Water Birth and Water Immersion During Labour

Dr. Alicia Power and Heidi Machnee, Registered Midwife, review the evidence, risks, and benefits of immersion in water during labour, and water birth to both the delivering parent and the newborn, including reasons it may not be appropriate to consider a water birth and what safety factors care providers need to think about to ensure a good experience for the birthing person and baby.

Resources

• BC Women's Hospital Guide to Water Birth

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Transcript

[00:00:50] Dr. Alicia Power: Today, registered midwife Heidi Machnee is taking us for a deep dive into water birth and water immersion during labor. We'll discuss the risks and [00:01:00] benefits to both the delivering person and the newborn, and talk about whom this might be appropriate for and who it may not be. Heidi, why don't we start off by you introducing yourself.

[00:01:10] Heidi Machnee: Hi so happy to be here. Yes. My name is Heidi Machnee, and yes, I've been a midwife in this community for a couple years. I've been practicing for three years, so again, by no means I'm, am I the expert in water birth. But really excited to speak to it because it just is something that clients often ask about and it is just growing in popularity. So definitely something that is good to shed some light on and provide some good quality evidence around. I have a background as a registered nurse in pediatrics since 2006. So quite a breadth of time in healthcare and yeah, I feel super passionate about birth and choice and water birth is definitely a a topic that I'm very interested in and have gathered a pretty solid range of research around. Yeah, let's dive in and talk about it.

[00:01:53] Dr. Alicia Power: Awesome. So when we talk about water birth, we're talking about a couple of different things and some of [00:02:00] the studies that we looked at are, they don't really separate them out very well, so I think it's important that we say there's like water immersion during labor, so laboring in the water and then there's actually birthing your baby in the water, which are, which sometimes that's goes from one end into the other, but oftentimes they're separated. So some pregnant people labor in the water, but then get out and birth on their bed or in the hospital, whatever that looks like. And other people are there the whole time. And so it's two different things we're gonna chat about today. So water don't, we start about kind of water immersion so that laboring in the water. So that's during that, early to active phase, so before we actually start pushing.

[00:02:35] Heidi Machnee: When you're looking at research studies difficult, difficult to pull those pieces apart. One of the, one of the outcomes that's specifically focused around labor is does immersion water have any negative or positive impacts on the birthing person? So we're not getting to the birth part yet, so we're just thinking about the birthing person. A lot of the studies look at a couple things.

[00:02:54] So one is, what does it do for pain control? And this is probably one of the most common reasons that people, the [00:03:00] general population knows about water birth and the uses of it, or the desire for it. And so it's, am I more likely to not need an epidural if I use water immersion in labor? Some of the studies are a little bit inconclusive. There's this database called the Cochrane database, and they do huge kind of like meta-analysis, the systematic reviews of lots of different studies and they pull out data and, a lot of the commentary in there was like, poor quality data and like diff difficult to pull the information outta these studies. But there are enough studies out there that actually that, that absolutely do have a finding that says yes actually, pain control and decreased epidural use is something that we do find with with water immersion and labor, which is great.

[00:03:40] There's a couple other things. So it, there's this idea of hydrostatic pressure. So the pressure of the water on the birthing person's body. There's some evidence that it can increase cardiac and renal function the perfusion of blood into the placenta. The idea of buoyancy, so freedom of movement, ease of position changes in the water warmth. Just being [00:04:00] a comfort and a choice, some people really enjoy water and they like the option of using that in labor.

