August 15, 2001
Volume 3, Issue 33
Midwifery Today E-News
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Five days of discussion, demonstration, hands-on practice and unique and useable midwifery knowledge and techniques--that's what you'll get when you attend Midwifery Today's 5-Day Midwifery Intensive with Doña Irene Sotelo, Aug. 27-31 in Eugene, Oregon. For more information, click here.

WATERBIRTH: BABY BIRTH MOVEMENTS, CLASS TAUGHT BY Cornelia Enning at Midwifery Today's international conference in Paris, France. Cornelia reviews 20 years of waterbirth outcomes with a focus on the behavior and interaction of the baby with his environment. Breakthrough discoveries in birth psychology and newborn reflexes will be illustrated with amazing video sequences.
This is just one of the stimulating classes you can attend at Midwifery Today's international conference in Paris, France, 18-22 October 2001.


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MIDWIFERY TODAY STOREFRONT: The place to go for information about waterbirth!

Quote of the Week:

"I am grateful to be connected to my inner sense of the 'rightness' of natural homebirth, but I find it totally bizarre that I have to become a modern-day Joan of Arc to accomplish that goal."

- Piper Allan Severns

The Art of Midwifery

After a waterbirth, moms sometimes have trouble getting situated for breastfeeding or even holding baby, especially if the cord is short. Instead of bailing water to lower the water level, simply slip a plastic step stool under her so that she lifts up out of the water just enough to expose her breasts and lift the baby up.

- Barbara Harper, Global Maternal/Child Health Assoc.

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News Flashes

Heated baby bottles made from polycarbonate, a clear rigid plastic, were shown to leach the chemical bisphenol-A into simulated baby formula. Bisphenol-A is known to create endocrine disruption in lab animals by mimicking the effects of estrogen. The amount of the chemical found in the simulated formula was about 4% of what had caused damage in test animals. According to Consumer Report, "safety limits for infant exposure can be set as low as 0.1% of the level that has adversely affected animals."

- Mothering, July-Aug 1999


The place to go for information about waterbirth!

Midwifery Today Issue 54 (Waterbirth)

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August 21, 1999 should be remembered as a landmark in the history of birth pools. On that day the British Medical Journal published an unprecedented study about waterbirth. This study is authoritative for several reasons: The conclusions are based on large numbers: the authors traced the 4032 babies born under water in England and Wales between April 1994 and March 1996; the authors belong to a prestigious department of epidemiology and public health (Institute of Child Health, London, UK); the report has been published in a respected peer review medical journal.


>From April 1994 to April 1996, all 1500 consultant pediatricians in the British Isles were surveyed each month by the British Paediatric Surveillance Unit and asked to report whether or not they knew of any births that met the case definition of "perinatal death or admission for special care within 48 hours of birth following labour or delivery in water." At the same time a postal questionnaire was sent to al National Health Service maternity units in England and Wales in 1995 and 1996 to determine the total number of deliveries in water during the study period.


There were five perinatal deaths among 4032 births in water; that is a rate of 1.2 per 1000. In the context of the UK this rate is similar to low risk deliveries that do not take place in water. Furthermore, none of these five deaths were attributable to delivery in water. There were 34 babies admitted for special care; that is a rate of 8.4 per 1000. Rates of admission for special care of babies born to low risk primiparous women are significantly higher than for babies born in water.


Give great importance to the time when the laboring woman enters the pool. The BMJ survey clearly indicates that many women stay too long in the bath. The midwife should help women be patient enough so that they can ideally wait until five centimeters dilation to enter the water.

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

Temperature: It is easy to check that the water temperature is never above 37 degrees C (the temperature of the maternal body). The fetus has a problem of heat elimination.

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


Miscellaneous waterbirth facts and tips

  • Practitioners throughout the world recognize increased safety for the breech baby if it is born in water. The most experienced doctor we know of is Herman Ponette, an obstetrician who practices in Ostend, Belgium. He has attended well over 2000 waterbirths, including breeches and twins. To him, a frank breech position as an indication for a waterbirth.
  • Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but some of the literature reports the same frequency of tears for primips in or out of the water (Burn, Garland).
  • A useful way to identify the extent of postpartum hemorrhage is how dark the water is getting. Can you still assess skin color of the mother's thighs even though there is blood in the water? A few drops of blood in a birth pool diffuse and cause the water to change color. A waterproof flashlight comes in handy at this point. Dropping a flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during the birth.
  • Some hospitals still restrict a woman from laboring in the water if her membranes are ruptured. Based on the current and past literature, this is absurd. No evidence exists of increased infectious morbidity with or without ruptured membranes for women who labor and/or birth in water (Eriksson et al., Garland).
  • Some parents are concerned about mother-to-mother infections or contamination from viruses such as HIV or hepatitis. There is no reason to restrict an HIV-positive mother from laboring or giving birth in water. All evidence indicates that the HIV virus is susceptible to the warm water and cannot live in that environment (Favero). Universal precautions still must be adhered to, however, and proper cleaning of all the equipment after the birth must be carried out.

