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2. Neonatal water aspiration
3. Maternal hyperthermia may contribute to fetal hypoxemia
4. Neonatal hypothermia
5. Cord immersion in warm water may delay vasoconstriction, increasing red cell transfusion to the newborn and promoting jaundice
6. Blood loss estimation and assessment not accurate
7. Maternal and Neonatal infection may be increase - not supported by the evidence
8. Risk of acquiring blood born infection or sustaining back injury for caregivers

Recommended Criteria for the use of a water pool

1. An uncomplicated pregnancy of at least 37 weeks gestation
2. Established labor pattern - good regular contractions
3. Reassuring fetal heart tones
4. Absence of bleeding greater than bloody show
5. Spontaneous or on-going labor after misoprostol or Pitocin

Contraindications for birth in a water pool

There are no contraindications to labor in water, as evaluated by the literature and from experience.  Immersion is a client/provider decision.  Birth in water comes with a few "ABSOLUTE" contraindications and a few "CONTROVERSIAL" contraindications.


Absolute contraindications

1. Pre-term labor
2. Excessive vaginal bleeding
3. maternal fever> 100.4, or suspected maternal infection
4. Any condition which requires continuous fetal heart rate monitoring
5. Untreated blood or skin infection
6. Sedation or epidural
7. Fearful Attendant
8. Inflexibility in the client

Controversial contraindications

# Meconium staining in amniotic fluid
The presence of meconium should be evaluated with fetal well-being not taken by itself as a reason to ask the mother to leave the water.  Meconium washes off  the baby in the water. Baby can be suctioned as soon as it has been brought to the surface of the water. Some practices are now only limiting thick meconium cases.

# HIV, Hepatitis A, B, C, GBS
Evidence shows that HIV virus is susceptible to the warm water and cannot live in that environment. Proper cleaning of all equipment after the birth needs to be carried out. Hepatitis should be the discretion of the attending medical caregiver.
There is absolutely no evidence that GBS positive cases should be asked to leave the water.  Most hospitals allow IV antibiotic administration while in the water.

# Herpes
Some providers will cover the lesion, especially if it has peaked and is sloughing off.  Others will require a cesarean.  Some feel it is safer to deliver in the water due to the dilution effect of the water.

# Breech or multiple births
In the H. Surreys Hospital in Ostend, Belgium, frank breech is an indication for a waterbirth. Their experience has led them to believe that the absence of gravity, the warm water and the buoyancy create the perfect environment for a hands free breech birth.  Labor in water for both breech and multiples is well documented and recommended.  This should be a client/provider decision.

# Induction or augmentation
Many hospital practices will now allow mothers whose labors are initiated by Misoprostal or Pitocin to get in the pool as soon as a labor pattern is established.
Some even allow mothers with a Pitocin drip to labor in water, as long as fetal heart rate assessment can be monitored with continuous underwater equipment.

# Intrathecal use
A few hospitals will allow a mother into the water after receiving an intrathecal
Monitoring of the baby is suggested as continuous, but some hospitals allow intermittent monitoring.

# VBAC
As the controversy over vaginal birth after previous cesarean section continues, it has been noted that mothers who labor for subsequent births have a much higher success rate in giving birth vaginally.  Some hospitals refuse to allow women into the water because they don't provide waterproof continuous fetal monitoring.

# Shoulder Dystocia or Macrosomia with suspicion of Shoulder Dystocia
This is usually considered an obstetric or midwifery emergency by most. Current protocols in most hospitals require the mother who is anticipating a large baby to leave the water. There is mounting evidence that providers find it is easier to assist a shoulder dystocia in the water. It is believed that tight shoulders happen more often because of mom or caregiver trying to push before the baby fully rotates. Better to wait a few contractions, with the head hanging in the water and allow baby to rotate. Because position changes in water are so much easier than dry land, a quick switch to hands and knees or even standing up with one foot on the edge of the pool helps to maneuver baby out. (research indicates that you can't predict shoulder dystocia)

# Tight nucal cord
Under no circumstances should the cord be clamped or cut under the water.
Babies can be delivered through the cord and 'unwound' under the water.
Be cautious of cord snapping.

# Water temperature at time of birth
Some providers will not allow women to birth in water that is lower than body temperature due to the possibility that the baby will attempt to inhale under the water from a change in temperature. There is no evidence that supports this theory, in fact there is more evidence that now shows that lower water temperatures increase the baby's muscular activity and awareness.  Water babies are slow to start breathing due to the delay in stimulation of the trigeminal nerve receptors in the face and around the nose and mouth.  You must consider the birth of the baby from the time it leaves the water, not from the delivery of the baby into the water.  German midwife, Cornelia Enning, states that babies are more vigorous at a temperature around 92-95 degrees Fahrenheit.  If the mother is comfortable in the water, the temperature is OK for baby with only one restrictive parameter - NEVER higher than 100 degrees Fahrenheit.

# Placental delivery in water
There is no reason not to allow the birth of the placenta in water. Objections include inability to judge blood loss, possible water embolism and inability to contain all the by products of conception in one place.  Evidence now shows that delivery of the placenta is safe, blood loss can be estimated by color evaluation and determination of where the bleeding is arising and there is absolutely no scientific basis for worry over water embolism.  Placenta and pieces can be placed in a floating bowl in the water without difficulty. Cutting and clamping of the cord is not recommended with the delivery of the placenta in the water.


Helpful reminders for the use of water immersion for labor and birth

1. Midwives should discuss the potential advantages and disadvantages of water immersion for labor and birth with each woman prior to labor.
2. The fetal heart should be monitored according to accepted guidelines. Use of a waterproof Doppler is recommended.
3. The woman should be encouraged to maintain adequate hydration and leave the pool to urinate at regular intervals.
4. The woman should be asked to leave the water if there are any concerns about her or her baby's well being.
5. The water should be kept as clean as possible. Stool and blood clots should be removed from the pool immediately. The pool should be drained, cleaned and refilled if contaminants cannot be easily removed.
6. A small amount of blood often looks like a lot.  Undisturbed blood in a pool often congeals at the bottom of the pool into a small clot.
7. The pool or tub should be deep enough for the mother to assume any position comfortably.
8. Encourage mother to help guide her own baby out.
9. Suturing may need to be delayed due to water saturation of tissues.
10. The baby should be born completely underwater with no air contact until the head is brought to the surface, as air and temperature change may stimulate breathing and lead to water aspiration. If a change in position during delivery causes the baby to come in contact with air, the birth should be finished in the air.
11. Care should be taken to avoid undue traction on the cord. There have been reports of cord tearing.
12. The warm water helps maintain the newborn's temperature to prevent hypothermia. Keep baby submerged with head out only for best heat conservation.  Next to mother is best.
13. Encourage breast contact immediately, but breastfeeding is not always possible in the water, especially due to water high water levels.
14. You can insert a footstool or other object (husband) to raise a mother up high enough after the birth.
15. Birth pools should be cleaned completely between uses with a chlorine-releasing agent.  All pumps and hoses should also be rinsed with bleach.
16. Outdoor hot tubs are OK to use for labor and birth, if they are cleaned and maintained prior to the labor.
17. Jetted pools are ok to use if they are cleaned properly between patient use.
18. Small amounts of chlorine or bromine are not harmful to mothers or babies