) and this question always comes up from those midwives (and doctors) in discussions who are not familiar with using water for labour and birth.

Anecdotally, I hear midwives say this theoretical risk of water embolism is one reason why they are scared of waterbirth and will not offer it to women [but these people have a rather large range of issues with physiological birth anyway usually]. I have heard doctors say the same thing - in every instance I ask them to let me know of any instances they have heard of this happening and where it is reported. There appears to be no reported cases, as you say.

At out new hospital (tertiary referral unit, 4000 births per year) opened in Feb 2009, we have 12 labour and birth rooms and every one of them, including the HDU rooms, have a bath or birth pool. I have initiated ongoing data collection round the use of these pools and baths for labour and birth. In this city, the only place for birth, apart from home, is in the tertiary maternity unit [sadly]. One of my aims is the reduce our CS and intervention rates and increase the normal birth rates and the use of water for labour and birth is one way in which we might support women to birth physiologically [notwithstanding the considerable difficulty achieving this in a tertiary unit!!] One of the key targets is to work with the midwives to increase their knowledge, competence and confidence to do this.

I think we are lucky to have managed to get a bath or pool in every room. Many maternity facilities have to struggle long and hard with everyone from the plumber, electrician, infection control officer to the health and safety people [and many in between and beyond] just to get one bath/pool - all because these people do not have an understanding of the impact of the environment of birthing women and put up barriers, such as the theoretical risk of water embolism that has absolutely no evidence of existing, it is such a battle.

I think that any references to this theoretical risk in textbooks are in relation to trying to dispel the myth which is persisting in the minds of some. See the excerpt below (the second edition is due out before the end of 2009) from:

Maude, R. and Caplice, S. (2006). Using water for labour and birth. In: Pairman, S., Pincombe, J., Thorogood, C. and Tracy, S. Midwifery Preparation for Practice.

Third stage and blood loss

There have been no documented cases of complications in relation to the third stage being conducted in the bath. In 1983, Odent proposed a theory that water embolism could be a risk factor. This has now been largely dismissed, and Odent himself has withdrawn the hypothesis, admitting that it was unfounded and a mythical concept.

Concerns about Alleged Risks

Won't the Baby Drown?

It is primarily the air touching the skin and cord that are signal to the baby's body that it should start to breathe.

Many birthcare providers I have spoken to about this issue feel that if there was placental separation and the baby was in distress as a result, it would be easily and immediately visible to the midwife or doctor, who would bring the baby right out of the water. Also, regarding the time for the baby to be kept in water or brought out to the mom: Rapid emersion, when the baby is brought up and out of the water within a minute or two, is the most common approach. Right after delivery, the mother is usually anxious to hold and touch the baby, and so the "slow emersion" method would be frustrating to her because she would not be able to touch and hold the baby right away.

There are a couple of reviews about when to bring babies to the surface at a waterbirth.
Johnson P (1996) To breathe or not to breathe? Br.J. Obs.Gyn - can't remember the volume number/pages but it was April or May last year.
Rosser J (1994) Is water birth safe? The facts behind the controversy. MIDIRS. vol 4(1).

What about aspiration pneumonia from meconium aspiration

Isn't the current idea that aspiration pneumonia occurs before birth, given that suctioning on the perineum doesn't seem to help much.

In the case of the mother, the risks include: infection from exposure of the uterus to maternal feces

I read somewhere that statistics showed a lower infection rate for water birth, probably because all the water dilutes everything.

Possible Risk of Mom and Baby Staying in Tub with Unclamped Cord and Attached Placenta for 35 Minutes

This weeks Lancet carries a report from a London teaching hospital (well known to be sympathetic to both home and waterbirths). The birth was at home in water. Water temp was maintained at 36 Celsius. She wanted a physiological 3rd stage. The cord was left intact and baby went to the breast. 3rd stage lasted 35 minutes. No immediate problems.

Subsequently baby was plethoric and peripherally cyanosed and admitted to hospital. All investigations and observations were normal, except for marked polycythaemia - PCV >85%.

Authors postulate that mechanim is that in prolonged physiological 3rd stage in warm water that there is a large progressive placento-fetal transfusion, as cord vessels remain open in warm water. They advise clamping cord after ~5mins in these circumstances.

Babe needed dilutional exchange transfusion with albumen.

Don't think you'll find it in Lancet WWW version as it's a "research letter", but will be listed in "contents".

But what's their theory for the cause of polycythemia when in occurs in an "air" birth?

seems to me that polycythemia shows up on very rare occasions; if it shows up more often in waterborn babies than in airborn babies then the theory might carry some weight. Interesting...

(I don't recall any case of polycythemia -- might be something to ask global-maternal-health ( -- the waterbirth group -- with barb harper)

What are others' thoughts on this theory? It seems like pure speculation to me. Another case of the one person sample population being used to discredit an "alternative" birth practice.

I've attended many waterbirths with physiological 3rd stages and know of some midwives whose practices are almost entirely comprised of such cases, and I don't know of any resulting polycythemia. The only case of polycythemia in one of my clients' babies occurred after a hospital delivery where the beautiful, fat, pulsing cord was cut within moments of the baby's birth. Had this woman chosen to deliver at home, I'm sure my practice of waiting for the placenta to deliver before cutting the cord would have been blamed for the condition. (When a complication occurs in the hospital, authorities assume it happened DESPITE the location of birth. When the same complication occurs at home, they assume it happened BECAUSE of the location of birth.)

I think I'm going to suggest adding the categories of waterbirth and time of cord-clamping to the NM quarterly report forms so we can collect some statistical information on this issue.

Water Temperature

Keeping the baby warm at birth is vitally important. During the first five minutes after birth, the blood vessels to the baby's lungs have to expand as part of the conversion from umbilical oxygenation to "adult circulation", i.e. getting oxygen from the lungs.  If the baby is cold, the blood vessels to the lungs will not expand properly, causing complications.

Once this process has happened properly, it's less important to keep the baby warm, but extended cold periods could still cause hypoglycemia and related complications.

If you read the protocols pages carefully, you'll notice a distinction between temperature requirements for labor and birth.  For labor only, the water can be any temperature that is comfortable for the mother, as long as it's cooler than 101 degrees.  For birth, the water temperature should be between 95 and 100.9 degrees.

I was just at a birth where the midwives said to keep the water at 85, 90 at the highest temp...it was so COLD!!! They said, Anne Fry, Midwife said to keep the water at that temp.  I would say, 97-99...IF it is too warm for the mother, holding ice, drinking fluids, add some cool, get out, take it moment to moment...the water at 85-90 is TOO COLD for the baby!!!  When I started working with this modality in 1987...use to be, 99-102 degrees...now over 99 is considered TOO HOT!  Best, for the comfort of the mother...women are warmer during labor anyhow...but the 87 degree water for a transitional woman was too cold for her!  She made the comment, so we kept adding hot water.  Hope this helps.

I agree!  In addition to wanting the water warm enough to keep baby warm at birth, I think warmer water is more relaxing to all the muscles, and it increases oxygenation to the uterus. The increased uterine oxygenation increases oxygen transfer to the baby and decreases uterine muscle spasms from lower oxygen levels.  For moms who like warmer water in their baths, I suggest 100 degrees; for some reason, they do NOT seem to feel overly hot.  If they do, the quickest way to cool them is to have them hold ice or put their hands in cold water, as there are special heat radiators in the hands. [Mammals have specialized blood vessels in their palms and other hairless skin surfaces—ears, nose, cheeks and soles of the feet—that are designed to dissipate heat. See Just Cool It]

Anne Frye had this in her Holistic Midwifery (Vol II: Care During Labor and  Birth, 492):

Cool water results in babies who  are more actively involved in their own birth, exhibiting better muscle tone and  more movement as they emerge.  These babies seem optimally conscious and  aware at the time of emergence from the water and stabilize more quickly than  those born into body temperature water or hotter, who tend to be limp and  lethargic.  Several newborn reflexes are elicited during emergence in  slightly cool water.  The baby will reflexively push himself out with his  feet as he emerges.  In addition to the diving reflex, the asymmetric tonic  neck reflex (ATNR ) is triggered as the baby reaches out with one arm and bends  the other.  The baby will also flex into a fetal position.  The  symmetrical tonic neck reflex is then triggered as the baby cross crawls with  his head extended, all of which result in the baby spiraling out.  If all  is well, the midwife should not touch the baby as he emerges, allowing this  dance to proceed.  At the time of birth, the undisturbed mother reaches  down to touch the head as the baby spirals out and the baby, with the assistance  of the ATNR, turns to face his mother as she touches him, they make eye contact,  mother lifts the baby under the arms and brings him to her chest.  A  healthy, unstressed newborn, when gathered to his mother enface against her  chest will turn his face and anterior body to his right and the mother's left  side (over her heart).  Unhealthy babies tend to go to the opposite side  (Enning, 2003b; Polin & Spitzer, 2001).  After birth, immerse the baby  to the nipple line with the heart under water; the increased water pressure  helps increase the blood volume in the heart chambers.

Cultural Differences in Waterbirth Practices
by Gail Hart December 1, 2017 [Editor’s note: This article first appeared in Midwifery Today, Issue 124, Winter 2017.]

It's my feeling that being in the tub is supposed to be as comfortable for the woman as possible.  If she's too hot, and certainly if she's feeling enervated, then you can cool the water and meanwhile cool the mom with cool washcloths, a fan, and cool drinks.

re: For babies who are slow to breathe, you can dab cool water around the mouth.  This stimulates acupressure points to encourage breathing.  I believe this is why animals lick their newborns' faces.

The baby cannot tell that the mom is in a warm tub unless the mother's temperature goes up.  It makes sense to monitor a woman's temperature if she's feeling overheated and take more aggressive steps to cool her down if necessary.  A baby's heart rate goes up if they're overheated, and an attentive midwife will notice this and take corrective action.

If a woman feels enervated in the tub, then you can cool her down a number of ways .

I completely disagree with the European notions that warmer water slows labor.  It may seem to reduce contraction activity by eliminating the adrenaline contractions (which only impede labor), but they seem only to increase the oxytocin contractions, which are the ones that get the job done.

Many multip births have a rapid descent down the birth canal, with very little time spent with the scalp on the perineum.  It's really hard to believe that this is going to cool the baby's scalp in any kind of significant way while the head is still inside.

It's my understanding that the European waterbirths of the 1970s were done in Michel Odent's facility, and he brings the babies up fairly quickly, although smoothly.

I agree that the water temperature should be whatever the mom finds comfortable.