[00:04:05] Dr. Alicia Power: So another benefit they talk about is, so yes, sticking with the pain. So we decrease the amount of pregnant people who need, or who request an epidural if they have water immersion during their labor. There was no difference though on the amount of opioid use. So that's like morphine or fentanyl that we use. But the other thing that they showed was there's actually a decreased amount of time from when you're in active labor until you're fully dilated, and that was about half an hour. So oftentimes those are in first deliveries. Those are like, six to eight hour periods. So decreasing by half an hour is pretty significant. And so that's, I suspect part of that is some of the things that you mentioned, Heidi, and also that ability to like, relax and just feel more comfortable. Mm-hmm. I actually pulled out a quote from one of the studies; so "women also reported experiential benefits that included feelings of relaxation, warmth, privacy and an improved ability to maintain control during labor. And so I think, I often see that [00:05:00] people who are scared of the pain or scared of the process aren't able to relax into it as much. So they're almost fighting their body a little bit. And there's, there's a lot of evidence around I dunno about evidence, there's a lot of people around hypnobirthing and they're talking about how just reframing the pain of contractions and reframing that in your brain just allows you to give into it a little bit more, which then allows all of your body to relax. And if our pelvis is more relaxed, if our perineal muscles are more relaxed, we're gonna allow baby to descend a little bit. So it totally makes sense that's the case there.

[00:05:33] Heidi Machnee: Yeah I think something that's interesting. I'll just throw this in as a bit of a, as a bit of an addition, but I think sometimes we can get into this frame where we think about labor and birth as just this very physical event. Like my uterus is contracting, and then the baby's coming down and then we, then I push and the baby comes out. But it's so hormonal and we think about oxytocin, this main hormone that is produced in by an area in our brain and lands on our uterus and causes those contractions or waves bringing the baby [00:06:00] down. Oxytocin is super linked into how we feel. So Alicia just mentioned kind of an anxiety or feeling like not, not comfortable in their surroundings. Oxytocin flows best when you are in a private environment, when you're safe, when the lights are low, when there's familiar people around you, when you feel loved, when there's not a lot of like strenuous kind of sounds and beeping and dinging and so I think, sometimes this idea of being immersed in water can really just feel that like comfort and safety and potentially add to that oxytocin flow in your body that's gonna keep your labor moving along. And that just links into the, that person's sense of autonomy and choice over the option to use water for their labor. I'll speak to a couple of things that are important to consider when you're using water immersion and labor, is that, in the research often there's a few spots where it speaks to at the initiation of active labor, so if you are one centimeter dilated, you probably don't wanna get into the tub yet. Your body hasn't kicked into that really beautiful, strong pattern yet, and water immersion can actually slow things down in the early phases of labor, but once you're an [00:07:00] established active labor, your cervix is like five to six centimeters dilated, then these benefits really kick in.

[00:07:05] Dr. Alicia Power: And then in those kind of reviews, in the studies that have been done that are higher quality or they've pulled all that, there's, so we talked about how there's a decrease use of epidurals and a decreased time to full dilatation as benefits of water immersion during labor. The things that they found no difference in were the use of opioid use or in perineal trauma, need for episiotomy, assisted vaginal delivery or cesarean section between those who use kind of water immersion or not.

[00:07:30] So there's a lot of great benefits, but I think in terms of kind of those outcomes, there's no difference between whether or not you use water or not. So if you're going to use it for pain management, for that feeling of relaxation, and those, those types of things, which are extremely important as well.

[00:07:45] The other thing that they there's two, we've got two patients or clients here. So we've got the pregnant person, the laboring person, and we've got the baby. So we always like to look at both sides of the puzzle. So in terms of water immersion during labor, in terms of neonates, there's no benefits or risks to using [00:08:00] it or not, so that nothing, absolutely. There's no concerns around baby as long as, again, everybody's healthy going into it. There's no concerns for babies in terms of if you choose to do that or not do that.

[00:08:11] Heidi Machnee: There were some studies that really, that made sure that they made the point that, water immersion should not inhibit us from doing our normal sort of careful, watchful evaluations of babe and the birthing person. Absolutely the listening to the fetal heart rate every 15 minutes through labor like that shouldn't be compromised by the person being in water. So our ability to do vital signs on the birthing person and listen to this baby's heartbeat should continue to be the same and not be inhibited by that use of water.

[00:08:36] Dr. Alicia Power: The other thing to note is that not all hospitals have birthing water tubs. Our hospital in Victoria, we don't have tubs. We've got showers with lots and lots of hot water, and we know our laboring people love to go in the showers for that same kind of like relaxation feeling, but we don't have tubs where some other hospitals actually do, and so that's gonna be different from one community to another. But certainly if you're at home during that time or you're planning for a home birth, [00:09:00] that is one thing to think about as well. The next thing we want wanna talk about is actually the birth in the water. So an actual water birth. So delivering your baby in the water. So Heidi, why don't you talk about that piece of the puzzle?

