The gasp reflex during water birth - has anyone heard of this or the risk that it could increase...

[VBACmama4]

Hi All. I am a VBAC mom, expecting my 4th baby who according to my initial ultrasound is past due. We are 42 weeks as of today, however all of my kids have been at least a week "late" even though they ultimately showed no signs of being truly post term. I had one cesarean in 2001, and since then I've had 2 successful VBAC's, one a water birth which was the only experience in which I could manage pain effectively, find a good birthing posture, and feel calm and serene during labor and birth. Since that experience, standards in this state have changed and no hospital or birth center will allow a VBAC to use a birthing tub. I found one hospital that said they "may" allow me to use the tub to labor but I'd be forced to get out to push. When I asked why, I was told that because I'm post-term according to my ultrasound date, there could potentially be a gasp reflex when the baby's head is born causing him to ingest water and possibly aspirate. I have searched far and wide online and at no time did I ever read any article or any other material that gives this claim any validity - in fact the only mentions I've seen of the gasp reflex state very clearly that prior to a baby being born, if the placenta is not supplying enough oxygen the fetal heart tones will show true decelerations and I would be forced to leave the tub anyway, well before ever attempting a tub birth. 

Has anyone had experience with this particular issue? Does anyone know of an article or other study I could quote on my birthplan to possibly counter their claims? I'm hoping to at least be able to labor in a tub and without this information I'm worried they will continue this ridiculous scare tactic. Thanks for any help you can give!

[onthenest]

Here's what I know- you can take or leave this information.  A member of my family is a neonatologist.  I am having a home birth which she seems to be supportive of, but she asked that we please not deliver the baby in water.  Apparently, she has seen babies end up in the NICU because they've inhaled water.  Obviously, in the NICU they will see the most extreme cases, so I'm sure that unfortunately she is full of rare horror stories.  This is my first pregnancy, so I am extra concerned about all of the little things that may or may not go wrong.  We have agreed that if we choose to have a tub at our place we will labor in it, but get out when it is time to push.  I know you already had such a great experience birthing under water, so that will be a tougher choice for you to make.  Good luck!  I'm sure whatever you decide will be great.

[VBACmama4]

Thank you for giving me an example of someone who has actually seen babies aspirate, I honestly haven't found others that deal with the gasp reflex. Did she mention at all what the precursors were for those babies? Were they in distress, post term, etc? I'd really like to have a reason to either believe them or totally disbelieve them, since the last thing I want to do is cause risk to my baby. I just remember the wonderful experience of birthing in water - my son barely cried at birth and instead was alert and ready to nurse - and I hate to be denied for a reason that I can't find valid info on! 

[onthenest]

Yes, I think you will find far more good stories than bad when it comes to water birth.  No, I do not know any more details than what I just told you.  Sorry to be so vague!  I truly hope you get to have the birth experience that feels right for you and your family.

[fruitfulmomma]

No waterbirths here but from my reading I remember water had to be at a certain level to keep baby from feeling any air while still submerged so they don't try to breath.

Aspirating babies I could imagine would come from a baby already in distress or not being picked up fast enough after the birth when the cord starts slowing down. 

Not sure about the postdates thing unless they are expecting her to be distressed and/or the placenta has started to break down. 

[VBACmama4]

That's basically the same info I've found, fruitfulmomma. I have read over and over again that a baby born in water will not gasp unless being deprived of oxygen prior to birth, which is fairly easy to detect with monitoring. I've had a biophysical profile and non-stress test done so I know at this point that my little man is safe and sound, so it really angers me that a trained midwife affiliated with one of the few hospitals in this state that has birthing tubs would be handing out misinformation or partially true information without explaining how easy this issue would be to prevent. From what I've read and been told by other birth professionals, the baby doesn't need oxygen from an external source til the cord is no longer viable. Now I really need to write a letter to the head of Labor and Delivery at that hospital to let them know that their midwifery team is either ill-informed or lying! I wish I had the money to become a midwife!