Concerns about Shoulder Dystocia or Very Tight Cord

On one birth story I watched the cord was wrapped super tight and they had to cut it before the body was birthed. I am assuming you couldn't do this under the water or else the baby wouldn't have any oxygen. I am guessing you would have to stand to cut the cord and deliver the body.

Anyone have any experience on this?

From my reading and my limited waterbirth experience, I've come to believe the following:

In the relatively weightless and frictionless environment of a waterbirth, the baby will either rotate itself away from the resistance of the cord or do its own somersault maneuver, which is a way of birthing the body without cutting a very tight cord.  This is the best way of keeping the baby's oxygen supply intact while the baby figures out the breathing thing.

You can only get the cord around the neck if it is nice and long.  In the book "Waterbirth" by obstetrician Yehudi Gordon and exercise instructor Janice Balaskas, Dr. Gordon tells practitioners not to even feel for the cord and to just let the baby come out in the water tub and then unwrap it.


Just got in from the International Waterbirth Conference.  Barbara Harper outdid herself this year.  The speakers were truly international and the new videos and ideas were fantastic.  Meconium in the water was largely thought to be handled best underwater.  This came from physicians and CNMs as well as CPMs and LMs.  Lots of good reasoning and anatomical explanations.

Waterbirth and Group B Strep (GBS)

Does anyone have any thoughts on a waterbirth for a woman who is Group B Strep positive (who makes informed choice to decline antibiotic therapy)?  Extra infection transmission risk to baby from being born in water or not?

As someone who studied microbiology, I would have thought that anything (such as water) which diluted/washed off vaginal secretions/amniotic fluid present on the baby's face would tend to reduce the risk of infection, especially as baby won't inhale until above the water line. Not research based, but logical I'd have thought.

Waterbirth and HIV

[Water births and the exposure to HIV].  [Article in German]
Colombo C, Pei P, Jost J
Pflege 2000 Jun;13(3):152-9

Because of the diluting effect of the poolwater, we estimate the potential risk for a HIV-exposure to intact skin as minimal and, therefore a potential HIV-infection as "low level" and to be unlikely. However, a risk for nosocomial HBV-infection is significantly higher. We recommend wearing long-sleeved gloves, waterproofed garment, and HBV-vaccination to all HCW.

I sent a question about the possibility of HIV infection during waterbirth to Dr. Rosenthal who has a Q and A page link from the WB web page and got the attached response. I had never been worried about it until I ran into a doc who said she wouldn't do them because of this "risk". Now I feel better informed and am sending her a copy. It would be great if she decided to offer this option in this area (Mt. Shasta, CA). So far no other docs do.

Date: Wednesday, 19-Mar-97 08:58 PM

From: Dr Rosenthal             \ Internet:    (mrmd@earthlink.net)

To:   Troy Taschereau          \ Internet:    (troytash@ptw.com)

Subject: Re: Fwd: HIV risk
HIV is a very fastidious virus, meaning that it has a very hard time surviving outside of its preferred environment. You can't get it from a toilet seat or from any contact that is not intimate and that would allow rapid entry into the blood stream, such as through break in the skin. It would never survive contact with bath water.

Hepatitis virus is another story. It does survive in varied conditions. Even so, there are no reported cases of hepatitis transmission at water birth.

Fear of HIV transmission is a pretty weak excuse for not wanting to participate in water birth. If anything the water would provide a barrier to transmission that is not available in a hospital delivery room. It is not uncommon for a birth attendant to get fresh blood in a "surprise" splash or squirt at the time of birth. When the mother is in the tub that blood goes into the water first.

I always HIV tested my patients during prenatal visits and that provided 99. 99+% assurance that I wasn't going to get exposed.

Third Stage / Placental Delivery in Waterbirth

[Summarized from a discussion on the list in November, 2002.]

Can anyone here point me in the right direction for evidence that a 3rd stage in water is safe?  My midwife told me I would have to leave the pool to avoid water embolism.

There's a section about this in Waterbirth Guidelines.

From  RCOG Statement on Birth in Water

"Consider leaving the pool for the third stage Warmth has a relaxing effect on uterine muscles that could, theoretically, lead to increased bleeding after delivery of the placenta or possibly retained placenta. The amount of blood lost during delivery may also be difficult to estimate when diluted in the birthing pool water. Also, if the placenta is delivered under water the combination of vasodilatation and increased hydrostatic pressure could theoretically increase the risk of water embolism. Again, this is a theoretical risk and there is no evidence about whether or not it is a real concern.

Until further evidence becomes available it might be prudent to advise women to leave the pool for the third stage. "

In other words cover your behind practice means get em out.  I think if the risk is theoretical my inclination would be to decline if I felt I wanted to remain in the pool.

At the 1995 International Waterbirth conference in Wembly, Michel Odent said he invented/dreamed up some theoretical risk in waterbirth when writing a medical paper for fear that his obstetric colleagues would negate the whole article unless he came up with some "down" sides.

The waterbirth video used for training purposes at the John Radcliffe Hospital, Oxford, has a pool placenta birth - and this is common practice up

Staying in the water after birth?  Third stage in water?

Fainting in the Water

I have attended many waterbirths, most without incident.  Just lately we've experienced 4 women who have birthed beautifully in the pool, had little or no blood loss, birthed their placenta, and then promptly fainted.  All has been well but it's getting to a point where I'm going to have to start pumping iron just in case!  Dragging an 80kg woman and her baby out of the pool in the middle of the night isn't my idea of fun, and while the women have all been fine, their partners might need some counselling for a while!  (Just to clarify, this is not a case of PPH, there has never been significant bleeding associated with any of these situations). My partner and I don't want to start insisting that women leave the pool immediately after the birth of the baby, but I'm wondering what other midwives do in this case?  Is it common practice to exit the pool soon after the birth of the baby, or do others support women to birth the placenta in their own good time, wherever they feel comfortable?  Keeping in mind what Michel Odent says about that time, we should really be disappearing into the wallpaper and just letting a woman get to know her baby, with no focus at all on the 3rd stage, so hauling her out into the cold just doesn't seem right to me.

Blood pressure can be very funky in the hours shortly after birth.  During pushing, she's got huge adrenaline levels going, which raises her blood pressure.  Then, after the birth, her adrenaline levels fall, and her body starts shedding all that extra fluid she put on during the pregnancy.  You know . . . when women start "peeing like a horse".  All of this can result in unstable blood pressure.  My practice in general is to get a woman to stable position within about 15 minutes of the birth, so she doesn't need to be moving around during the time when blood pressure is most changeable.  This is even more important when she's been laboring in the water, which pushes fluid out of the tissues and into the blood stream, another wild card for blood pressure, especially if she hasn't been drinking enough during labor.

Midwife Equipment

The 'Howes Birth Mirror' is a new design by midwife Virginia Howes that provides the visibility you need without the hazards of glass or the sterilization challenges of plastic mirrors.

My waterbirth kit list is (in order of importance!)

Torch and mirror (Torch is quite small and unobtrusive rather than million candle industrial size one I see in a lot of hospitals!! and my mirror is a mirror tile from the bathroom dept of IKEA which should satisfy and health an safety worries as is has no nooks or crannies to breed bugs!)

digital thermometer (mine is just a cheap one - you can check mum and water temp with it - I don't check room temp - you would want it warm anyway)

Change of clothes - I always get soggy arms and boobs and have on one occasion climbed in the pool to get better access!!!

Some of my colleagues use long gloves - i don't.

Midwife Technique - General

See also: Third Stage for Waterbirth

A few weeks ago I had a really great conversation with Barbara Harper on this  very subject of cords. I was telling her that I was teaching my apprentices that you don't have to touch the cord to know when it stops pulsing, especially with waterbirths, which is pretty much all I do. What I have noticed is that  every time the baby starts to give a little cry, it seems that mom is having a ctx, and then when the placenta is full off, that is when we see a good long cry, and mom gets "the Look" and says hmmmm... I think I felt something.

I also know from experience that water babies don't start to "breathe" like land babies. They are pink with good heart tones, but irregular resps. With each cry, they start to breathe more regular till that final good cry.  I was telling Barbara all this as my apprentices were having a difficult time with this as I generally cite studies as to why I am so hands off, and for this I  had no studies, just what I know and am comfortable with.  Well Barbara proceeded to tell me that there is a good amount of research out there being done combining neonatal and hyperbaric (diving) studies explaining what I am seeing. The mechanism is as follows and supports that we should not be touching cords or baby faces unless absolutely necessary.

First- in land or water births the stimulation of the trigeminal nerve which extends into the baby's cheek area, signals the shunts in the baby's heart to close, moving the respiration system from a maternal-fetal to a pulmonary  system. You want that fetal-maternal system to be working as long as possible so don't stimulate it unnecessarily.

Second- when the baby's head breaks the perineum or the water, the change in  air pressure changes the blood ph by changing the cellular pressure gradients and activating the NA and K+ ion pumps. This in turn, changes the ph of the cerebrospinal fluid which triggers the release of a hormone ( I don't know the name) from the hypothalamus, which in turn signals the shunts in the heart to close, and brings about a SLOW and GENTLE change to pulmonary circulation.

Third- with each ctx., 15-20 ml. of blood moves from the placenta to the baby and even minor third party touching can disrupt this process.  When the placenta finally comes off the wall it is estimated that close to 60ml. of blood goes to the neonate. We have known for awhile now that early cutting encourages jaundice, and now we can see why. It is estimated that the baby gets anywhere  from 120 to 200ml. of  needed vit. K rich blood if this process is left undisturbed.  Anyway I was THRILLED to know that this research was going on.  It is being done by a doc at Columbia in NY and I can pass it on if you would like. I also have to thank Barbara for sharing all this with me.

I often agree with you and have felt the same thing--- but I do see much more TTN on babies that have a lot of mucus and can't clear it.  The best way to clear it is to have good cries and suction if necessary.  Not every baby is wet== and not every baby needs suction-- but some really do.

we still agree! Every baby is unique. Crying and/or suctioning are things which some babies need.  (I do carry a bulb syringe and delees. I don't use them often, but i got 'em) I think though --- that we might just see babies doing better at handling the transition to air  breathing, if we allowed them to handle it at the pace they were designed for -- a more gradual 30 sec  - 90 sec process -- rather than the more rapid process we can "stimulate" them to attain.  Laid head downward in a draining position, lightly handled (not rubbed and flicked) -- just allowed to rest for a moment -- the baby is designed to begin the transition-to-breathing process with very shallow, almost imperceptible respirations, and to gradually breathe more deeply as his lungs and alveoli expand;  within several cycles he is generally breathing well and may do a deep inspiration-cry.