[00:09:12] Heidi Machnee: Sure. So if we're looking at the birthing person, again, there's not really much that changes in the research. We talked about evidence around, not much difference in regards to the degree of tearing that might happen after a birth. So no significant increases of like more significant tearing in that person that births in the water versus on land. Same thing for pain control and progress and pushing. It's, there's really not much difference between the two, but the main focus becomes the newborn because, they are gonna be born under the water and coming up. We'll talk specifically about criteria, so inclusion and exclusion criteria a little bit later.

[00:09:46] But speaking to the research, the things that are really analyzed and looked at in the research are things like NICU admissions, so babes that require, potentially more or the same number of rates of admissions into the neonatal ICU. [00:10:00] Infections in the babe. What are their APGAR scores, which is like a scoring system that we all use to evaluate how is this babe transitioning from the inside to the outside. Looking at rates of hypothermia. Are babies more likely to have temperature instability after water birth versus not? Are there increased rates of respiratory distress? So babies that are breathing, using their muscles to breathe and breathing faster than normal. Pneumonia is something that is rare, but something called cord evulsion, so like the cord actually snapping before the baby is, like fully born. Shoulder dystocia, the baby, baby's like top shoulder kinda getting stuck behind the pubic bone. So they're, they really do look at this comprehensive range of rare but things that kind of are on their mind for a baby being born under the water. And there was this great study that was published again, I really like to talk about like data that really reflects our environment, our site, our population.

[00:10:47] So yes, Alicia just said that we, we don't have tubs in Victoria, but BC Women's Hospital, which is like the Provincial Referral Center, they're the big tertiary center, they actually luckily have these [00:11:00] beautiful birthing rooms with these massive tubs. And they have this protocol where, you know, all of the hospital staff are trained in their comfort and knowledge of how to safe offer water birth in the hospital.

[00:11:09] And so there was a midwife that has an incredible research background that works at BC Women's Hospital and published, helped to publish a study in the journal of Obstetrics and Gynecology of Canada just in 2019. And they looked at 25,000 births done at BC Women's Hospital and 2,500 of them were in the water. And so they just, they compared these populations and they looked at all of those, neonatal outcomes and they found that absolutely water birth was not associated with higher rates of neonatal, poor neonatal outcomes. So that's a really great study to be able to have in our back pocket when we look at, local BC specific data.

[00:11:45] Dr. Alicia Power: I'm just gonna caveat that, that there's very specific people who "quote unquote" qualify for a water birth. Yes. And there's very specific protocols that are in place around the kind of the tub use there, which we'll definitely talk about. So I just wanna make sure that this is within an appropriate population, in [00:12:00] an appropriate, safe setting that that these studies were done. Which is very important. Yeah. And so definitely most of the data shows that there's no benefits or downsides in terms of those outcomes to giving birth in the water or on land, outta the water, for moms. Other than those kind of feelings of, which are extremely important right, that we talked about before, that kind of feeling of empowerment and choice and those types of things, which is a huge, a hugely important piece. But in terms of kind of those measurable outcomes that we have, there's no kind of major differences one way or the other.

[00:12:28] And in terms of the neonates, I think the only thing that was found, and I don't know if it wasn't in that study, but another one that we looked at was that cord evulsion piece. And so that's when, sometimes babies are born with a cord, a very short cord, and so we can't get them all the way up if we're delivering on a bed or on the land. We can't get them all the way up to mom's chest. But if you're in the water, you may not be able to recognize that as well. So there was a higher rate of kind of cord evulsion, so that cord breaking apart and the baby bleeding, right? Before they were able to clamp it and there was a very small rate [00:13:00] of babies needing to go to the NICU and very small rate of them needing a blood transfusion. So that's the one piece there that might be a bit of a higher risk of having a water birth as opposed to a land-based birth that was found.

