 I want to just close this poll. Let me just close this here and then we'll put the public chat back up. All right, so Barbara Harper welcomes so much. Barbara, as you heard if you were here earlier, Barbara is joining us from China. Barbara is an internationally recognised expert on water birth and gentle birth. She's the founder of Water Birth International and is a nurse and midwife and she is an amazing person to know. So I'd really like to extend a grateful welcome to Barbara. You should be able to unmute now, Barbara, if you'd like to go ahead and give us your presentation. You should be able to see your slides. I do. Thank you, Jane. Thank you everyone for joining us. My time at 6.08 in the morning I think on this side of the planet we've got plenty of people from New Zealand and Australia and on the other side of the planet it's evening so this is just so exciting to be the first presenter on 19 the IDM the 11th year and it's such a privilege Jane for for being here and welcome one and all and I do circle the planet every single year teaching about water birth and gentle birth and here in China one year ago exactly today it was yesterday in China but I attended a water birth and held a baby and the water in my hands and that mother came in yesterday to the hospital brought her one year old and at the Suzhou maternity hospital we had a fabulous celebration of midwifery and and the one year old birthday of this this little baby and I found myself on the stage presenting this this one year old with a Suzuki violin so that her life would be blessed with music and and that she would progress in talent and we're welcoming 500 midwives into the hospital auditorium and I'm going to be giving a three-hour presentation on addressing your own fears around birth and midwifery practice for three hours today so I'm starting the day early and thank you thank you thank you for joining us today and and I just have to see how to make my slides progress and and I I don't see my I don't see my my progression thing so Jane if you could help me out there that would be good so okay now I can see it excellent excellent so I'm not going to spend any time talking about me if you want to know about me you can read my my bio on my website at waterbirth.org but just know that when I gave birth 35 years ago to my second baby in water at home it changed my life and I turned to my midwife and I said oh my god I have to tell every single woman on the planet how easy this is so here I am 35 years later still talking about it several articles and books published and a website and I tell every single person how can we increase the normalcy of birth well just add water by using water immersion for labor by using water immersion for birth it changes the course of labor very often it will settle a woman it will give her the opportunity to gather her thoughts it'll take her into a deeper state of subconsciousness and it provides greater comfort easier mobility she conserves her energy because she doesn't have to work as hard her whole body is relaxed in the water and that's what promotes a deeper relaxation there was a book published in 2014 by Dr. Wallace Nichols he's a marine biologist and his book blew mind how being near on or in water changes your brain and Dr. Wallace Nichols talks extensively about the actual brain changes that go on in your neurological system when you're just even standing near water so if you can't put a tub into a facility you can put a water a little water fountain and that might even help a woman relax so the recognized benefits continue by not having any use of narcotics or epidural um at Elizabeth Clewitt in 2004 published in the British Medical Journal a randomized controlled trial of using water or pitocin for a stalled labor the pitocin group delivered two hours later than the bath group so it does cut the labor time as well your blood pressure drops you have an easier breathing you have more control over your second stage of labor because you can get into any position and it challenges providers because when a woman is in a different position your hands are off sometimes you can't see the perineum you don't have to support the perineum you have water supporting it a thousand hands just think of the hydrostatic pressure from the water as a thousand hands and the studies do show less frequency of tearing and less severity of perineal tearing there are a couple of studies that have more tearing but that's an issue that we'll talk about later it's not the water that's preventing it it's the position of the woman it's her freedom of movement it's her guiding the baby as well and one of the things that we discovered early on with with helping women birth in water was that the baby always every time came immediately to her chest now just imagine 35 years ago when people were still separating babies before Niels Bergman and other researchers did the the research on kangaroo care and the benefits of skin to skin we saw it immediately that without cutting the cord we put the baby in what I call the sanctuary the sanctuary where baby is protected and we saw that the benefits were enormous so what are the the recognized benefits for the baby because if there's any objection to birthing in water not just using it for labor it's around the newborn the american academy of pediatrics in 2005 even thought that every baby was going to take a breath under the water that doesn't that doesn't happen 35 years later we have on paper over 100 000 cases of waterbirth researched and um jennifer van der leyen and patricia hall and um mary jane lewitt published in 2018 a meta analysis a summary of the review of literature about neonates and water and they found less nicu admissions um better outcomes for all the babies that were