There will be exceptions -- the kid who is howling as his head is born etc. -- but generally the process is slower than US-trained docs and midwives are taught to allow. It ain't very long -- but it can seem long to those of us who were taught to instantly rub up and dry off babies --- and it DOES need to be interfered with if we have a kid who shows he isn't doing well -- or who is born in bad shape --  but I think the kids might be better off in the long run.  The natural process lets kids self-expand and self-adapt during that first half-minute or so while the placenta is still functioning and supplying the baby with oxygenated blood and his normal blood-volume. When his is fully breathing well he will often/generally cry on his own -- or if needed we can stimulate him then. I just wonder whether our interventions in those initial 30 seconds or so might be causing some of the problems we sometimes see with poorly expanded lungs, wet lungs etc.

I was thinking about this recently when remembering Dr Leboyer --when was that --mid to late 70s?  He advocated "minimal handling of the baby, low lights, quiet, for the first minute or so - and is famous for the "leboyer bath" -- allowing the baby to relax in warm water just after birth. Changing standard american practice from harsh lights, routine head-down-hangs, and even spanking the baby, wasn't too hard. But the other part of his advice has been almost forgotten - and seldom implemented -- letting the baby adapt WITHOUT STIMULATION during that first minute or so. Many of Leboyer's recommendations were pretty rapidly adopted even by the medical unity --- not just because it was clearly a more "humane" way to deliver a baby -- because he was able to document the health advantages.  I think my next project is gonna be studying those physiologic changes in the first minute of life -- and trying to see how we can best help this process.

It seems to me that the most important issues are:

- Safe temperature regulation, i.e. lower temp whatever is comfortable for mother, but don't go above 37 - 38C
- Water hygiene if the water was not freshly drawn, i.e. check it's not manky stuff that's been sitting around untreated for a fortnight.
- Monitor with waterproof sonicaid or get mother to raise belly out of water to use normal sonicaid or Pinard.
- Get out if any suggestion of foetal distress in case baby gasps when born
- Baby either all in the water, or all out of the water, for birth - not part in, part out, in case sensation of air on body stimulates it to breathe early.
- If any complications once head is born (shoulders, tight nuchal cord) mother can stand up in the pool.  Action of stepping out of pool apparently frequently resolves stuck shoulders.
- If baby born in water, bring to surface immediately and keep warm
- Be aware of issues regarding third stage in water and possible risk of overtransfusion of blood to the baby through dilated cord vessels.

 "Water for Labor, Birth and Beyond" A 12 CEU's course approved for ACNM/Nsg/MEAC credits This is an educational journey into the realm of water for professionals wanting to incorporate WATER in their prenatal or intrapartum services, the course covers from prenatal water exercises to waterbirths, implementation, protocols, and benefits. This is more than a workshop this is an experience in the tropical waters of Florida. In The Florida Keys August 5 to 8, 99 In Panama City Beach in September 16 to 19, 99

Contact Marina Alzugaray of the CoMadres Institute for more information.

CoMadres Institute is based in the Florida Keys, directed by Marina Alzugaray a midwife with over a 15 years of waterbirth experience and developer of the American AquaNatal exercise program.  Marina is an international speaker and author who has had a long relationship with dolphins in the wild.

CoMadres Institute is dedicated to the enhancement of women and family health through the art and science of midwifery.  CoMadres has an international scope with a multidisciplinary board including Michel Odent, Margot Early, Carol Lankton, Gloria Medcalf, Sakae Kichuchi, and Anne Davenport.

There's a midwife in Florida who teaches midwives about waterbirth:

The educational program is given in a retreat style and lasts 4 days in the beautiful Florida Keys where we can go snorkeling and have fun in
Key West, too. It is approved for 12 CEUs for Nursing and ACNM/MEAC. With 3 hours of AquaNatal prenatal water exercise program, 4
hours on labor and birth including dealing with common complications. The rest of the education program deals with water care promotion,
global overview of water care, strategies for implementation, hospital protocols, CDC recommendations for tubs, maintenance, etc. For more
information contact:

Marina Alzugaray, CNM with 14 years of experience as a waterbirth midwife and also a diver.
PO Box 420180
Summerland Key, FL
33042 USA
(305) 744-3370

[NOTE - These courses are apparently conducted in sea water, so Marina might be the expert on the safety of ocean water or sea water during pregnancy.]

If you need more room in the hips for the baby to descent or rotate just before birth, a mom in a birthing tub can "straddle" a stepstool to hold her femurs wider without too much effort, especially if she rocks a bit to "jostle" the baby through.

Does the Midwife Get Into the Tub?

I am curious about the technicalities of doing water births.  Does one  lean over the tub, do the tub side walls hold the weight or do people climb in the tub also.  Is it hard on the back to lean over and then how do you support the perineum during the birth.  What position(s) can the mother be in?

I try not to lean. I usually pull a chair up next to the tub and sit near the mom. Leaning over the tub is a drag -- very hard on your back. better to kneel beside it if you need to.

some of the blow up pools will give way and let water slop over. some are more rigid. The non-blowups are firm and no problem, will usually hold the full weight of someone sitting on the edge.

I never get in the tub.

I don't support the perineum at all during a waterbirth.  I verbally coach mom, she can use her own hands to give a little
pressure if needed. There is generally no need to give perineal support -- in spite of what we are taught --  Peris do fine without it!  The incidence of tearing seems to be the same or lower as air birth.  Just let mom do what she needs to do -- concentrating on relaxing as the head is born, and then gently bringing her baby to the surface. Coaching a mom to catch her own baby is the neatest thing!

On rare occasions I may put my hands in to direct shoulders or something. I try to stay out unless really needed.  If delay with shoulders it's best to get mom to stand up anyway. Usually that takes care of things.  If it doesn't then mom steps out of tub to the chair or floor space beside the tub. It's really hard to do any maneuvering under the water (too much buoyancy, difficult to get any purchase).

Moms can be in any position they want. But this brings up a thought. Some think they see more tears in their waterbirths I'm wondering if maternal position might contribute to this. When in the water, a mom can really open wide her legs, she can be in the equivalent of a full squat and be quite comfortable. I think this might put more stretch on the perineum and maybe we should be watchful and remind moms to keep their legs a bit closer together.

In our experience, we prefer the inflatable tubs where the sides are three rings of inflation and when inflated are about 8-10 inches thick.  They will support MILD leaning, and the midwives can usually manage to lean over without spilling the water.  The mother however, can get completely unconcerned about spillage and if she feels like leaning too much on the sides then you will have a wet floor!  We like a big sheet of visqueen under the pool for that reason.  We do not do perineal support in water births because you just can't reach it.  We do reach in to help the baby to the surface if needed, though usually the mother will do that.  Our support is mainly to keep the baby's body in the water for warmth and the face just out of the water to breathe. We've never had sticky shoulders in the water, which I think is just luck, but would surely require quick thinking and a possible trip into the tub.   For labor comfort, the moms try lots of positions and one of the favorites is stretched out in the water with the belly down and her arms draped up on the sides of the pool.  It's like lying on her stomach but with no pressure on the belly.  For delivery, most do a semi-reclined, semi-sitting position.  We've had one who got over on her hands and knees but then the baby came out above the water!

I my mind, almost ALL births are hard on the midwife's back!  That's why I love training apprentices.  The hardest thing about the water births is that you can't see what is happening as well as you can in the air, or on the bed. So, you have to trust more, and just peer down into the dark, wiggly water til something looks familiar.

i love the idea of pulling up a chair to the tub to save my back. duh, bet i'd stay drier, too, not kneeling on the floor.  getting drenched is my biggest problem.....

i haven't noticed more lacerations with water births but i have noticed a strange phenomenon in the freestanding tub, that the woman in there alone seems, i don't know, awash, and it's hard for her to get in a really good position to push since there's nothing solid to hang on to, especially for primips.  (by far, if my intending-to-water-birth-clients change plans at the last minute it's because pushing is more challenging in the tub.)

so, my favorite position for water birth is for the partner to be in the tub too, seated, legs extended, leaning his/her back against the side of the tub. mom sits on his/her lap, with her back against partner's front, in a sort of semifowlers, partner's arms encircling.  then, there's an extra set of hands/arms for bracing against,  partner gets to feel the intensity of pushing from closer up, mom can melt onto partner between contractions, and when she lifts the baby from the water (i basically keep hands off, too), they all three get to be en face.  awesome.

A good trick during pushing is to have 2 helpers (one on each side) with a big sheet or blanket under you lift you up in the water so you are kind of weightless, it really helps.

I think the baby's face should be lifted to the air immediately and that a bit more stimulation than usual is required to get them to inflate their lungs. Then the hard part is..... 1) getting Mom to leave her baby's body in the warmth of the water. Mothers want to hold the child to her heart which is in the cooler air ( I do not fill tub above her fundus. This allows room to suction if mec necessitates moving her to hands and knees in the tub).... 2) Delivering the placenta....either standing in the tub with a metal bowl floating/held between her legs ...or get her out and deliver placenta on land. The latter makes pp blood loss assessment and management much easier!

I personally have never gotten in a tub with a laboring woman. Some do. I just lean over the edge with short sleeves and shoulder length equine delivery gloves on. Also have immersible Doppler.

Do the Tubs Slow Down Early Labor?

There are various theories about good times to get in the tub.  Michel Odent recommends waiting until the mom feels like she needs more help with the intensity of labor, and then starts filling the tub.  He says the woman is typically 6 cm when she gets into the tub and usually gives birth within a couple of hours.

In my own practice, I do like to keep a woman active, squatting, walking, carrying on the activities of daily life until her labor is very well established and working on an even pace.  In other words, the contractions are long and strong and close together.  If I check for dilation, I like to see a woman at 5cms or better if it her first baby, before encouraging her to use the bath. But that parameter is bendable depending upon each individual woman. One of my clients was having her first baby and she had been induced with prostaglandin gel on her cervix.  She had also done castor oil before coming into the hospital.  So, the combination of both of these things made her contractions almost intolerable right from the beginning.  They were long and strong from 1cm on.  For her I recommended a bath after dancing, squatting and walking for over an hour.  She got in and four hours later had a baby.

So, it is hard to judge with hindsight whether or not the water actually "slowed you down."  It may have, but I always find that your mental ability to focus, turn off all other thoughts and relax are much more important than where you are physically within the birth environment or physically. I tell women that birth happens between your ears, not your legs, illustrating, as you pointed out, that many other factors come into play, not just the water.