- Barbara Harper, Midwifery Today Issue 54

Burn, E., Greenish, K. (1992). Pooling information. Nursing Times 89(8): 47-49.
Garland, D., Jones, K. (1997, June). Waterbirth: Updating the evidence. British Journal of Midwifery 5(6): 371.
Erikkson, M. et al. (1996, Aug.). Warm tub bath during labor: A study of 1385 women with prelabor rupture of the membranes after 34 weeks of gestation. Acta Obstetricia et Gynecologieca Scandinavica 75(7): 642-44.
Garland, D., Jones, K. ibid.
Favero, M. (1986). Risk of AIDS and other STDs from swimming pools and whirlpools is nil. Postgraduate Medicine 80(1): 283.


The uterus at full term is a tautly extended, powerful muscle. The point at which the placenta attaches to this muscle is the deciduas basalis, the decidual plate, lying right up against the myometrium. The uterus contracts powerfully as the baby is born, surging down from near the rib cage to around belly button level. In a normally implanted placenta, the line of cleavage along the decidual plate opens. The spiral arterioles are sheared off; the next few heartbeats of maternal blood pour out and the retro-placental clot forms, further detaching the placenta from the uterine wall due to the pressure of the blood flowing in. Remember that at full term, about 500 mL of blood/min are flowing into the placenta from the maternal circulation. The uterus firms up around the placenta and clot, slowing the blood flow. The spiral arterioles clot off. Maternal blood flow to the uterus drops off rapidly.

The placenta may not be delivered for a while, but the mother's blood does not continue circulating into the maternal lakes to provide oxygen and other essential substances tot the baby. Unless implantation is abnormal, the contraction that births the baby separates the placenta.

Keep an eye on the cord the next birth you attend. At first it is stiff, turgid, deep blue. Look again at one minute. It is becoming flaccid, gray. True, if you feel carefully, near the baby's body you can feel a pulse for several hours. But the flow of heavy blood to the placenta and back is at an end. The little capillaries in the villi are disrupted, deprived of access to maternal blood. The blood in the baby's body needs another oxygen source, and a perfect one is available: the baby's lungs.

The only safe way to practice waterbirth is to bring the baby out to where it can breathe directly after birth. Certainly a baby might be supported gently with its face out and body floating as it transitions from placenta to lungs as the organ of respiration. In the mother's arms is a good place to accomplish this.

- Marion Toepke McLean, CNM, Midwifery Today Issue 54

MIDWIFERY TODAY ISSUE 54'S THEME IS WATERBIRTH. 14 articles about waterbirth, columns, tricks of the trade, and more!

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A Web Site Update for E-News Readers


WATERBIRTH; AN ATTITUDE TO CARE, book by Dianne Garland. Guide to waterbirth in hospital or home.

BIRTH INTO BEING: The Russian Waterbirth Experience, videotape produced by Barbara Harper. "The footage will take your breath away."

Midwifery Today's Online Forum

I am a natural childbirth educator and have a woman in my class who has congenitally dysplastic hips and has a very limited range of motion. She walks with the assistance of two canes. She cannot open her legs if her knees are bent. Does anyone have any suggestions for her laboring and birth? She very much wants to have a natural childbirth.

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Question of the Week

Q: What are midwives doing when women test positive for group beta strep in pregnancy? What protocols are midwives implementing at the birth and postpartum?

- Anon.

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Question of the Week Responses

Q: I'm 20 weeks pregnant (first time) and am seeing a CNM. At our first ultrasound the baby measured great but they told us we are on the low end of normal for amniotic fluid (an 8). Is there anything I can do to increase my amniotic fluid? Is this number particularly low? What are the possible chromosomal effects of having low amniotic fluid?

- Melinda Collins

A: Yes, 8 is a low number for a gestation of 20 weeks. There are no chromosomal effects for having a low amniotic fluid. Also, a doctor may tell you to drink a lot of fluid, but really, your body is what controls your amniotic fluid, not the amount you take in.

- Misha Spencer-WhiteMagpie


A: These are questions your midwife should answer. I wonder if you have chosen the right midwife if you seek the opinions of strangers worldwide rather than her? You are trusting her with one of the most intimate times of your life; surely a fluid-level question isn't too much to ask. Drink lots of water and soak in a tub. The fluid level doesn't affect chromosomes, but the baby's condition can affect fluid level.

- Evelyn B. Walker


A: Low fluid has nothing to do with chromosomal anomalies--those are determined at conception. It can influence cord compression and possibly lead to fetal distress. The mother can increase her intake of water and rest a bit more to facilitate increasing the amniotic fluid volume. If the baby is growing well, moving well, and is otherwise fine, it may have no relation to a poor outcome. Usually a repeat ultrasound is done every four weeks to assess the fluid volume and starting at 34 weeks gestation, nonstress testing (monitoring movements & response to those movements with a fetal monitor) can help assure a good outcome. It is important for mom to be aware of fetal movements, especially after 28 weeks. A good indication of well being would be at least 10 movements per day.