compared in those 35 studies that they looked at and a benefit for the baby is immediate and uninterrupted skin to skin contact and I have to mention the complete expression of the primitive reflexes if we're not bringing the baby out as midwives it's our job to quote unquote get the baby out water has released us from that job and we get to sit back and watch the baby express its primitive reflexes the the pares reflex the galant reflex the the placing reflex we can see that happening live right in front of us as the baby extends and and reaches I want you to go to the vidm website and watch some of the videos that I asked them to post we can't do videos in this presentation because it takes up too much uh bandwidth so right now I would show you a video showing that baby expressing its pares reflex and extension extension extension and then pushing off into the water and expressing the placing reflex so we have delayed court clamping with every single water birth we don't whisk the baby off into a warming tray or table we leave the baby in the sanctuary we keep the cord attached and I'll talk about that also in just a minute and it becomes a gentle transition from womb to room most hospitals around the world have accepted a very narrow criteria one baby that baby is in a vertex or head down position the mother has completed 36 weeks of gestation and she's in labor the those are your criteria for getting into the water not just active labor but in labor so she has a labor pattern that has increasing frequency and intensity and no visible signs of skin or blood-borne infections this is the narrow criteria now some of you have possibly attended births outside of the hospital and outside of the hospital we still want a healthy woman expecting a low risk pregnancy uh pregnancy experiencing a low risk pregnancy and expecting a low risk birth however variation of normal is breach variation of normal is twin and today a variation of normal is a vaginal birth after cesarean so here we see a photo that was donated by Diane Garland a UK midwife who's written a wonderful book called revisiting water birth and attitude to care and you see the birth of twins in water at home I've participated in twins I've participated in breach and many many vaginal births after cesarean in water so you can look at that and if you're experienced in breach experienced in twins then add water if you're not experienced in those water is not the place to begin what does it take to start water birth in any facility well it's mothers asking for it consumer demand provider support mother friendly facilities to begin with it would be nice if you had a gentle birth program or a low risk maternity unit midwifery care and then water is the best element to include in that evidence-based practice yes there are many papers that you can find on waterbirth.org I can send them to you if you need assistance in in finding research we can send it to you and staff education my my water birth certification course has been accepted by the american college nurse midwives by the spanish nurse midwives by the american college of obstetricians and gynecologists as a means to begin understanding and education and yes I want to shout out from india today and show you some slides from the sanctum birth center with vijaya krishnan um the only certified uh professional midwife in india she's in hydrobot and a few years ago i was there with with vijaya at her clinic and with diane garland as well and i just want to point out that that what do you do okay if i'm not bringing the baby out if i'm not uh doing perennial massage and and perennial pressure and delivering the baby what do i do you are attentive you're observing quietly you're doing what i call masterly in activity you are keenly observing and using all of your senses to support this mother's primal instinctive behaviors you're keeping the distractions at a minimum and keeping the room quiet so that she can focus you're supporting her instincts so that she can unfold in the ways that she needs to do that and the baby can unfold in the ways that he or she needs to do that so i put here singing in labor yes you can even tell what the dilation is by watching the mother's cues by listening to her voice and this pretty this particular woman was chanting om namishna vaya when she's three centimeters she can do the whole chant when she's 10 centimeters she can just say oh and we assist her in catching her own baby having her reach and put her hand in the water and assisting bringing the baby up if she needs our assistance the only thing i ask um mothers to do is stop for a moment as the baby comes out just stop take a breath and look for a cord check for a cord reduce the cord first and then bring the baby up don't be in a hurry babies don't wear watches and they cannot take a breath in the water so what does the american college of obstetricians and gynecologists think about water birth well the 2016 statement was actually going into a different direction which which was better than their 2014 statement and they said the benefits and risks of this option have not been sufficiently studied they want 10 000 population randomized controlled trials and the only place we're going to get that is here in china there's one hospital chowning hospital in shanghai that has actually had 10 000 water births they started a randomized controlled trial in 2005 and abandoned it in 2006 because their first 45 outcomes were all excellent and they didn't want to do a randomized controlled trial we can see that um that it's not necessary to do a randomized controlled trial you can look at your prospective studies and you can look at your retrospective data and get good um statistics from it so in 2014 they were worried that every baby