My usual recommendation -- subject to mom's whims in labor -- is to use the pool for late dilation/transition and maybe those first few kinda-sorta-pushy contractions. Then I usually suggest getting out to go to the bathroom "one last time before birth", and mom can push a bit on the toilet. When we start to see some head, then we make our way back to the tub for the crowning and birth.

For multips, it's OK, but for a good portion of primips, the early pushing seems to go better out of the water (and I LOVE the toilet for this!)

We do a lot of in and out with the tub. I know others who get in and never get out. I think there are advantages to using the water interspersed with walking, toilet/stool, standing etc. etc.

I use a small exam light with a flexible head. I aim it into the water just in front of the woman's perineum, but have the head low enough that it is not shining in the eyes of the couple or really lighting up the room much. Then I can see everything clearly. We happen to have a white tub, so once you aim the light straight down at the bottom of the tub, the reflections light up the whole underwater area. You could do the same thing with a strong focused flashlight beam -- do not point it at the perineum, but point it at the bottom of the tub just in front of the woman. The light spreads by refraction in the water and reflection from the sides of the tub (obviously light colored tubs spread more light).

I also find that I have to do very little during the actual birth. We have a very small padded stool (about 6 inches high) that I kneel on next to the tub. I am perpendicular  to the woman, kneeling next to one of the long sides of the tub. Because I am right handed, I like to be on the woman's right side. Luckily our tub is open on three sides, so we have a choice.

Most women seem to naturally assume a semi-sitting position, some partners want to go behind them as someone else described. Our tub has handles on both sides about halfway up, so sometimes women grab hold of those to get some  leverage. Our tub also has these cut outs below the handles that can work like stirrups to put your feet in, if the woman is short enough. The handles and the cutouts can help a lot. Of course those of you using inflatable have none of that.

With the gentle light shining to illuminate the perineum, I can coach her as she births the head. One other trick with the light. If she wants to squat, I still want to see if there is progress, so I slide a small mirror onto the floor of the tub (right under the perineum) and shine the light into the mirror. The light reflects onto the perineum and from the right angle, you can see everything.

I do like to still check for a cord after the head is out, but I also find the perineal support is impossible to do and seems useless. The counterpressure supplied by the water will do much of what our hands would have done.

With the next contraction, I ask her to push for the body. I keep my hands there to guide the body out, and once the whole baby is in the water, I gently lift the kid up to moms arm. If it doesn't come, I find I can easily do the usual maneuvers to deliver the shoulders, as long as she keeps her butt down on the floor of the tub. Once in a while the woman is freaking and aches her back and lifts up her butt and you are trying to push down on the head to free the ant shoulder and nothing is happening because there is nothing to push against. Tell her to keep her butt down. It is also very easy to change to hands and knees for sticky shoulders. The only problem then is that the head is out of the water and you have to be very careful as the body delivers not to dip that face back down in the water. I have asked the nurse to put her hands under the head to make sure the head stays out of the water as I deliver the body. Then, of course the mom has to stand up so you can slide the baby between her legs and she can sit back down in the water and hold her baby.

I can do all of this by leaning over the tub, with my knees on the small stool. My belly is on the edge of the tub and for really sticky shoulders I have leaned all the way over, so that my legs left the stool (once was enough for that). Of course, again, that would not work for an inflatable.

We also keep the tub room very very very warm for a water birth. The nurses and midwives are sweating and stripped down to tee-shirts, but the wet baby can lose a lot of heat from evaporation. I have found it is hard for the excited mom to keep the baby's body but not head under water, so we lift the baby up to chest level and put a towel over the baby and a hat on its head. Even if the towel is wet, it still provides some protection from heat loss.

What do you all do about the placenta? Most of the published sources on waterbirth recommend not delivering the placenta underwater, because of the theoretical risk of water embolism. I start to drain the tub right after the baby comes out, so either the tub is empty by the time the placenta is ready and they deliver the placenta squatting or sitting in the empty tub, or if the placenta wants to come sooner, I put a shower stool right in the tub and have the mom sit above the water to deliver the placenta.

One more cool thing about waterbirths -- the placenta pan will float on whatever water is left in the tub. After I cut the cord (when pulsing has stopped) I like to let the blood drain into the pan (some say it aids separation). So mom is sitting on the stool (holding the baby) and the pan is floating in the water below her and the cord trails down into the pan, keeping it right there. Then she can squat over the pan, or I can do controlled cord traction and drop the placenta right into the waiting pan. I happen to think it is pretty neat.

Extra-Long Gloves - Sources

Something I've discovered that works really well is to use the vet gloves with a latex glove on top.  For extra dexterity and sensitivity in my fingertips, I cut off the fingertips of the vet glove.  The water doesn't get inside the latex glove, so I'm protected.

Those vet gloves are enormous.  We put rubber bands around the top of them on our upper arms, and regular birth gloves snug on top
of them on our hands.

we just purchased water birth gloves. they come in a bright blue- the other choice was orange!!. We bought those elastic hair tie-scruchies  to hold the gloves above the elbow/upper arm.

our supplier - Birthwaves- will happily ship anywhere.


The Tubsider is is an orthopedically designed, kneeling seat designed for adults who are bathing kids.  It happens to work beautifully for midwives attending waterbirths.  [NOTE - Production of this may have been discontinued - if you want it and can find it, buy it quickly!  Old info: You can call 1-800-314-3535, Fax 213-269-7418  Tubsider, 5315 Lindbergh Lane, Bell, CA 90201]

Waterproof Dopplers

I'm curious about what type of water Dopplers people have and how well they like them. I bought the first one that came out (or at least the first one I saw) (1995?), but I didn't like it at all, made the salesman take it back. But I sure do get tired of encasing my arm and non-waterproof doppler in a plastic trash bag!

We use the Huntleigh AquaDoppler.  Works very nicely in water and out.

I believe the one we have is the Sonicaid.  Works well, but wish the digital display was backlit, as someone has to hold a flashlight to see it because we always have just a little night light on in the tub room.

I have a Sonicaid. It's okay....looks like a star trek phaser ...it works . I know people who have a Huntleigh and like it. Some of the waterbirth gurus seem to like the Huntleigh best.

I love mine...but works better in water of course....out of water picks up a lot of other sounds

I have an Imex Pocket Dop OB for which I bought a waterproof head.  I works very well both in and out of water - very little static, FHT easily found.

Aqua-Eez offers waterproof Dopplers.

Birthing Tub Rentals

In the United States

There used to be a lot of different places that offered tub rentals, but they seem to have disappeared.  AquaDoula stopped renting tubs out around 2012. Alas.  I take this as a good sign that they're so busy making them that they can't also maintain a rental business.  This must mean that there are a lot of tubs out there.  HURRAY!  It does seem that more and more midwives are offering tub rentals or loans for their own clients.

Home and Hospital Rentals from Aqua-Eez- their web pages don't provide a lot of information about what kinds they rent, but you can call or email them.

AquaDoula rentals local to Mountain View, CA

In the UK

Gentle Water birthing pools - another British tub rental company.

Homemade Birthing Tubs

How to Make a Portable Waterbirth Tub by Melanie Moore

Sources for Purchasing Tubs

See also: Birthing Tub Rentals - many rental companies also sell high-grade tubs, especially suitable for purchase by midwives who provide tubs for their clients or who offer local tub rental deals.

Cascade is now selling the Birth Pool in a Box (as of 5/09)

Everything Birth, Inc.- they sell tub liners and other tub equipment

Waterbirth International no longer sells or rents portable pools.  They recommend a couple of inflatable tubs that can be purchased at www.waterbirthsolutions.com

Birth Balance maintains an excellent list of a great variety of tubs!!

They also have a great list of accessories

AquaDoula Waterbirth Spa Rentals and Sales - a U.S. company that manufactures and sells tubs.  [NOTE - if the floor pad doesn't have the holes pre-cut, they should be 3 and 5 inches from the edge, i.e. 2 inches apart.]  1-888-217-2229 or (425)348-6729, e-mail: waterbirth@AquaDoula.com  The folks at AquaDoula have been heavenly in their support of my "stable" of four AquaDoulas - they've provided information on debugging problems, and they've provided terrific turnaround time on repairs.  I am THRILLED with my AquaDoulas!  [NOTE - TUBS TO GO! Inc. is the company that makes the AquaDoula.  They are now also making the Portable Baptistry tubs, and they make one that is significantly bigger and takes 435 gallons of water.  This might make sense for a birth center, although the bottom isn't flat.  And they offer portable electric heaters that could be used with any tub, as well as the propane-powered "instant heater", which would be ideal for a birthing tub far away from hot water.  Anyway, I think these folks are pretty ingenious!] [NOTE - AquaDoula stopped renting out tubs around 2012.]

Here's the AquaDoula instruction manual.

Aqua-Eez Deluxe Hydrotherapy Pools - some portable units and some suitable for permanent installation in hospitals or birth centers.

La Bassine - An Inflatable Birthing Tub

La Bassine - a more affordable inflatable birthing pool from the UK - "This is the pool we have all been waiting for."  It really does seem as if they've given this a lot of thought, incorporating some important improvements, i.e. oval shape for faster filling, pushing handles that also hold the fill hose in place! $95.00 (+ S/H)

External:  65" long (165cm), 53" wide (135cm), and 25" deep (65cm), Internal:  45" long (115cm), 37" wide (95cm), Because of its oval shape a 100 gallons gives you the perfect water depth. (They also offer a larger Labor & Birth Pool. This pool measures 72" X 25" and holds 190 gallons.) [NOTE - The calculation of the area of an oval is (Length x Width x 0.8)  So, the area of the internal bottom of the La Bassine is 45 x 37 x 0.785 = 1307 square inches.  The area of a circle of 45 inches = 1590 square inches.  So the ratio of the oval to a comparable circle is about 82%.]

Midwife feedback about La Bassine:

I have done 2 births in this pool, and really like it a lot.  We have been using the 3 ring kiddy pool from IMEX for a few years, but it just wasn’t quite deep enough for some of our moms.  The extra couple of inches in the La Bassine seem to make all the difference.  Also the bottom and sides are soft!  I had one mom that really liked the handles on the inside during second stage.  One thing that really surprised me was how long the water stayed warm.  We filled the tub at 9am and laid a plastic sheet over the tub, and right on the water. She was ready for the tub at 9pm that night and we checked the temp thinking we were going to have to drain and refill.  But, the water had only lost 1 degree in all of that time.

I offer both pools because the IMEX one only costs $25 where the La Bassine is a little over $100. But, at a little over $100 it is still much less than a rental tub, and the family gets to keep it after the birth.

