Why many choose Waterbirth

Research on water immersion in labor shows it can reduce pain and anxiety and may shorten labor and reduce use of epidural/spinal analgesia in low-risk pregnancies.
Large evidence reviews on intrapartum water immersion (labor ± waterbirth) also report:

• Less use of pharmacologic pain relief and fewer interventions overall

• High maternal satisfaction

• No clear increase in serious adverse newborn outcomes when appropriate candidates and protocols are used

A large matched cohort study of community births (home and freestanding birth centers) found waterbirth was associated with:

• Lower postpartum hemorrhage and fewer postpartum transfers

• Fewer newborn transfers/hospitalizations

• A small increase in cord avulsion and a small increase in postpartum uterine infection (without increased hospitalization)

Risks

Waterbirth is generally considered safe for low risk clients but it’s not “risk-free.”

Key risks discussed in the literature include:

1) Infection (rare, but can be serious)
Case reports have described newborn infections after waterbirth (including waterborne organisms like Legionella and Pseudomonas). Infection risk is minimized by clean water supply, strict cleaning/disinfection, avoiding standing warm water, and using equipment that doesn’t promote bacterial growth.

2) Umbilical cord avulsion (“cord snap”/tear)
This is the most consistently noted increased risk in waterbirth versus land birth. It’s usually preventable (gentle lift, awareness of cord tension/length) and manageable if recognized immediately (clamp promptly).

3) Temperature regulation (mom + baby)
Water that’s too hot can contribute to maternal/fetal hyperthermia; too cool can chill baby. We monitor the temperature.

4) Aspiration concerns
A healthy newborn has reflexes that typically prevent breathing underwater, but distress can override reflexes

Who is a good candidate?

In general, water immersion/waterbirth is best suited when all are true:

• Low-risk, single baby, head-down, term (≥37 weeks), within your midwife’s scope and protocols

• You’ve had informed consent about benefits, risks, and alternatives

• You can enter/exit the tub quickly with help if needed

When we may recommend “no tub” or ask you to get out

Your midwife may ask you to delay entering or exit immediately if any of the following occur (examples):

• Non-reassuring fetal heart rate or inability to adequately assess fetal heart rate

• Maternal fever/elevated temperature

• Moderate to thick meconium

• Excessive vaginal bleeding

• Slow progress or contractions that significantly slow/stop in water

• Dizziness, or low blood pressure

• Breech or multiples (if birth is delayed)

• Short cord / cord tension concerns

• Need for intensive newborn resuscitation

• Placenta issues (prolonged/difficult delivery or bleeding where we cannot accurately estimate blood loss in the water)

• Any condition that requires transfer of care under Texas midwifery rules or your midwife’s clinical judgment

  Waterbirth is optional. Safety is not. If your midwife asks you to stand or exit, it’s because the risk/benefit has changed in real time.

How we keep waterbirth as safe as possible

Homebirth: Pool selection and setup

• Tub is cleaned/disinfected per protocol (germicide & bleach) and set up so the midwife can access you from at least two sides

• No essential oils/aromatherapy/additives in the water (they are not proven to prevent infection and can create other issues)

• For homebirths we recommended use a new disposable liner for each birth (for portable tubs)

Filling the tub (infection prevention)

• Tub is typically filled once active labor is established (not days in advance)

• Water is changed after prolonged use (commonly every ~6 hours, depending on the situation)

• For birthing pools: use a new, unused potable water hose

• Run hot water at the tap for several minutes before filling, then fill to target temperature

• If a client uses well water, it should be tested through an appropriate certified lab within the year prior to the due date

Water depth and temperature

• Water should cover your abdomen but not reach your neck

• Water temperature is kept comfortable and below 100.4°F, checked and documented (including after adding water)

First stage in water

• We encourage you to stay hydrated

• You’ll be encouraged to empty your bladder regularly

• If fetal heart tones can’t be reliably monitored, you’ll be asked to exit

• If the water becomes contaminated and can’t be cleared, you’ll be asked to exit unless birth is imminent

• We keep a ready “land birth” area next to the tub (dry towels, warm blankets, safe footing)

Second stage: Pushing and birth in water

• Birth should be hands-off and physiologic, avoiding unnecessary stimulation of baby’s head

• Baby’s head is brought to the surface immediately after birth and must not be re-submerged

• Cord is never clamped/cut underwater

• Special attention is paid to cord length/tension to prevent cord avulsion

Third stage: The Placenta

• We recommend moving out of the water to deliver the placenta as blood loss can be difficult to assess in the tub

Newborn resuscitation readiness

• Waterborn babies can have a slower initial transition; we plan for warmth and airway access (typically, baby responds well to light stimulation to illicit a good cry)

• We prepare a firm, warm surface near the tub if a full resuscitation is needed

• If moving baby to the resuscitation area is necessary, we may recommend cutting the umbilical cord sooner

• Your midwives are NRP (neonatal resuscitation program) certified and follow NRP guidelines

Different U.S. organizations interpret the evidence differently:

• ACOG (American College of Obstetricians and Gynecologists): supports water immersion during first stage for healthy, uncomplicated pregnancies at term, but states evidence is insufficient for underwater birth and recommends birth on land.

• AAP (American Academy of Pediatrics): cautions against waterbirth during/past second stage due to concern about rare but serious infections and emphasizes rigorous infection-control if offered.

• ACNM (American College of Nurse-Midwives): supports hydrotherapy as a safe, effective option for pain relief and physiologic birth in appropriately selected low-risk clients, including second stage (delivery of baby!) when protocols are followed.

What this means for you: Waterbirth is an area where evidence is substantial, but professional opinions differ, largely because rare complications are hard to study and protocols vary widely.

Client Agreement

If you choose tub use/waterbirth, you agree that:

• You will follow instructions to change position, stand, or exit the tub immediately if requested

• You understand the key risks and the ways we reduce those risks

• You understand that we may recommend a land birth at any point if safety changes