While hanging out with Dr. Anonymous at Ustream a couple of weeks ago, I was chatting with Mexico Medical Student and Medi-Medi-Mary about waterbirth. I don't know the exact origins of this childbirth practice, but it is very popular up here in Rural, CA. In many communities it is available only for homebirths, but my hospital's maternity unit permits waterbirths for select women. Criteria for waterbirth include documented negative serologies for Hep C and HepBcAg. If HSV-2 serology is positive, a woman must take acyclovir in prophylactic doses beginning at 36 weeks. Of course, the woman's pregnancy and labor must be low-risk to permit waterbirth.
Despite these hurdles, a lot of women in our practice elect to try a waterbirth. Most of them do not end up giving birth in the Aqua Doula tub, which they rent from a local woman who is a homebirth and waterbirth advocate. Some woman find the tub too hot at the required 99-100 degree temperature. Some women find they dislike being in the water as their labor progresses. Of course, if labor is not straightforward, a number of medical interventions might require a woman to get out of the tub for closer monitoring.
The doctors and midwives at the hospital had to go through special training sessions to attend waterbirths, and we also have to wear the most uncomfortable protective gear you can imagine:
- Surgical robe
- Long veterinary gloves, made out of Saran wrap like material, which must be secured at the armpit with Coban tape
- Latex gloves over the vet gloves
At first, I wasn't sure how I'd feel about attending waterbirths. I'd all been warned about contamination in the water. Women are instructed to bring a cat litter or fish tank scoop to remove poop from the water. (Labor is a poopy process, goes with the territory.) In my fervid imagination, all the blood, urine, feces, amniotic fluid, vaginal secretions and meconium that usually stains hospital linens had the potential to take on sinister, Petrie dish-like qualities in the water.
Fortunately my first waterbirth experience was wonderful from beginning to end. The woman's name was Miriam. I met her early in her pregnancy because she made an appointment specifically to discuss the plan for managing her Crohn's disease. She'd been on a number of disease-specific medications before attempting conception, but tapered off all of them in hopes of a pregnancy. She didn't want to risk exposing the fetus to any teratogens.
Miriam was a scientist herself. She had a master's degree in oceanography and in fact was in charge of teaching students how to scuba. I did some research on scuba diving during pregnancy (not recommended) and printed out the abstracts of the studies for her to read.
Fortunately Miriam's pregnancy was completely uneventful. She had no Crohns symptoms at all, enjoyed prenatal swimming and yoga classes, and worked in her non-scuba responsibilities until late in her third trimester. She was one of those women, I used to tell her, that make it all look so easy.
Miriam hired a doula named Dee to support her during labor. She told me she was interested in a waterbirth. I explained the hospital's policies to her and she went through the orientation session, the labs, and put down a deposit on the tub. She asked me to be at her birth--what the doctors and midwives call a "special" patient, one who "belongs" to a certain doctor/midwife no matter who is on call. I explained to her that I'd do the best I could, but there was no guarantee that I could be there. If I was up the night before she went into labor, I'd want her to be attended by someone who was well-rested rather than show up bleary-eyed and do a less-than-adequate job.
I got the call from Labor & Delivery on a night when I was relatively well-rested, so off I went. The birthing tub was set up in the labor room, filled neck-high with prewarmed water at the correct temperature. A protected heating element maintained the temperature. Dee had laid down several layers of towels and blankets around the tub, so the floor wouldn't get too slippery for Miriam if she wanted to get out, or for the rest of us as we moved around the room.
Miriam was already seven centimeters dilated when I arrived. She was leaning on one edge of the tub when I arrived, eyes closed in concentration. She was heading into that deep place some people call transition, but not quite there yet because she greeted me pleasantly and asked how I thought things were going, quite in the moment. Not in the otherworldly way transitional women speak to me. I told her I thought she was laboring well, encouraged her to drink some water because the heat of the tub water increases insensible fluid losses. Laboring women need a lot of hydration in any case. The process of labor is very athletic, like running a marathon in bed. Sometime I think Gatorade should make a commercial set in a labor room.
One of the great things about a waterbirth is the slowness and do-nothing attitude it imposes upon a birth room. It is possible to examine a woman when she is in the tub, but it isn't particularly comfortable to do, so I was able to resist the impulse to examine Miriam too often. Continuous fetal monitoring is possible but not usually done because the equipment needed to do so is very finicky and often doesn't work. Instead, Dee and the nurses used a Doppler to verify adequate heart tones periodically.
There was a sense of being out of time in Miriam's labor room. Her husband, River, was a man of few words, although he had a ready smile for me and the rest of Miriam's attendants. Dee was an experience doula, who seemed to be in constant movement, either wiping Miriam's brow with a wet washcloth or offering her sips of ice water, or checking the temperature of the tub water on the floating thermometer that bobbed and drifted around Miriam as she labored. The room was dark and warm, womblike, I suppose. Every time I stepped out of the room I blinked about seven times to let my pupils adjust to the lights over the nurse's station.