[wissa19]

Quotes from

http://journals.lww.com/amjforensicmedicine/Abstract/2010/09000/Forensic_Issues_in_Cases_of_Water_Birth_Fatalities.14.aspx

It has been postulated that newborns will not breath or swallow while immersed in warm water, and that respiration will only be initiated on exposure to cold air. This has been used to support assertions that drowning and aspiration of water cannot occur with underwater delivery. However, animal studies have demonstrated that this reflex can be over-ridden, and given that respiratory movements occur in utero, it is difficult to see why this process would not continue in a neonate delivered into water. The documentation of cases of near drowning and respiratory distress with apparent aspiration of fluid would also be supportive of the occurrence of breathing under water. In addition, the finding of hyponatremia in certain of these infants would be in keeping with inhalation of fresh water, as lowered sodium levels have resulted from fresh water drowning.

Sepsis has also arisen from underwater deliveries, ranging from umbilical and ear infections to septicemia and pneumonia. The source of such infections has been contamination of birthing tubs, hoses, and taps with virulent organisms such as P. aeruginosa and Klebsiella pneumoniae. These bacteria have been found despite careful cleaning of systems between deliveries. Lethal Legionella infection has occurred in an underwater birth reported from Japan and other organisms such as amoeba and Mycobacterium avium have been found in spa baths...

[VBACmama4]

Wissa19, thank you for that link and info. The link you provided goes only to an abstract that requires membership to review the complete study, however I believe several parts of this study have been used in literature I've seen before. If I'm correct, one of the passages in this study states: (the study) found that out of 4,030 deliveries in water, 35 babies suffered serious problems and 3 subsequently died. It is unclear if any of the deaths can be attributed to delivery in water. However, of the 32 survivors who were admitted to the NICU, 13 had significant respiratory problems including pneumonia, meconium aspiration, water aspiration, and drowning. Other complications attributable to water birth include 5 babies who had significant hemorrhage due to snapped umbilical cord. In all, 18 babies had serious complications directly attributable to waterbirth. The risk of serious complications necessitating prolonged NICU admissions was 4.5/1000.

The first thing that I'd like to point out is the fact that the study states specifically that it is unclear if water birth is the common factor that caused the deaths of these infants. Second is that the rate of 3 deaths out of 4,030 water births is significantly lower than the total infant mortality rate of 7 in 1,000 live births, http://www.webmd.com/parenting/baby/news/20081015/infant-mortality-us-ranks-29th. Third is the fact that meconium aspiration and hemorrhage due to snapped cord are not symptoms of water birth specifically, these complications can occur during any birth, including those not in water. Snapping an umbilical cord is a result of pulling too hard at delivery, not of any complication occurring as a result of submersion in water. 18 of the over 4,000 infants studied here born in water had complications, whereas on average 5-7 out of 1,000 infants suffer from complications during all births http://www.rightdiagnosis.com/c/childbirth/complic.htm#complication_stats. As you can see the rate is nearly the same for water birth as with all birth. 

The problem is, in a study of a small group of fetal morbidity, mortality and infection being attributed to water birth, there is no mention of the comparison between the deaths "caused" by water birth - which are often found to be less unpredictable then originally believed as precursors include meconium in waters, fetal heart decelerations, decreased fetal movements, vaginal bleeding, and more - and the deaths that occur during bed or "land" births or cesareans. Based on my research (and I've been researching this for almost 10 years), cases of MRSA, pneumonia, inexplicable "rashes" that are viral in nature, and many other examples of infection are found in high numbers among land births as well. Keep in mind that even though an infant is not submerged in water during a land birth, they are exposed to not only the vaginal cultures of the mother but urine, feces, and yeast as well as the viruses, germs and bacteria presented by handling of several members of any hospital staff. Hospital birth in and of itself presents a risk to a laboring mother and her baby. 