Sources in the US

Your Water Birth.Com - These nice folks offer a 10% discount for midwives, so register before you place your first order.

Sources in Canada

With Child

Inflatable Pools

Sevylor Pool List from Shipstore.com.  (There are pictures of the 60" pool in use available from an online waterbirth album.)  They also have pool covers and air pumps.   The Aquarius Pool seems to have universal appeal to pregnant women - everyone wants to climb in to try it out.  This is the aqua colored one, the SP60 (or SP60-A) with a external diameter of 60", an internal diameter of 48", and a capacity of 72 gallons.  If you want a larger pool, the Sea Life Pool - SP72, has an external diameter of 72" and holds 111 gallons; however, it comes in a very bright orange color which I find unsuitable for a birthing environment.  Fortunately, Sevylor now manufactures the aqua-colored Aquarius Pool in larger sizes - the SP60-B has an external diameter of 72", capacity 111 gallons, and the SP60-C has an external diameter of 80" and a capacity of 150 gallons.  Lots of choices, but I'm not sure that they are all available at this site.

Please also be warned that the Sevylor pools are made of PVC vinyl, which has a very, very strong odor and will probably cause a reaction in someone with chemical sensitivities.  It's not my first choice for materials, but the pools are otherwise great.  One approach to the problem is to order the pools ahead of time, inflate them, and leave them outdoors in the sunshine for a couple of months before the birth.  Far from ideal.

More pools from Sevylor

Inexpensive inflatable tub kits from yourwaterbirth.com

You can get the Intex Aquarian Birth Pool (60" X 22") for $35 from birthwithlove.com  These pools don't seem to have much of an odor at all and didn't cause any kind of reaction in my very sensitive body.  [I haven't been able to find the tub at the previous site, but you can contact the manufacturer - Intex Corp. - to ask about local distributors or mail order.]


Inflatable Aquarium Ocean View Swimming Pool from The WetSet costs only $18.95.

If you're a do-it-yourself kind of person, you might enjoy hunting down all the plumbing parts you're going to need for filling and draining these pools.  If you really dislike doing that sort of thing, just order one of the kits or get one of the rental packages.

Intex tubs are also sold at qualityinflatables.com.

Advantages of Inflatable Tubs

I have been to births where an inflatable tub is used for labor and birth and I generally bring an inflatable tub to a client's home for them to use if they wish.  I love them.  Mine even has the fish on it!  I plan to birth in it myself.

The advantages are:

So far I can't think of any negatives that I have seen.  However, I do worry that it will somehow break or leak.  It might be a good idea to have a backup (an extra tub) Make sure you look for them as soon as the weather runs out as they are hard to come by in the winter and end of summer months.

Dolphin Circle Waterbirth Tub Kits - They also carry really cute t-shirts that say, "Water Babies Rise To The Top!"

Some people are using the Rubbermaid 150-gallon trough.

Or, you can rent or buy a "factory direct" "super portable waterbirth spa from 1-800-882-7864 or tubman@wa.net

Comfort Line Spas are portable, heated spas.  They're expensive, but are suitable as rental tubs or for midwives or doulas who want to provide them to their clients as part of their service.

You can purchase a Spa-N-A-Box tub from Gentle Beginnings.

spadeals.com carries the SPA-N-A-BOX from Comfort Spa!

The birth pool on Dinah is one that can be purchased at Toys R Us.

I haven't seen a rental tub in use.  Most of our clients use an inflatable kiddie pool that costs about $40 from Wal-Mart, Toys R Us, etc.  It inflates in several sections - the bottom inflates which is nice and cushiony as well as being a good insulator.  The sides inflate in three sections which adds strength.  Every one I've seen is sorta aqua-green on the bottom with fish printed on clear sides.  I've also heard that Sharper Image sells a similar pool (maybe the same one at a highly-inflated price??) for about $150. (Less on sale in winter.)

This mom did indeed go to the local feed and grain store and spoke with the owner telling him the purpose of her purchasing a cattle trough manufactured by Rubbermaid. The cost of this large tub (with drain, hose, @4 feet high) was $120.00. Imagine the store owner's surprise when she told him it was for a birthing!! Since the "tub" would only be used once, he agreed to return all but $20.00 of the purchase price upon return of a "clean" tub"!!

You can get tubs from Barbara Harper that are really nice, and lots of other places, but I used a Rubbermaid water trough from the local farmer supply store. It's VERY sturdy plastic or rubber or something, with rounded edges, the perfect shape and depth for a laboring woman (with even back supports if she wants to sit sideways!), holds 150 gallons, the water stays warm, fits even through a trailer door (of course you have to do the birth in the kitchen then) (great story there sometime!), a very determined midwife can wrestle it around alone if necessary (empty of course!) and it only cost $120-150! (I can't remember exactly) It will last forever, easy to clean and disinfect. The only problem is that it's black, so it's hard to evaluate blood loss, but I made a white flowered flannel liner for it and that solved that. I hope Rubbermaid doesn't find out how perfect it is for water birth or they'll raise the price!

They have 3 different sizes but the 150 was just right.

Tub Liners

Whether you're using an AquaDoula, a Rubbermaid trough or an inflatable tub, you'll want to use disposable liners to prevent cross-contamination if the tub is being used by multiple families.  AquaDoula offers nice Form-Fit Disposable Liners (4 mil thick?) or you can just buy some 10x12 4mil drop cloths from your local hardware store - they're not quite as nice, but they're cheaper, and you can buy them in smaller lots without paying the shipping.

I was reading a feng shui book that talked about the shape of the circle:  From Subtle Energy by William Collinge, "Circles serve as funnels or vortexes for the movement of energy . . .  This shape is very conducive to creativity because it is a natural vortex for earth energy emanating upward.  As the energy is in effect 'funneled' upward through the circle, it also circulates or spins, and this vortical action stimulates ideas and creativity."  This brought to mind my preference for having women labor in circular tubs, rather than rectangular tubs; it was just a feeling that the private circle was like the womb - a very creative place - perfect for laboring.

Heaters for Birthing Pools

I'm interested in hearing about experiences using waterbed heaters under birthing tubs.

Does this work with tubs that have an inflatable bottom?  It seems as if the air in the bottom would insulate the water in the tub from the heater, but maybe not.

I had one experience using waterbed heaters and I think everyone should hear about this.  I sent the couple home with instructions for use, and they set up during early labor.  The husband was German Speaking with English as a second language.  This couple had an inflatable children's pool and they put it on top of two water bed heaters, on top of a waterbed liner on a hardwood floor.  The water stayed about 94F through the whole labor, which was slightly too cold, and she complained on hot spots on the bottom.  She had to sit on rubber pads to avoid getting the hot spots.

After the baby was born, and she moved to bed, her husband and I took apart the pool.  We found that the water bed heaters had not been rolled out flat.  He had put them under the pool all rolled up, they actually melted through themselves and started melting the water bed liner and pool. Another hour or two and the mom and baby would have been at serious risk for electrocution.

Thank God the baby came when he did.

Not my personal experience, but was related to me by someone who tried to use a waterbed heater under an inflatable tub. She said the bottom melted pretty quickly!

I simply don't have any desire to feel responsible for the use and safety of a water heater in my tub.  #1, I'd rather rely on the good ol' fashion "stick my elbow or wrist " in the tub, use a thermometer in and (ugh) add #2 the extra water as needed.  No ideal waterbirth is worth the risk of harming any mom or baby in my practice.

Tub Accessories

One Midwife's Waterbirth Supplies and Logistics


I encourage dimly lit rooms for births, but I also like to have enough advance warning about baby's arrival that my assistant and I have time to put on our sterile gloves.  I used to hold a large Maglight, but that contaminated my gloves once they were on.  I happened to be at a birth when my flashlight was getting a bit dim; instead of going to get replacement batteries from my car, the dad brought out their flashlight, which had a very nice crook that hung perfectly over the edge of the AquaDoula and put a nice light right onto the mirror on the bottom - it worked great!

It was a Craftsman #00911390000; you can see a picture of it if you go to their web page and search for 00911390000

I was thinking of getting one, but it's a rechargeable model, and I'm guessing that the battery and charger are fairly expensive.

I really like the long lasting LED bulbs in the Gentle LED Birth Lights. The bulbs last for 100,000 hours (not the 10,000 hours he mentioned) using just TWO AAA batteries.  You just hold the light in your hand and use it flashlight style.

You can also use those snake lights and shape them as needed!  They're also handy for suturing, since you can drape them over your neck.

SpaSupplies.com carries weighted spa pillows for $12.74

Aquarium supply houses are great places to find the plumbing parts for filling the tubs - contamination-free hoses, faucet adaptors, anchor tubes.

You can get the fish nets at your local discount pet supply place, or online at petexpo.com. They also sell all the Python airline quality hoses and faucet adaptors:

PYC25 $ 22.95 ... 25' No Spill Clean & Fill
PYC50 $ 37.95 ... 50' No Spill Clean & Fill
PYE10  $ 8.29 ... 10' Hose Extension
PYE20 $ 11.85 ... 20' Hose Extension
PY13A $ 2.49 ... Hose Adaptor

pythonproducts.com has a nice schematic of the No Spill system to help identify the parts.

Here's another source - aquariumshoppe.com

You can also find the Python parts at MOPS - a Canadian aquarium site.

About Tub Logistics

Do it Yourself Waterbirth Set-Up by Ril Giles- this is a great web page from a waterbirth  mom who wanted to share her strategy for a budget setup.

One Midwife's Waterbirth Supplies and Logistics

If you're using the AquaDoula or another rigid-sided tub frame, you can easily create a cushion all around the edge of the tub frame.  Some tub users have purchased some inexpensive pipe insulation to put around the edge of the tub frame.  They got 2 six-foot lengths of pipe insulation (1 ¾” diameter) and put it around the edge of the tub, under the thick plastic aqua-colored tub liner.  This works beautifully!

I put three layers under the tub:  the bottom layer is a big waterproof tarp.  On top of that, I put a utility underpad, which provides some cushioning and some water absorbency for any water that might slosh over the edge of the tub.  Then, on top of both those, I put a king-size sheet.  This is a nicer surface underfoot than the bare tarp, and it is a lot less slippery!  I don't want my moms slipping as they get out of the tub holding their precious new baby!  I have found the Kimberly-Clark All Weather Utility Pad to be the ideal underpad for all kinds of tubs.  It is just the right size and it is the lightest I've been able to find, so it doesn't add much weight to the tub kit.