I work in a large private hospital-based practice. We follow lots of "high risk" women and they have had excellent outcomes in spite of low amniotic fluid volumes.

- Sage Brook, CNM


A: An AFI (amniotic fluid index) of 8 is OK. You can increase your fluid by increasing your water consumption. Low amniotic fluid is usually caused by failure of the fetal kidneys to produce or inadequate intake of water. Drink, drink, drink.

- Lynda Comerate, RN, BSN, PHN, LCCE, HBCE


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Out of frustration from trying to find an affordable option for a labor pool/waterbirth tub for our clients, we have come up with the following option:

  • A 60" X 20" Aquarium inflatable pool made by Intex available at discount stores or on line. These pools cost from $20 to $35 and are of excellent quality. They have three inflatable clear plastic rings with fish on them so you can still see through the pool in places and have an inflatable bottom. We find the 60 inch pool to be the best--any larger takes longer to set up and fill and is very taxing on any hot water tank.
  • Floating thermometer (or any thermometer will do)
  • Multisize faucet adapter
  • Betadine solution (for cleaning)
  • Air pump
  • Instructions for set-up, general use and clean-up
  • New hose (family purchases and keeps)

This entire set-up costs under $100. Most of our clients want to keep the pools and purchase their own at the beginning of their third trimester. We try to keep a couple extra new pools on hand as they can be hard to find at times.

Our labor/birth pools kits are available to all our clients at no cost. The pool kit is left at their house at around 35 weeks gestation but sometimes we deliver them sooner if they are experiencing back or other body aches or excessive swelling. Soaking in a deep pool can provide relief for these discomforts. We had one mom fill her pool every evening with warm (not hot) water in her living room (she used a large plastic drop cloth and had lots of towels on hand) and float for several hours for relief of back pain (she is a well-padded gal and also loved the feeling of weightlessness while in the water). Her five year old would join her and it was the perfect treat during a cold winter pregnancy. Learning to relax in water prior to birth is a great way to help your body become familiar with this type of relaxation when water therapy is planned for labor and birth.

- Debra Nelson, Traditional Childbirth Assistant
Othello, Washington


Re: question about the safety of breech [Issue 3:31]:
The concerns you have are based on two different and independent factors:

1. Cerebral palsy: Increased risk is usually a result of the birth itself, which is why most Obs and CNMs (not having been trained extensively in vaginal breech births) won't even consider the "risk." The potential problem is with decreased blood flow and oxygenation of the baby's brain while the head remains inside mom.

2. Birth defects: Certain birth defects (such as those that result in hydrocephaly) can prevent the baby from turning into a head-down position, so the defect actually contributes to the baby remaining breech.

3. Other factors that may predispose to persistent breech presentation: Maternal pelvic structural variations, uterine fibroids, maternal uterine structural variations, low-lying placenta or placenta previa, really short umbilical cord or cord wrapped all around the baby. In short, anything that interferes with the baby turning around in the womb.

If you have a skilled practitioner who is experienced in handling breech births and has informed you of the various scenarios that might occur during the birth as well as indications and plans for additional interventions, your baby should be fine.

- Gabrielle Long Wright, CNM
(hospital-based practice in which all breeches are scheduled for c-section)


I had some wonderful feedback forms for my clients that described in pictures the results of their Pap smears. The forms came in pads about 1/3 page in size, and showed a graphic of a normal cervical cell, an ASCUS cell, CIN-I and so forth. Both my clients and I loved them--but I have misplaced the re-ordering information. Does anyone have it? If so, email me at

- Cynthia Flynn, CNM, PhD


In response to the question regarding what to expect at a hospital birth with twins [Issue 3:32]: It depends on the type of hospital and the individual care provider. Some things to think about ahead of time and to keep in mind during the birth: monitoring of two babies is trickier than just one. If continuous monitoring is being used, nurses tend to get frustrated with trying to keep both babies on the monitor, especially if mom wants to move around (as she should!). If there is a delay between the babies' births, how will the practitioner handle it? Manual repositioning of second twin, ruptured membranes, Pitocin, etc. In the hospital where I work, all vaginal twin deliveries must occur in the OR (don't even get me started).

- Anon.


During a homebirth in 1998, I had to be transported to the local hospital. My midwife was diligent in calling ahead and explained the situation to the nurses in the "women's center." When we arrived, we discovered they hadn't listened to a thing she said to them on the phone! They had to search for the ultrasound machine, wasting precious time, and didn't even have a wheelchair ready. I had to walk to my room at 9 cm dilated with two feet presenting. While my daughter's heart rate shot up to 280 (due to a malformed electrical pathway) the anaesthesiologist messed around trying to get a spinal started. Finally giving up, they gave me an emergency c-sect with general anaesthesia; my daughter's 1-minute APGAR was 0. She survived, but I haven't forgotten the disregard with which they treated my LDEM and the fumbling around that endangered my daughter's life.

I don't know how to make the hospitals pay attention to midwives in transit; I am under the impression that it is a dangerous situation we need to remedy.

- Anon.


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