I don't remember how long it was before Miriam felt like pushing, but it seemed to take both a long time and no time at all. I did a quick and soggy exam to verify complete dilation, and gave her the thumbs up to start pushing if she felt like doing so.
Instead, Miriam lost the urge to push for about twenty minutes. Her contractions subsided during this time. This happens in almost every labor, after the cervix is completely dilated. Contractions slow down or disappear and if the birth attendant has already gotten gloved and gowned, they will have what seems like an endless wait before labor kicks back in again. It's as if the body is giving the woman a break before the onslaught of pushing kicks in.
At first, Miriam didn't push very convincingly. Her expulsive efforts were brief and exasperated, and for some contractions she didn't even push at all. This is not an uncommon pattern of pushing, in the water or out. I call it warming up. Some childbirth educators don't advocate pushing as soon as the cervix is dilated. If the woman is able to labor without pushing until the urge is irresisitable, she is likely to push more effectively and for a shorter time. Unfortunately, there is a commonly-held idea out there that a woman must push the minute she is completely dilated. Women and birth attendants both get seduced by this idea. I think the rationale is that starting to push will "get it over with" sooner, but I'm not sure. I've seen plenty of women push for two or three hours before their pushing becomes truly effective. Some of these women would have benefitted from waiting an hour or so for the urge to become irresistable.
I can often hear the moment pushing is getting serious, from the sounds a woman is making. Instead of tired, discouraged cries, suddenly I was hearing deep, continuous, athletic vocalizations coming from Miriam. I shined a flashlight into the tub--yes, her vulva was starting to bulge. Even before crowning occurs, the vulva will begin to bulge outward and the labia will splay open under the pressure of the descending fetal head.
Dee and I started coaching Miriam in earnest. We encouraged her to hold her pushes as long as possible. I did not have her hold her breath with pushing, because vocalizing didn't seem to be making her pushing efforts any less effective. Some women do well hollering up to the heavens, some don't.
Miriam pushed on hands and knees, in a squat, and reclining against River, who had climbed into the tub to labor with his wife. Pretty soon we were seeing a Tootsie Roll-sized glimpse of head emerge.
"He's got hair!" Dee announced.
"Do you want to watch him come out?" I asked. We have mirrors in which women can watch the progress of their pushing. Miriam shook her head. Some women really like seeing the results of their efforts, but Miriam was a concentrated pusher. She kept her eyes closed most of the time. I figured she didn't want to be distracted by visual stimuli.
The next push brought an egg roll-sized peek of the head. A few more pushes, and we were seeing a plum. Then an apple. Then an orange. I was so wrapped up in the sight of the baby's head emerging, distorted by the movement of the water, that Dee had to remind me what was happening.
"It's crowning," she whispered to me. Oh, right. I handed the flashlight off to Dee and climbed into the gown, vet's gloves, latex gloves, and tight tape. It was about as comfortable as a leather corset, but a lot less fun.
Waterbirth advocates will warn you that everything takes longer in the water. Crowning, birth of the head, restitution, birth of the body--everything seems to take forever. This is true. I don't know if it is actually true in units of time, but watching the progress of birth through the distorted surface of the tub adds what seems like hours to the process. The hardest part for me is keeping my hands off the process. Especially when the hands are sweating under two layers of gloves, and the nurse has secured the armpit-high vet's gloves too tightly with Coban.
Finally the baby's head was born. I waited as Miriam caught her breath and waited for another contraction. It was a strange sight, looking down at a baby's head completely submerged in water. Waterbirth advocates assure us that, as long as the water temperature is 99-100 degrees, the half-born infant will not attempt to draw a breath. It is the shock of the cold air outside the birth canal, they say, that stimulates the first breath. Since Miriam's birth, I have learned of babies that have died of drowning because they did draw their first breath underwater, so you have to be careful. Yet waiting at the side of Miriam's tub, I willed myself not to reach into the water. Not yet.
With her next contraction, Miriam gave a mighty push. There was a small spurt of bloody amniotic fluid. Another push, and the baby's shoulders appeared. I had my fingertips on the baby's head, controlling the path of emergence, and once the shoulders were born I laid my hands alongside his body to help ease him out. Miriam is the one who pushed one last time, and young Lyle was born. I floated him up to the surface of the water, exposing his head to the cold air, but keeping his body submerged. The warm water of the tub also helps the baby maintain his temperature after birth.
Dee and I suctioned Lyle's mouth, then helped him backstroke to Miriam and River. They rocked him, half underwater, for another twenty minutes while we bustled around getting the bed ready for Miriam to get back into bed. Our hospital won't permit the placenta to be delivered in a birth tub, which is all for the good since that can be a bloody business. Miriam had me clamp the cord and River did the cutting, and as we helped the new mother out of the tub, River stayed in the water with Lyle. I delivered the placenta with Miriam in bed and checked her for lacerations--none!
Little Lyle didn't make it to land until he was close to 30 minutes old. He was calm and alert and breathing fine the whole time he floated with his dad in the pool he was born into. How perfect that two oceanographers would have a water baby.