[00:13:11] There was also a couple of infections, but when they actually looked into them, like one of the people had filled their tub up two weeks prior. So it was contaminated with bacteria because it had been sitting there for two weeks. Don't do that. And the other one looked at it was a hospital birth and the actual, the water had legionella in it, which is a well-known contaminant that can cause pneumonias in anybody who uses that or it's aerated. And so there was a really good reason for that. So not a, no kind of obvious reason for, to worry about an increased risk of infection or anything like that. So that was really reassuring as well, I thought.

[00:13:44] Heidi Machnee: And there's just some interesting physiology that's that's helpful, I think, to know when you're thinking about what's going on for that little baby in that process where they're, they've just come through the birth canal. They're outside of the birthing person's body. What, what's going on for them? What are the things that trigger their transition to start [00:14:00] breathing and things like that. When we think about what causes a newborn to take its first breath, it's often triggered by a temperature change, right? So if they're birth, if they're birthed in a, on land they, there's this ambient room temperature change. So that kind of like the colder air from inside the birthing person's body to the air, so the receptors in their skin kind of sense this temperature change and that can cause them to breathe.

[00:14:22] There's a rise in CO2 levels that can cause them to breathe. So there's a, there's tactile stimulation. Touch and stimulation also can cause them to take that first breath. There's something called the dive reflex that newborns have, and actually I think they maintain it for quite a while. I can't remember exactly when it goes away, but I wanna say even up to a year of life. When there is plain water at the entrance to the larynx, it triggers apnea. So it triggers the baby to not breathe, to not inhale and take that breath in and stimulate swallowing instead of that breath into the lungs. And so there is this idea of, water being this [00:15:00] stimulant to not actually breathe.

[00:15:01] There's also hormonal factors in the second stage of labor, just in general that decrease the likelihood of any infant from inhaling prior to them being outside of the birthings person's body. So there are these physiologic things that actually are protective in newborns. We talk about risk. Some of the candidate selection, some of these things come up, for example, you know, care not to, when you look in the water and okay, the baby's head is born, don't get in there with your hands and touch that baby's head. You do not wanna stimulate them before they're scooped up and out of the water. We're careful with the temperature of the water. We'll, we're careful with tactile stimulation while they're under the water, so as to not ruin some of these physiologic benefits that are in place naturally.

[00:15:44] Dr. Alicia Power: Exactly. Exactly. So why don't we talk a little bit about candidate selection or who is appropriate for a water birth? And this isn't necessarily, part of this is water immersion as well, but definitely water birth and who is not. And then we'll talk about kind of some of those safety mechanisms that we [00:16:00] need to make sure are in place. So certainly in terms of kind of those people who are appropriate, we want people who are term so greater than 37 weeks. We don't want to be delivering preterm babies in the water. So over kind of 37 weeks. And another important piece is like people who can actually mobilize so they're alert and they're able to physically get themselves out of the tub if they need to. And so this is that's a really important thing and I'm gonna, we're gonna speak a little bit, remind me Heidi, to talk about like safety planning around this. Because we do that, I do that with when with pregnant people delivering people who've had a previous shoulder dystocia or who have a really big baby and I'm worried they're gonna have a shoulder dystocia.

[00:16:39] We like practice the steps while they're in labor before we get there so that they know what to do. And that's the same thing you can do that if you're planning on water birth practice the steps of if we need to get you out quickly, for whatever reason, this is how we're gonna do. So everybody who's there can have their role and support that.

[00:16:54] Heidi Machnee: Yeah, absolutely.

[00:16:55] Dr. Alicia Power: We also normal vital signs pregnant, the delivering person and the baby. And so [00:17:00] that's really important. And so that's, Heidi was talking about that we still have protocols that we need to follow that we're listening regularly, we're taking temperatures, et cetera, et cetera. And the temperature piece is another one that we wanna make sure that you keep your water temperature right, so that we're not giving moms high fevers in labor because that affects their babies too, from the temperature.