I think Dad needs to be out of the picture as far as set up of the tub at the time of birth.  If you are going to offer waterbirth in our practice, it is imperative for the midwife to be l00% responsible for the logistics.  Own your own plumber's wrench, tap/hose adaptor, clean hose, designated "dirty" hose, sump pump, washers, air inflator, pools, tarps, etc. and learn to use them just as you know how to use your speculums and hemostats (it's all plumbing, right?)  I believe that a birth is a birth of a father as well and it is our job to support him in being present at his birth i.e. not taking photos or cleaning up water damage.  [Ed. - I think it is unrealistic to add yet another set of tasks to a homebirth midwife's already rather full plate.  However, I do agree that the dad has a more important job to do . . . support the mom!  It seems to work very well to have the dad set up the tub ahead of time, and then have a family friend responsible for filling/draining the tub.  They don't have to stay for the birth, but they'll have the joy of seeing a very fresh baby as they're waiting for the tub to drain.]

For us it's been pretty simple.  The inflatable pools are pretty well insulated just by the air in them.  Most people put down a plastic liner (just a cheap roll of visqueen from the hardware store) to protect the carpet/floor and then use blankets and/or old towels around the pool on the floor to soak up splashes and keep us from slipping in puddles.  The towels/blankets are also extra insulation.  Draining is easy with a waterbed kit.  Water can be drained in labor and replaced with more hot water. The other advantage, besides the $$ savings, is they're more readily available - you don't have to worry about renting one and not having it in time or having to pay more if you keep it past the return date.

The only complaint we had about the dark Rubbermaid trough was that because it was such a dark color it was very hard to see. We wished we had a good underwater light or something. We used a flash light but it didn't seem to work very well. We also thought (for future births) about putting something light on the bottom or even painting it if that could be done safely. It really was dark.

Well, What I do to solve that problem is have the mother purchase 2 king size WHITE sheets, and a roll of 3 mil plastic as part of her "supplies needed for a water birth." Before we fill the tub, we line the rubbermaid tub with the sheets, then the 3 mil plastic. We drape the plastic to the bottom of the outside of the tub, and tuck it under, or duct tape it to the bottom area of the tub, and fill. We now have a white waterbirth tub! When it comes time for clean up, we pull the liner out, throw it away, and OUR rubbermaid tub is DRY and CLEAN. People seem to like the idea that no one elses birth goop has ever actually been in their birth tub.

I made a light flowered flannel "fitted sheet" that had elastic all around edges and is as big as the tank. It's pretty, provides the light background for assessing water color (for blood loss or meconium) and it's sterilizable between clients!

the liner of my pool is almost black. The only drawback to the color is it makes it harder for the viewers to see (though I kind of think it adds to the moms unconscious sense of privacy).. ANyway, a long time ago I found a suitable compromise --- just have mom sit on a white towel if you need to see better. No need to line the whole pool - just the spot where the head is emerging.

That hasn't worked for me because it seems that hardly any of the women I work with ever sit.  They are kneeling, swimming around, squatting, etc. It seems like anything not held down by the liner just floats around.

I use a 150 gallon Rubbermaid feeding trough I got from a feed store. It cost $70 and I picked up a spigot at a plumbing store for $12. I put the spigot in the drain plug. The parents get two hoses, one must be new and not weathered from out side. This one they hook up from the kitchen sink, never direct form the hot water tank or you will get sediment. The other hose is for drainage. We put a old shower curtain under it and use a new one for the cover with a blanket for insulation. Every hour we drain off some water and add hot. We clean it with germicide (we have the parents do ) when they bring it home and before they bring it back.

The problem that I have found with these kiddie pools is that most people's hot water tanks are not big enough to fill them high enough to cover the mom's belly. I end up boiling water forever. I really dislike it. Next time someone wants a waterbirth they are going to have to rent a real water tub or I will buy one and they can pay me a fee.

My tub has a heater, but all heaters take a while to raise the temperature (mine will go about 5 degrees an hour). Heaters are great for maintaining temperature; they are slow to heat and we still usually need to fill the pool with warm water. With a fast labor we sometimes end up topping off with hot water because we don't have time to raise the temp with the heating unit.

Here's a trick which usually works -- Run about an inch of cold water into the tub (to protect the plastic); then turn on the faucet to HOT WATER ONLY... Start to fill the pool and keep an eye on the temp of water coming from the hose. When it begins to cool off, turn the hot water OFF to let the heating tank recover. Continue to fill with COLD water only until the temperature begins to fall below 102.. By that time the hot water tank will often have recovered -- many gas tanks only need 30 minutes -- and we can begin to use hot water (only) to fill the pool to the proper level.

It's a good idea to have a good supply of water simmering on the stove in case it's needed.

Regulating temp is pretty easy since a LARGE body of water takes some time to cool off!

Also consider purchasing a "thermal blanket" -- looks sort of like a bed sized sheet of bubble wrap. You can cut this to size and it works quite well. Mine cost $12 I think...

I rented from my midwife because it was deep enough for the water to come up to and partially cover my shoulders. This meant I was buoyed and supported and surrounded by the warm water, and it felt positively delicious! For the Gate Control Theory of Pain to take effect (as describes in Water Birth by Janet Balaskas) it is best to have as much as the body covered as possible, so that the pleasurable nerve sensations block out the pain nerve sensations.

Renting the tub was the best investment I ever made!

I highly recommend renting from Global Maternal/Child Health. You'll have everything you need - you won't have to worry about how to keep that water warm - and the right temperature is important. You'll also get a pump to help you remove the water after the birth.

I recommend using 2 hoses of different colors - one to fill it up, and one to take water away - if you have don't have a heater, and need to add more water to keep it warm.

To get a kiddie pool that would ensure enough depth to allow floating and water over your belly, you could sit on the floor, measure to where you want the top of the water to be, and then find a pool deep enough. Some women go to Farm Supply stores and get Rubbermaid cattle troughs (I think that is the name).

You'll need 2 hoses of different colors. One for filling, and one for emptying. That way you can take out water and add more warm water. The new tubs from Global Maternal/Child Health have warmers built in.

If you get in the water too soon, it may slow down your labor. Being in the tub too long can slow things down as well. Some women use the tub for a while, then get out and labor while walking around, and then try the tub again.

We set up the tub in a separate room, with a tarp under it (in case). It can be set up in any room, as long as the floors are strong enough to hold the weight of the tub full of water.

Set it up a few weeks before your due date, in case you're early. Do a test run, and time how long it takes to fill up. Remember to leave room for the water to rise 1-2 inches for each person who gets in the water. When you start labor, you could fill it half way, and then cover it with a sheet. Then you can fill it the rest of the way when you need to get in.

The pool could be in a bedroom, living room, a finished basement. Wherever you want it to be, as long as there is enough room and the floors are strong.

The standard pool is 60" x 22", 3-ring inflatable pool with inflatable bottom by Intex.

If you are in early labour, water may have the effect of slowing or stopping ctx, this is good if it's the middle of the night and you want some sleep before the real work begins! :-) Otherwise it could be best to hold off on the pool until you are in really active labour, where it will probably have the effect of helping you relax and cope better with ctx.

Don't know what the rules are, here's how ours is set up. Shower curtain on the floor, covered by a comforter, followed by 2 waterbed heaters covered with thin cloth (I used pillowcases) and the pool is on top.

Well, since generally a midwife will not do a homebirth before 37 weeks, it doesn't need to be done before then. As for filling it, the best way to find out is to have a trial run. Some people need a few hours for this depending on the size and temperature of their hot water heater.

We use inflatable or firm-walled portable, foam tubs, primarily. I would think you could certainly use any clean tub. Here are some of the things that come to mind in relation to birth in water.

The temp should be kept between 97 and 100 degrees F, on the warmer end when the baby is born. Tap water, with it's chlorine seems to be OK. After delivery I would empty the tub with an immersible sump pump that drains via hose to the toilet (toilet seat down holds hose in place). Then re-fill it with tap water and add a cup or more of chlorine. Run the jets, run the filter and let that drain. I would not think there would be any need to run the filter during labor.

We filled up our pool (Kay Bee Toys has 5ft by 22 inch pools for $20!) with straight hot water from our sink using a hose (we have a 50 gallon water heater). Then we covered the pool with a piece of plastic. When I went to get in the pool HOURS later it was so hot that we had to add a lot of cold water. So I wouldn't worry so much about the temp if you keep the pool covered.

What we did to keep the pool nice was: When we first filled it we added bleach to clean it and then drained it through the garden hose outside, thus cleaning the hose as well. We then hooked up the hose to the kitchen sink and filled it 1/3 way until needed. When I was ready to get in the first time, we filled it another 1/3 with warm water, then everyone kept the water warm by near boiling it on the stove & pouring it in. The second time I wanted to use it they drained 1/3 out and again filled it from the kitchen. Another option is to take out water by the large pan-panful, boil it, and add it back. For this to be effective, you should have several pans going at once.

We bought an inflatable child's pool with I-beam construction in the sides. That supports the weight of an adult sitting on the side. It has an inflatable bottom also. Here is how we used ours.

We filled ours on a daily basis for a few days before the birth. I used the water to calm rather obnoxious Braxton hicks. On the big day (!) we filled it with water that was slightly hotter than the recommended 100 degrees, say 102. Then of course we had to wait for the midwife to come and check me to make sure that I was past 4 cm so that I could use the water to help speed my labor, not stop it. I was 5-6. We waited through another two contractions for her to get a good feel on the position of the baby and her head. By that time I was 6-7. Our water heater ran out of hot water before the tub was full enough (15" deep), so we got out all of the pots I have and filled them and heated them on the stove. We used a floating spa thermometer to monitor the temp to keep the boiling water from over heating the pool.

I didn't have the problem of being in there long enough for the water to get cold. My darling little daughter was born about 25 minutes after getting into the pool. Our plan was to just remove a few pots or buckets full of water and have that amount boiling on the stove handy.

If you can, keep the pool in a room where you can close the door and trap the heat in the room. That was really effective for us. It helped having the room warm for the baby too (nice perk). We found that if you need to get out of it but think you might want to get back in, that if you cover it with a mylar sheet (like the emergency blanket you can buy in sporting good stores) and lay it shiny side down, that really trapped heat in. Our baby was born in the middle of February in Indiana, that's the coldest month of the year here so we know it worked.

My friend had a few things in the pool with her (sterilised of course)...inflatable pillow and a little plastic step/stool (the kind children stand of to reach the sink or toilet.

Where to Set Up the Tub?

In which room do you give birth ? My midwife says that it's best to give birth on the same floor as you have your bathroom. For me this is upstairs, but I don't have place enough for a pool there. Downstairs is easier, but no bathroom. So what do you think is best ?