was going to aspirate and we know now that that's not going to be a problem so what do they object to lack of education that's why we're doing this session this morning and not having strict protocols or guidelines and no large prospective studies but we're doing those now so um establish an inclusion criteria an exclusion criteria and start safely attending births in water i wish that i could look at all of your your comments on the side but i'm taking jane's advice and i'm not even looking at that because i'll get distracted so what are our contra indications any pathology any prematurity um although last year in Mexico i did talk to doctors who were attending births of babies that were only 35 weeks gestation or 36 weeks gestation and i said that's great just keep track of it and um and publish your statistics publish your studies because we're going to have the same breathing mechanisms whether a baby is 35 weeks or 34 weeks or or 37 weeks but right now for research purposes we want the narrow criteria so any moderate to severe preeclampsia any maternal fevers just choose your intervention wisely if you're using the water as an intervention such as a borderline hypertensive you can put them in the water monitor their blood pressure and see if it works because it will drop 15 to 20 millimeters of mercury sometimes using water might bring the labor back to normal such as a labor that is stalled out now why does that work because the woman releases her fear she goes into that deeper state of relaxation and she suddenly is producing hormones in her brain more oxytocin more endorphins and she relaxes in the water so i put up a whole bunch of things and contra indications to possibly consider i've seen these on protocols in hospitals in the us in spain in mexico in china and i don't agree with most of them just giving you a minute to read the slide uh thick meconium if it happens at birth as the baby's coming out finish the birth in the water the thing with meconium is washes off however if the water breaks and it's thick meconium and it's your protocol in your hospital um to remove the woman from water then that's a concert indication to consider if they're at any point there are non reassuring fetal heart rates either tachycardia bradycardia or or no variabilities don't stay in the water please come out high body mass index is not a problem it's never going to be a problem if the woman has mobility can she get in can she get out proof of mobility is more important because we don't have to worry about dragging her out bring the bed right beside the tub have her stand up and get on the bed we'll look at that later as well so premature rupture of membranes with prolonged latency there have been studies from sweden that showed that your membranes can be ruptured for three days or more and still have birth in water expected fetal weight greater than 3.5 kilos no no no no no no in some places around the world that's an indication for a cesarean not in my book um average weights of of babies in my previous practice were eight pounds and and eight and a half pounds that would be 3.8 kilos uh not a problem and we already discussed the backs and twins and grandma tips one woman in my practice had her fifth sixth seventh eighth ninth tenth eleventh and twelfth baby in water and wouldn't do it any other way so um i'm going to go on but just consider is the contraindication a variation of normal and would water be an assistant water assisted labor can be used almost in every situation so i'm since i'm in china i want to show you a couple of pictures from china this hospital it was their first water birth i've had the privilege and the honor of assisting with many hospitals setting up their practices here and and then coming back a year later and seeing that they've had 1500 1800 2000 water births in one year the hospital where i am today i mentioned when i first started if you just joined us they had their first water birth and here's a picture of it um last year um at the sujo maternity hospital and this baby celebrated her first birthday yesterday she was born on the international day of the midwife and i remember commenting that in the delivery room that day and now she's a beautiful uh one year old i wish i could show you the picture from yesterday's celebration and um here she is from a different angle it's just just incredible and they've had 55 water births um and yesterday they gave me a photo album with pictures of all 55 water babies so i'm just really really thrilled about that um so what does water provide well if we look at this list yes privacy intimacy weightlessness equalized hydrostatic pressure those are all kind of physics terms but what happens to your brain when you experience all those it changes the way your brain works your brain pumps out more oxytocin and more endorphins in every one of those situations so you have a more relaxed mother and when can you get into the water anytime you need relief use water as your friend use water as your first tool and yes if it's early labor she might take a nap she might go to sleep why do we have um a time clock on her anywhere is she in labor or is she not in labor use the water so that you can have some relief in another study done by Vern Katz Dr. Vern Katz a physiologist and neonatologist he found that even one hour in the bath will change her brain function for the next 24 to 48 hours so the average length of time spent in a pool throughout the labor is about four hours so in and out is best and so here you are the the once you set up your program and pick your tub it's easier for the mother it's easier for the husband or partner it's easier for the nurses and the midwives and this is my friend Lonnie Morris a 40-year veteran midwife practicing masterly