[00:17:17] Heidi Machnee: And for the baby. So a baby that's born into water, that's like a little bit on the cooler side, they're maybe more likely to take that gasping breath underneath the water if the temperature is not kept appropriate. So it's actually really important, so it's like hourly, if not even more frequently, like checks of the temperature of the water and checks of the birthing person. So making sure that their temperature is not rising. Anytime a birthing person's temperature is greater than 37.5, we ask them to get outta the tub, spend some time out of get on the birth ball, spend some time on the bed until their temperature normalizes, cuz it's likely not a true fever, it's just that their body is adapting to the, maybe the water is too warm in the tub.

[00:17:56] Dr. Alicia Power: Exactly.

[00:17:56] Heidi Machnee: The other things are, I think I talked about established active [00:18:00] labor. So making sure that person is in good, strong labor so that we're not gonna slow down this progress by getting them in the water. Clear amniotic fluid, so no evidence of meconium. So that's that baby, some babies sometimes take their first poop on the inside. That requires a bit more monitoring. And so the a, the amniotic fluid has been clear and interesting. BC Women's Hospital says that if your water has broken, it's still okay to be in the tub. And even if you're GBS positive, which is a bacteria that is present in about 30% of the population, you're still okay to be in the tubs. So those weren't exclusion criteria.

[00:18:32] Dr. Alicia Power: You're probably getting your antibiotics though if you're at BC Hospital. Exactly. Exactly. And are positive. Yeah, and at home. Exactly. Yeah. And so that's, yeah, those are the things that I have for kind of inclusion. Anything else that you can think of?

[00:18:43] Heidi Machnee: No, I think that's pretty comprehensive.

[00:18:45] Dr. Alicia Power: Okay, so for exclusion, so people who may not be appropriate for a water birth, so we talked about it. So either a physical or a medical condition that makes the laboring person at increased risk for falling. So this could be obesity, this could be somebody who's got some paraplegia or [00:19:00] muscle strength issues or multiple sclerosis, those types of things.

[00:19:03] So somebody who can't physically get themselves up and outta the tub quickly. Or another thing is, you have to be alert and awake, so you don't want you falling asleep in the tub. And you can't have opioids on board. So morphine and gravel or fentanyl on board. So still having effects while you're in the tub and an epidural is one of those exclusion criteria cuz your legs are numb, you can't get out obviously. Yeah. But also probably an increased risk of infection site as well. Yeah.

[00:19:27] Heidi Machnee: And there's a couple things. So speaking to the opioid use, so morphine or fentanyl. So I think one of the reasons a.) yes is that you don't want the birthing person to be drowsy in the tub. Those opioids have a short term effect, a safe but short term effect on the newborn. And so we don't want newborns who are exposed to opioids being born under the water either, again, to not have them be in a situation where they would wanna do that gasp and have that sort of dive reflex compromised as they're being born. So it's also a newborn piece as well.

[00:19:54] Another thing on this list is if the birthing persons person is on medications for anxiety or [00:20:00] depression. So SSRI use. And again, I think that has a lot as well to do about the newborn. We want newborns that are, picture perfect, normal, who are gonna protect their airway and have that dive reflex that's not gonna cause them to breathe under the water. And who are, likely to transition well on the outside.

[00:20:16] So sometimes SSRIs can make that process a little bit slower and a little and those babes need a little bit more help. So that would be the reason around that.

[00:20:24] Dr. Alicia Power: But can we just make a very important point? People? Yes. Yes, please. If you need your SSRIs, please take them. Stay on them.

[00:20:31] Heidi Machnee: Absolutely.

[00:20:31] Dr. Alicia Power: Don't forego them for a water birth. You're mental health. You're more important to be a stable human being. Parenting your new baby.

[00:20:39] Heidi Machnee: 100%. 100%. Thank you, Alicia.

[00:20:42] Dr. Alicia Power: We don't want pregnant people who have a maternal infection for a bloodborne pathogen. So we're talking HIV, hepatitis, syphilis, those types of things. Birthing in the pool because increased exposure to baby, but also increased exposure to the care providers as well. I dont know that's necessarily the reason why. And then we talked about the meconium stained fluid. So if baby's already had their [00:21:00] first poop, then probably not appropriate that you birth in the tub.