Some things to think about which may make it easier for you to decide:

If you have it downstairs the good thing is the bedroom and bathroom upstairs can be ready for you after you've given birth ...I like the idea of going upstairs with my baby and having a warm bath and getting into clean sheets whilst leaving everyone else to clear up downstairs (yes, it sounds very selfish, I know!!)

Different kinds of Bathtub Grab Bars are available online from Comfort House $(60), Able Medical Supplies ($17-$22), Bruce Medical, or search online for other sources.  (I bought mine on sale from those "Signature" flyers that come in the mail - 909-943-2021- orig $45, on sale for $29, Sept., 2001.)  These can be great to hold onto when moms are squatting in tubs.  I'm not sure how well it attaches to the sides of the portable spas.

Draining the Tub

When you use an electric pump to drain the tub after the birth, it is less efficient if you leave it sitting upright directly on the bottom.  I sometimes tip it on
its side or put the mirror under one edge if the mirror is already in the tub.  One clever midwife told me that she puts it in a metal colander.  Now that's

About Tub Weight and Floor Strength and Load Limits

About the Weight of the Water

I inflated our pool this week to "test" out the time it would require, etc, and now DH has panicked that it will be too heavy for our apartment to support.

My husband says standard residential code is 40 pounds per square foot for residential floors (currently) and it probably has been for a long time.
37 square feet under the pool times 40 pounds per square foot equals 1510 pounds -
He says that it would be safer to put it near a load bearing wall and to be careful not to overfill it b/c weight will add up fast.

For the 60 inches X 22 inches pool, the water capacity at 80%  of wall height is l09 gallons.  Remember - "a pint's a pound the world 'round".  (Except perhaps for some parts of Europe.)  That's 872 pounds distributed over about 20 square feet.  If you'd feel OK about having 4 football players standing in the area, you're probably OK with the tub.

About The Fill Hose

The standard garden hose is made with many dangerous chemicals (and technically shouldn't even be used to water a garden) these chemicals not only come out in abundance with the first use (flushed out along with manufacturers "grease" but leach out over time with break down of the hose. "Drinking safe hoses" are processed in a completely different manner and do not contain the same toxins or release toxins into the water. I do not have the list of chemicals anymore (they were on the paper that came with our outdoor hose) but I can inquire at the hardware store where I purchased all of our hoses (ones for birth rental/service and home use) and get a detailed list if anyone is interested.

It isn't necessary to use this sort of hose but I like to eliminate all unnecessary chemicals where possible especially in such a blessed, pristine event as a new life's emergence. For similar reasons people should flush their birth tub before it's first use. Not because of toxins but because of manufacturers grease. There is a lot of filth in most plants and this transfers to most products we purchase.  Like when you buy dishes, you was them before using them for the first time. Or when you buy pots you are supposed to boil them for 15 minutes to eliminate the harmful nickel (stainless pots) from them before cooking a meal. Manufacturers grease can be anything from actual grease, to glues, to unwashed hands. Just another effort to eliminate outside contamination to our personal inside environments.

My midwife supplies special "airline quality" hoses.  I'm not sure what they have to do with airplanes, but they're apparently completely clean inside - maybe they're the hoses used to deliver oxygen to all those little oxygen masks?  Anyway, she gets them from an aquarium supply store - the name on the hoses was "Python".

About Cleaning Tubs

Abstract about Cleaning Waterbirth Tubs and Infection Rates

Another trick I heard with this tub is instead of all the scrubbing, use a piece of plastic such is used for insulation inside houses, get at lumber yard. It is heavy plastic and comes in rolls of 8ft x25ft. Just cut off the piece, unfold it and put it in the tank. Just fits perfect. When birth done, throw the plastic away.

We have 2 jacuzzis at our birth ctr. After each use we fill tub with hot water and 2 scoops of dishwasher machine soap. Run the jets, cleaning with a cloth as necessary. Empty tub. Fill again with hot water and bleach. Run jets again. Of course we clean out any debris before filling the tub.

I have in my backyard a 7 person hot tub -  Now, I will be labouring and birthing in this tub in late July.  How would one go about preparing such a tub to be clean enough?

I would drain it, scrub it, rinse it, then refill with water and add the sterilizing agent which your manufacturer recommends. Then I would drain it, dry it, and wait till labor is imminent. Then I would fill it with plain water for labor and birth. Here we recommend using no chemicals in the water if used for birth.

I guess it it's already filled you could wait and take a short cut and just run a full sterilizing treatment through it, then drain it, rinse and refill.

The water will keep for a couple days with no chemicals (as long as no- one enters the tub).

It holds (for us Canadians) 1363 litres of water or 360 US gallons.  How much bleach would you add and circulate prior to use.

I use chlorine granules but brands are different. Better call your pool agent and get the best recommendations.

Would you use any chemicals or additives at all in the actual birth water?

Absolutely not!    Start with a clean tub, and clean water, and you won't need anything else. I would treat your hot tub the same as a portable tub and not count on having it always available as a hot tub. Either that or double check your chlorination when you go into labor and ONLY use the tub for labor rather than birth.

Folks here are quite strong on recommending against birthing in a hot tub treated with standard chemicals. It goes back to a birth maybe 15 years ago with a baby with undetermined respiratory problems (blamed --justly or not -- on the hot tub chemicals.). I don't know if there were other situations or if this is an example of "management by anecdote". One could make a case that any chemicals you are comfortable bathing in should be safe for a baby to be born in, I guess. If you did so, I would STILL recommend using a newly cleaned, recently filled tub.

How long does your tub take to heat up if you fill with cold water --- or with hot tap water?

I finally found out what our local hospital uses to clean their tubs, that the nurses call scrubbing bubbles.

Brody is the brand and it contains m-alkyl dimethyl benzyl ammonium chloride. Their phone number is 1-800-488-2436.

It takes a capful per large jetted tub.  then they fill the tub up over the jets and run the jets.  then take a long handled swab brush and wash the sides and the edges.  drain and rinse with clear h20, filling above the jets and running again.  each run of the jets is about 5 minutes.

Cleanliness of Water - Water Purity

Promoting Safety in Waterbirth - Resources on Legionnaires' Disease from MANA

Notes from the Field: Two Cases of Legionnaires’ Disease in Newborns After Water Births — Arizona, 2016

Arizona has published guidance on this topic for midwives

If your water supply is not considered suitable for drinking, then it is not suitable for birthing in.  During the birth process, the uterus opens, and it's possible that water from the tub could go up inside the vagina and possibly inside the uterus.  If there are any perineal tears, germs from the water could be introduced directly into the mother's bloodstream.  This isn't a huge problem if the water started out as clean water and then got the mom's germs in it, but if the tub water was undrinkable to start with, this could be dangerous.  Also, the baby could pick up nasty germs from the water and become ill from it.

This information is primarily from educated conjecture, rather than from any research.  In general, women are discouraged even from swimming in bodies of water (such as lakes and rivers) that might contain weird organisms that could get inside the cervix and infect the baby.  It makes even less sense to birth in questionable water.

However, you can disinfect water by adding household chlorine bleach. If your water supply is clear, add 1/8 teaspoon (approximately 0.75 milliliter) of bleach per gallon of water if the water is clear.  For cloudy water, add 1/4 teaspoon (approximately 1.50 milliliters) of bleach per gallon.  For an AquaDoula that holds 175 gallons, this translates to about 22 teaspoons of bleach for clear water, so really about half a cup of bleach for clear water or a full cup for cloudy water.

Use bleach that does not have an added scent (like lemon).  Ideally, use bleach that gives instructions for disinfecting water right there on the label.  Regular plain Clorox Bleach or generic is fine.

After adding the bleach, stir it around - a dinner plate can be a very effective stirring device - and then let it sit for at least 30 minutes to allow the bleach to kill all the germs.  Then, you can add boiled water or heat the water (if it's in a birthing tub with built-in heater), and the heat will help disperse the bleach from the water.  As the bleach leaves the water, it will tend to make the room smell bad, and you don't want a pregnant woman breathing this, so have someone else doing the work and, ideally, be able to ventilate the room as the bleach is leaving it.  The water should then be sanitized for birthing even if it no longer smells like bleach.

[From the CDC's web pages on Disinfection Water for Drinking, Cooking, and Personal Hygiene]

People sometimes ask about using hydrogen peroxide to disinfect water. Hydrogen peroxide must be used full-strength from the drug store (which is 3%, I think) to sterilize things. You'd have to have a lot of some really concentrated hydrogen peroxide in order to sterilize a birthing tub full of water.

It's tough to find something that's going to kill nasty germs but not be a problem for humans.  Heat is a good way but hard to manage with 175 gallons.  Bleach has the beauty of killing the germs and then evaporating when heated.  Although it smells bad while it's evaporating, after it evaporates, it leaves the water pretty pure. The chlorine levels used to disinfect clear water are less than the levels used in public swimming pools.  If you drink and bathe in tap water, you're probably already drinking and bathing in chlorinated water which has had a lot of the chlorine bleach evaporated already.  It's actually quite a good option.

If you want to learn a lot about sterilizing things, go and search on the internet for sterilizing things for brewing beer.  These are methods that are effective enough to kill any residual yeast spores (which are harder to kill than bacteria or viruses) and still not leave any residues that would affect the taste of the beer.

I'm concerned about the cleanliness of the water my baby might be born into.  Here I am buying a fishnet to scoop out fecal matter that might be pushed out ahead of the baby - doesn't this make the water toxic to birth in?

In a normal birth, the baby is born sterile and picks up germs from the mother during the birth process and infancy - from the vagina during birth, from the skin during skin-to-skin contact on the belly, and from the breasts during breastfeeding.  This is nature's ideal plan to colonize the baby's skin and gut with the friendly bacteria that the mother carries - the baby is already as immune to this bacteria as the mother because the baby has been getting the mother's immune system through the placenta.

In order to digest all that beautiful breastmilk, the baby needs some e. coli, and better that it comes from the mother than anyplace else.  I don't think it's an accident that the baby is born so close to the rectum!

And, of course, anytime you introduce antibiotics into baby's world unnecessarily, you're interfering with the natural colonization of baby's skin and gut that happens at/after birth.  This leaves baby vulnerable to being colonized with the germs of whoever is around when the antibiotic effect wears off.  This isn't a problem at home, where most of the germs in the home are germs that baby's already immune to, because they're germs from the mother's normal environment.  But if the baby is in the hospital, the baby might end up being exposed to nasty stranger germs just at the time that the antibiotics are wearing off.  And, of course, antibiotic-resistant germs aren't fazed by antibiotics, so a baby with antibiotics on board who's exposed to antibiotic-resistant germs is in the worst possible situation - exposed to the most dangerous germs without any competition from the normal, friendly bacteria that have been wiped out by the antibiotics.  So think twice before you put that antibiotic ointment into baby's eyes or agree to IV antibiotics.