Additionally, the dive reflex is unlikely to be overridden during submersion in water before 4 months of age. This of course is not a 100% invariable fact, but neither is a statement that birthing on land is always safer. An infant lives in fluid for the entire length of gestation and when born is still being supplied oxygen from the umbilical, which is rarely compromised unless the umbilical or placenta are compromised in some way. A fetus in utero mimics breathing motions with the diaphragm, even though they do not actually "breathe" amniotic fluid. Any fluid that enters the mouth is swallowed because the lungs are essentially collapsed until the infant takes the first breath. 24-48 hours before birth: Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements. When the baby is born and the Prostaglandin level is still high, the baby's muscles for breathing simply don't work, thus engaging the first inhibitory response.http://www.waterbirth.org/assets/documents/Waterbirth_Basics.pdf

Basically my question was only regarding the gasp reflex as associated with being perceived post-term, not whether water birth is viewed as "safe" or "unsafe", since there are so many sources of information touting one or the other by people who are biased in either direction. It's no different than the safety or danger of homebirth, since some people are advocates of it and some are absolutely opposed. I have already had a water birth, we were both safe and healthy, and never had any complications whatsoever. Could there be this time? I suppose, but there could be in a bed birth as well, or a home birth, or in precipitous labor occurring on the way to the hospital.

Thank you again for taking time to respond, I don't mean to sound oppositional but I'm really only looking for info on water birth as in pertains to post-term pregnancy. 

[sassyfirechick]

I don't have any studies, but I was always under the impression that babies don't "gasp" until they feel the air on their skin, or if the cord is cut too soon.  I do know more mom's who's babies ended up on respirators and even with pneumonia shortly after birth because they either had a convenience scheduled C-section or the cord was cut immediately after the baby emerged.  I wanted a water birth, unfortunately the midwife group I went with didn't have priviledges at a hospital that allowed it.  They had a tub for laboring only, and it was conveniently broken when I was in labor.  We did delayed cord cutting and I opted for no pain meds, so my daughter was born fully alert, only a tiny cry which stopped immediately when DH placed her on my chest.  She was a tad purple (mommy wasn't good on deep breathing after getting pitocin!) but even with a slight oxygen deprivation she didn't gasp for air.  She had a nice, gentle transition from cord carried oxygen, to lungs taking over.  I had joked with DH that if the tub was working, maybe I could sit there long enough to say "oops, baby's coming out, it's too late for me to move" haha.

[VBACmama4]

Thanks for posting your experience and the info you gave. I have also learned (well before my first water birth in 2002 since I never want to choose an option with unnecessary risks) that babies will not take a full breath until exposed to air. This is why I was so furious when I received this misinformation from a midwife no less! I've changed providers 6 times during this pregnancy, the most I've ever tried during all 4 of my pregnancies, and I get the same denials and quoted risks and complications, even though this is my 3rd VBAC. It's really sad how things are in this state, VBAC's are pushed into unnecessary procedures, interventions, poor birthing choices and almost no options. As someone who has already had a water birth with no adverse outcome whatsoever, being told I'm too risky to even use a birthing tub really burns me up. 

With my water VBAC, they gave me the option to cut the cord whenever I chose to, so we waited til I delivered the placenta totally before doing so. My baby was nursing when I delivered the placenta, so he had a really gentle transition and has never had any health problems beyond the common cold. My first child, who was a forced induction leading to a forced cesarean for no medical reason other than failure to progress (hurry, you're taking too long!!) has been mostly healthy but has had to contend with ADHD, oppositional defiant disorder and a metabolism so high we can't get him to gain weight to equal his height. My third child was a VBAC in a hospital bed, attached to a fetal monitor even though he never had even the slightest sign of distress, and he's had more colds than the other two plus he had a viral disorder at 6 months of age that caused pain in his wrists and ankles which made attempting to crawl painful. So, for me, the choice to avoid interventions as often as possible is an absolute no-brainer. 

[VBACmama4]

Incidentally, my husband was an EMT for 13 years and a bouncer in several bars part time for almost 20, so between those two credentials, he's told me in no uncertain terms that he would love to see any hospital staff try to move me if I don't want to be removed from the tub lol. He could honestly deliver this baby himself and we considered a home birth, but because we live over a half hour away from the nearest hospitals and it just happens to have one of the highest cesarean rates in this state, we were concerned with potential complications and how they might be handled *if* something were to go wrong. 