[00:21:03] And then again, we want this to be low risk people. And so if there's factors that increase the risk of your birth or complications of birth or immediately postpartum, we wanna keep you and your baby safe. So that's things like if your baby's not well down in your pelvis, or if you have a history of a big postpartum hemorrhage, so lots of bleeding at a previous delivery, or if you've got known fibroids that increase your risk of bleeding or a bleeding disorder. Those types of things. And probably not appropriate to. Birth in the tub, you can probably labor in the tub but probably better to birth in a more, a setting that we can support you quickly if we need to.

[00:21:39] Heidi Machnee: Yeah. And so then I think if we can move to what is the role of the midwife or the registered nurse who's helping to do this sort of, hour to hour management of and care of the person in the water. So we have mentioned a few things already. Temperature of the water is super important, so making sure that it's between that 35 and 37.5 degree mark and, adding more warm [00:22:00] water or adding cold water, just really caring for that. And we know that it has, it can have a really quick impact on mom on the birthing person and babe, if it's not in the right temperature. Making sure the water is clean. So sometimes that actually means we drain the tub and we get the person outta the tub and we drain the water and we refill because there's been a bowel movement or something like that. So keeping the water clean. Really important, again, this is a baby thing, but making sure the water levels are high enough so the baby has to be born fully submerged under the water. Like they can't be born with their, they're exposed to a bit of air and then they dive under the water like that person's, bottom has to be fully submerged. So either the baby's born fully standing, like outside of the water or fully under the water.

[00:22:39] Dr. Alicia Power: Yes. Also to that same thing. But the water can't be too high either because baby's birthed and then put brought outta the water on the delivering person's chest. So we need them to be able, we need that waterline not to be up to the pregnant persons neck. Yes. But, but high enough, the baby stays under until we are ready to take them out. But that can then get onto the delivering person's chest right [00:23:00] away.

[00:23:00] Heidi Machnee: And we talked about safe monitoring of vital signs for the birthing person and heart rates for the baby, and then, at the time of the birth. So we, again, we talked about a few of these things, but avoiding touching that baby. So we really avoid that tactile stimulation. Any exposure to cold air, we don't want them to take that breath under the water. So we really try to keep our hands off. But then as soon as that baby is out, we scoop them up and get their head above water and get them onto the birthing person's chest.

[00:23:23] We, we often do advise the birthing person to move out of the tub, onto our secondary prepared areas, to the bed or a couch that's protected for the delivery of the placenta. And that's just so that we can make sure that we're monitoring any blood loss, making sure that stays really safe. We usually wait actually an hour to do any stitches down below if that's required, simply because sometimes the tissues can take on a little bit of extra water and we wanna make sure that the healing is gonna happen. So waiting a little bit longer, that's a unique thing about people that have spent time in the water, we wait a bit before we do stitching.

[00:23:54] Dr. Alicia Power: I'm just thinking about how pruny my fingers get in the water.

[00:23:57] Heidi Machnee: I know, right? Yeah. Sorry. Yeah. [00:24:00] And and keeping babe warm and dry. Again, back to the research, one of the questions was, is " Hey, did these, how, what's the temperature for these babies?" we know that little babies who are wet can lose their heat really fast. So it is, so important that kiddo gets dried off and bundled up in warm blankets so that they don't drop their temperature too much. And that can lead to some unsafe situations for babes. So keeping that baby warm and dry right away is really important.

[00:24:25] Dr. Alicia Power: Yeah. And they also don't recommend cutting the cord underwater. So like you said, generally speaking, after you've birthed, you get outta the tub to a secondary area and that's where you would dry off, dry, baby off. Do your delayed cord clamping deliver the placenta. Do all your checks, et cetera, et cetera. Any other points that you wanted to talk about, Heidi?