And . . . even the midwife's germs aren't really part of the mother's normal environment.  As healthcare providers, midwives come into contact with lots of germs and could easily spread germs from one home to another.  As a midwife, I personally make a point of donning sterile gloves at the birth and for the first 24 hours afterwards before touching the baby.

For lots of interesting information about gut bacteria, read Gut reactions : understanding symptoms of the digestive tract by W. Grant Thompson.

Chloramine Filters from The Filter Guys - I find that aquarium enthusiasts seem to know the most about filtering water because their fish are so sensitive to water quality.  As a midwife, I don't worry too much about municipal water quality - if the parents are OK bathing in their household water, it's probably fine for the birth.

Then again, the San Francisco Public Utilities Commission offers excellent information about chloramine in bath water - QUESTIONS REGARDING CHLORINE AND CHLORAMINE REMOVAL FROM WATER [Updated November, 2007]

[Ed.: I think this must be ascorbic acid or sodium ascorbate.]

In the section, "Q: Can Vitamin C be used to remove chlorine and chloramine for bathing purposes?", they state, "SFPUC determined that 1000 mg of Vitamin C (tablets purchased in a grocery store, crushed and mixed in with the bath water) remove chloramine completely in a medium size bathtub without significantly depressing pH." [Ed: It didn't make sense to me that you would have to crush the tablets, but they dissolve pretty slowly.  I put them in the very hot water that I use to pre-heat the tub halfway full, and this dissolves them about halfway; then, I crush the remainder.]  Apparently, some of the commercial tablets specifically sold for neutralizing chloramine in bath water lower the pH more than is ideal for bathing.  And vitamin C is thought to be good for the skin!  It's a win-win solution, and cheap, too!

So, an "average bathtub" holds about 70 gallons of water.  The AquaDoula holds 175 gallons of water.  It seems that 3 or 4 grams of vitamin C should neutralize the water in an AquaDoula very nicely.

from Water Quality in the East Bay

"Chloramine Removal — Chloramine, unlike chlorine, will not evaporate from water by itself and not all water filters that remove chlorine will remove chloramine. For example, showerhead filters and filter balls that are used in bathtubs do not remove chloramine. Chloramine can be removed for drinking water purposes by a carbon block or activated carbon filter that can be installed on a kitchen faucet. According to the San Francisco Public Utilities District, boiling water for 20 minutes will remove chloramine. A short boil of water to prepare tea or coffee will remove about 30% of chloramine. Adding fruit to a water pitcher, for example slicing peeled oranges into a 1-gal water pitcher will neutralize chloramine within 30 minutes. Both chlorine and chloramine can be removed for bathing purposes by dissolving Vitamin C in the bath water (1000 mg Vitamin C tablet will neutralize chloramine in an average bathtub)."

from Chemicals in Drinking Water: Chloramines

"Chloramines can be removed from water using activated carbon with low flow rates (5 to 10 minutes contact time), followed by residual ammonia adsorption using mineral zeolite media.  The use of reducing agents such as sodium sulfite, sodium bisulfite, sodium thiosulfate and ascorbic acid (vitamin C) also removes monochloramine from water.  Boiling and aeration are ineffective methods for monochloramine removal."

What about Chlorine?

Here's a really nice discussion of how to neutralize chlorine - THE ENDANGERED SPECIES ACT AND CHLORINATED WATER DISCHARGES

"Water utilities have found that 2.5 kilograms of ascorbic acid will neutralize one kilogram of chlorine in water. For sodium ascorbate, 12% more is required."  I'm not sure how this translates to bath water, but . . .

This Vitabath ad claims that 1000 mg will neutralize both chlorine and chloramines in 100 gallons of water.  "Effervescent vitamin C de-chlorination tablets are comprised of ascorbic acid, citric acid and sodium bicarbonate. This powerful formula is designed to neutralize chlorine and chloramines in hot tub or spas."

Using Vitamin C To Neutralize Chlorine in Water Systems by Brenda Land, Sanitary Engineer, Project Leader - from the US Dept of Agriculture

Chlorine Concerns and the Endangered Species Act: Vitamin C and Fish by Greg Peterka, P.E., Engineering Manager, Public Utility District No. 1 of Skagit County

Adding Stuff to the Water

I've heard that the purpose of adding salt to the water is so that it has the same salinity as amniotic fluid and thus doesn't sting the baby's mucous membranes at birth.  [The ratio is one generous tablespoon for each gallon of water.]

Some clients add things. Usually comfrey, sliced ginger, salt, arnica oil and St Johns Wort oil -- comfrey, ginger, or other herbs go into a clean pillow case with the end tied tightly, salt and oils just get dumped in. This is for labor only, early enough that they were in their own bath tub.- the oil makes a strange bath tub ring! -- but it does clean up with no problem.

Mom said it seems to help in labor..... I would get a bit nervous about a baby birthing in it though-- but fine for labor if mom wants to try it!-

Hydrogen peroxide is good for mom's bath, but not for the birth because it hurts the baby's eyes.
International Bioxidative Medicine Foundation 405-478-IBOM, P.O.891954,Oklahoma City, Oklahoma 73189

Officially, Waterbirth International does not recommend adding anything like this.  But, as long as natural salt is used, I don't see the harm in it.
My suggestion to most women is two drops of your favorite essential oil and that is it. [Ed: Personally, I'm not comfortable with adding any oils to the water.  There's a theoretical risk that the baby might aspirate the oily water, and even a very thin layer of oil could affect respiration.  If a mom wants fragrance in the room, there are lots of ways to create that without adding any oils to the water.]

What To Wear

For my first water birth I wore nothing at all. But for my next, my son was 8 approaching nine and we thought he would be more comfortable if mom wasn't "starkers".  I wore a really light gauze nightgown, very "hippie earth mother".  It's a favorite now. At a birth I helped at in May, mom wore a tube top in the tub.  I thought that was terrific and helped with easy access for the baby to nurse afterwards.

I've decided on my floral Bravado nursing bra and an oversized man's shirt to wear when I am out of the tub. 

I saw a waterbirth picture once where the mom was wearing a black tank top.  I think it would be easy to find, too.  I think they are sold in the lingerie, sleep wear departments.  They are the kind that are form-fitting, not loose and baggy.  It would be modest, yet when lifted up to nurse, it stays up and doesn't fall down into baby's face, and when in the water it wouldn't float around and get tangled, or catch air bubbles when getting in and out.

Just FYI so you know my experience.  The first time, I don't remember thinking ahead so much what to wear, but I did end up wearing a tie-on bikini top.  That was modest and easy to untie the neck tie to nurse, but in some pictures people have seen the ties floating in the water and thought it was the umbilical cord! (the ties are pink).  The second water birth was so fast, and in my own big tub, that I had nothing on.  I do wish I had some pictures that are more modest!  My husband got in with me and had only his underwear on, kind of funny to remember the event and how at the time we didn't even think or care how exposed we all were!

I had a home waterbirth 6 Mo ago. I wore T shirts.  Next time I plan to wear panties too.  After the birth a friend in the Netherlands wanted to see a pic of my birth tub. I was wishing I had a pic w/o so much of my backside showing. I was on hands and knees(sorta), facing the camera so the pics i had to choose from weren't graphic by any means, but showed more of my hips than I would normally show. And for me personally, the panties wouldn't have made me even a tiny bit uncomfortable. So that's what I plan.

Also I don't plan to take the shirt off immediately after birth as I did (at MW's suggestion) last time,  I'd like the  moments after birth pics to be ones that I can share with everyone!  Just my (modest) opinion. 

Did you keep the things that you wore?  I can imagine that they become really special.  I mean - the clothes that I will wear to bring my baby into the world are really even more significant than my very fussed over and well preserved wedding dress.  Did anyone do anything special with your "birth clothes?"

I kept the dress I wore. I still wear the bra all the time. Sure, they become special things. 

I bought special frilly socks for each of my deliveries.  They were very special!!

I wore a short nightshirt for labor with nothing underneath, then just a sports bra when I got in the water.  I felt more comfortable with "something" on than completely nude. 

I wore the same short night dress with all my babies. It was soft on the inside & silky outside.  What I really liked was that it was buttoned all the way down the front so if I was hot I could un-button it so it only covered my shoulders, or so DH could rub my belly with essential oils without me having to keep pulling up or holding up my shirt. It was easy to nurse in. 

At the Hospital waterbirths I have attended (over 30) I have seen the Moms where anything from nothing, bikini tops and sports bras to actual long cover everything up maternity tops.  I just want Mom to feel comfortable -- so I say wear whatever (if anything) you like.  LOVE the tube top idea -- I will pass it on to the Moms I take care of.  I bought a midriff T-shirt for my own delivery, but I ended up delivering in my birthday suit! 

What do you WANT to wear? THAT's the key!

I wore a long sleeved black maternity dress until I got in the tub. Then I wore a navy blue cotton bra (Victoria's Secret) so it wouldn't turn transparent when wet.

Consider that you may be warm, you may want to move around, and you may get body fluids on the clothing. I think comfort is the key. And the items you wear will become very special to you!

OK, this is mostly a joke for a waterbirth crowd, but the manufacturers are serious about this garment - the Birth-Day Suit


We used the "Aquaria" DVD on our big-screen TV during the labor, and my wife absolutely loved it.  It was quite powerful as a form of visual hypnotic induction; she would look at it and identify with the marine life.  The colors are very striking, and it really brings people into a different part of the mind..  We also had some PBS-like DVDs of dolphins and orcas, but these didn't seem right.

I have some of those plastic quart-sized pitchers that the hospital gives out to every laboring woman, and they're great for hanging on the edge of the AquaDoula.  The midwife can keep her Doppler in one, and the mom can keep her glass of fluids in another.

I use a 5-gallon collapsible water container in the birthing tub.  We fill it with water so it sinks, and it makes a very nice cushy seat for the mom.

We use a brand new Ikea child stool at each birth.  They're the perfect height, they sink pretty well if you turn them upside down first to let out the air pocket, and then the family is going to be needing one of these in a year or two anyway.  Even though they're brand new, it's a good idea to rinse them well before putting them in the tub.  And PLEASE don't use an old stool from the bathroom; they're doubtless covered in grime and probably germs.


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