[wissa19]

Hi - VBACmama - I didn't mean to make you think I'm against water births.   I guess I shouldn't post when I don't have time to explain.  What I was trying to point out is that there are risks and sometimes hospitals view the risks differently.  As there have been cases with poor outcomes for the babies I can see where hospitals would put in place very strict guidelines about any water birth they do.  

For example, if they feel they can't adequately monitor the baby during delivery, etc then they aren't going to be willing to do it.  Plus, most hospitals these days VERY cautious about any kind of infection. I know women who have had water births with no problems and loved the experience.  One friend did end up having a very very short cord and her husband had to help lift her out of the water when her son was born.  It was a very scary moment for all of them because if she hadn't been able to stand right after the birth the midwife couldn't have gotten the baby above the water.  (this was at hospital).  So, there are things that can happen that would make a hospital overly cautious about their criteria for giving birth in the water.

I know it's hard to put things into the hands of others when you really know what you want and have had bad experiences in the past.  Hopefully, you will be able to communicate with the hospital staff and have beautiful birth with few interventions.

Oh, and would say if the c-section rate really bothers you..try to find why it's so high.  Sometimes those numbers are high because the hospital does a lot of high-risk deliveries.  I know this is true for one of the hospitals in our area.  They have the only level 3 NICU in the area, so they get high risk women from all the surrounding counties as well. 

And will say, if you haven't had that baby yet...I hope you do soon!

[VBACmama4]

Wissa, thank you for clarifying. I appreciate it. While I do understand that hospitals are very risk-concerned, and I also understand that they are terribly afraid of lawsuits, that doesn't prevent them from forcing procedures that cause as many complications as they prevent in many cases. Induction, for example, has a 20% more likely rate of cesarean than a natural birth and can often result in poor outcomes. It carries risks for the baby and mother that are rarely discussed, yet it seems the hospital views induction as perfectly acceptable regardless of if it actually prevents or improves anything and in most cases, in fact, it doesn't. In my case, everyone I talk to wants me to agree to induction, meds, bed-labor, etc that I have no indication of needing other than exceeding my medical expiration, or "due" date. As a VBAC, my chances of being left to labor naturally are already decreased exponentially, so I avoid as much as I can within the limits of safely giving birth. 

One of the many considerations my husband and I carefully made when deciding on a hospital water birth rather than a home water birth is the potential that if something does go wrong, we are not close to the hospital and we don't want to put our child in danger. Another reason is because it would be more difficult to detect and treat complications in a home birthing tub, as opposed to a hospital birthing tub, which according to medical standards must be able to drain in less than 30 seconds (probably for the exact reason you mentioned where your friend faced a complication with a short cord). Some of them drain in as few as 10 seconds to allow medical staff faster access to mother and baby. What concerns me most about putting my baby and his birth in the hands of the medical profession is the total lack of individual attention. While many people who have gone post dates may have experienced complications, my children are always "late" and we never have - this baby included. Yet every medical professional I speak with makes it very clear that they have protocol to follow that will make it very difficult for me to give birth without as many interventions as they would inflict on a woman who has serious risk factors. VBAC carries risk, but after 2 successful VBAC's that risk decreases until I'm almost equal to those of any birthing mother who has not had a cesarean. It's a level of frustration that I'm used to and sick of at the same time, it detracts from the happiness my husband and I feel for our new baby's arrival because we know that I'll be treated like a diseased patient rather than someone who's body is performing a normal function. It's very sad. 

We've contacted 9 hospitals and 2 birth centers in this state and none of them are even willing to entertain intermittent monitoring, no IV, unlimited length of labor, water labor let alone water birth, etc. I'm at a dead end and hearing a midwife quote an absolutely untrue medical "fact" about water birth was just more than I was willing to listen to. 

I really do appreciate your good wishes and words encouragement, even when other mothers have opposing views, it seems we always wish the best for each other. If you're expecting, I hope you have an absolutely safe, healthy and happy pregnancy and birth as well.