[00:24:43] Heidi Machnee: No. I think, yeah I'm grateful. BC Women's has taken research from all over the place, Australia and locally and other provincial guidelines, and I feel like they've really nailed it and in helping to set out those lists of, these are people that are great candidates, these are people who would encourage not to birth in the water.

[00:24:58] I've read some guidelines [00:25:00] around, really encouraging people to not think that they can get in the tub and stay in the tub their entire labor. Like we actually recommend that after an hour to an hour and a half, the person has about a 30 to 60 minute period outside the tub. And that's so that the electrolytes in their body and, their fluid levels in their body can just have this ability to adapt back and forth.

[00:25:18] Really good evidence around having periods of time outside of the tub before you move back in is actually good. In any labor, we really encouraged the birthing person to move their body. So changing positions, being active, not staying in the same position for the entire labor. And that just allows babe to rotate in your pelvis, move down, allows your hips to shift. Very possible that your support team, if you're having a water birth, will recommend that you actually have periods outta the water. And that's actually really a really safe and good thing to do, asking you to change positions. So I think that's something that's important to think about as well.

[00:25:50] Dr. Alicia Power: Yeah, totally. And we know, we know prolonged, like I said, my pruny fingers, it's because of the balance between outside of our cells and inside of ourselves shifts based on the fluid that's [00:26:00] around us. And oftentimes if we're in the water for a long time, our fluid shifts out of our cells slightly, which gives you those pruny fingers. And so you exactly also need to make sure that you're staying really well hydrated. And then, like Heidi said, getting outta the water and making sure you're moving around cuz it's harder to move around in the tub, I would imagine. Yeah. Than walking around.

[00:26:16] Heidi Machnee: We're gonna, we're gonna, get you to get up and empty your bladder every two hours max. So you're gonna be, it's gonna be this kind of fluid motion of using the tub, but also, changing positions and getting out and getting back in and having electrolytes in the fluids that you're drinking is really important as well. Yeah, the, these are just some kind of helpful tips, tips that kind of, again, just keep, we always think about safety, anything we're doing, we think about safety and these are all the things that help us be able to, happily and with confidence encourage and offer clients who want it and are good candidates to use water birth, but in a safe context.

[00:26:48] Dr. Alicia Power: Yeah. And the other piece is really important that you've addressed, is that if there's any concerns for the pregnant person, the delivering person or the baby's wellbeing, that it's gonna be recommended that you use your [00:27:00] alternate birth position, birthplace. So getting out and getting onto the bed because sometimes things don't go as we planned and we need to shift our position. So Heidi and I were chatting earlier, and it's always about, yeah, great if a water birth works wonderful, and you know what, if midway through you don't like it, that's fine too. And if midway through you or your baby needs something else to keep you healthy, then let's have this alternate possibility all ready to go in case we need it there.

[00:27:25] So have your bed made up with the double sheet set because maybe it's safer for you or your baby, or maybe you change your mind midway through and decide to have a bed birth, an out of water birth? No. A land-based birth instead of a water-based birth. And so just being fluid, no pun intended, around that nice one, that planning.

[00:27:43] Heidi Machnee: Yeah. And we talked about trusting your care provider and so this, this podcast is so great. Not just this one, but all of the podcasts that Dr. Sarah and Dr. Alicia are doing because they're just really looking at providing good quality evidence for people so that they can be really well informed and talk to your care provider and read the research and [00:28:00] get it, get involved in your care so that if your care provider is like, "Hey, I need you to, stand up now. I need you to stand up right now" or "I need you to get outta the tub right now." You know that the person is doing that because they're like, they've alerted there's something that's alerted them and there's a change that needs to get made to keep things safe. So trusting your care provider and being well-informed to just like point A and B of any, anything related to birth really.

[00:28:22] Dr. Alicia Power: Totally a hundred percent. And we will put that BC women's guideline cuz I think it's great as well, into the show notes, a link to that. Cause it's so good and so useful. So that people can have a look at that if they want a little bit more information as well.

[00:28:34] Awesome. Thank you Heidi for joining us. It was again, so lovely to talk to you.

[00:28:39] Heidi Machnee: Wonderful to chat. Thank you. It's been a pleasure.