activity with her knitting and as I said it increases that ecstatic hormonal cocktail that Dr. Sarah Buckley talks about in her absolutely wonderful article on the hormones of birth when you get more oxytocin you get more beta endorphins and then you also get more adrenaline the epinephrine that is necessary for both the mother and the baby to have a good transition from fetus to newborn and I can make the statement that water increases the production of prolactin because of the hormones that that are released from the brain and so therefore breastfeeding is better I'm including a picture donated by Karen flower she's a photographer in doula just look at this woman this surprise I did it from royal hospital in Cairo Egypt and they had the water birth training in Cairo about a year ago and we've certified thousands of doctors around the world so how often are you going to listen to heart tones the American College of Obstetricians and the a1 the association of labor delivery nurses hang on one second while I clear my throat I woke up with a slight sore throat this morning sorry every 30 minutes during the dilation phase every 15 minutes as we get closer to expulsion so expulsion stage passive second stage is 10 centimeters two visible baby hair laboring down and then every five minutes during active expulsion active pushing or after every expulsive or pushing contraction effort begin listening at the end of the contraction and continue for one full minute what you're listening for is an increase in heart rate you're listening for variabilities and leave the water if the heart rate drops in some cases below 100 without an increase between the contractions if you get severe bradycardia please leave the water and monitor appropriately and finish the birth out of the water what's the temperature of the water never higher than 38 or 99 we don't have to warm the water up for the baby the ideal water temperature is matching your skin temperature which is 32 to 35 Celsius or 92 to 95 Fahrenheit keep the woman well hydrated record the temperature of the water if you wish to add that to your research I came into the birth a night before last we had a birth here in China that I facilitated in their brand new LDR suites and I was so happy but I came in back into the hospital at night and they had filled the tub and it was 43 way too hot we don't want the mother to sweat and higher temperatures will cause fetal tachycardia so please shout out to austral all my friends at the university of austral where we did a waterbirth training last year in Buenos Aires and also a shout out to one of the midwives that got certified there Yanina Presta and her hospital in Mendoza thank you for taking the protocols back and establishing waterbirth practice immediately so encourage upright positions in the water different positions help the baby rotate if you need to see the whole if you need to see the perineum stick a mirror under her if you want to ask the mother to check her own progress I love doing that I did that night before last with this mother I ask her and encourage her and Chinese women are very very hesitant to touch themselves and put their fingers in their vagina that this woman did and she checked her own progress and her eyes widened and and I said did you feel the baby and she my interpreter asked her in Chinese and and she shook her head yes and and the smile came across her face because she knew what she was doing was effective and it was working and she knew that the baby would be in her arms and just a few more pushes and it changed her behavior in the tub when she connected so use use that as a technique sometimes if you're not checking for a cord you're not going to check on the perineum you are going to check after the baby's in the water 1001 1002 and then unravel and broken cords and torn cords come most often from lifting the baby too quickly out of the water don't be in a hurry allow that the baby to unravel and have patience I know we're going to cover a lot of topics in a short amount of time so I want to go on to newborn breathing but before I do I want to have you think about what happens if the baby has an intact sac the night before last here in Suzhou the her membranes never ruptured the baby came out into the water in an intact sac so I couldn't check for a cord I actually lifted the baby up and then tore the sac off the baby so the baby never touched the water that it was born into I lifted the sac off the baby as it was being lifted out of the water so an intact sac is indeed the original water birth just think about it for a moment and now let's talk about what keeps the baby safe so there are four protective mechanisms I'm only going to talk about three that keep the baby safe and will not allow the baby to take a breath the first one is a decrease in the fetal breathing movement I'm going to explain each one there's also a high pulmonary vascular resistance in the lungs and every single baby that's born on the planet starts out life with hypoxia initial hypoxia low oxygen levels and I'm going to talk about each one individually so fetal breathing movements happen from 10 weeks of gestation the the fetus is practicing breathing it's not breathing it's practicing moving the muscles so that it will set up a neurological connection in its brain so that when it is born the respiratory centers of the brain are stimulated by a shift in oxygen content in the blood and that oxygen content shift comes from the placenta so we'll talk about the placenta's job in just a moment but prior to birth those fetal breathing movements slow down and they stop in labor we don't want the intercostal muscles the diaphragm moving for either a breech baby or a water baby think about the breech hanging with the head in and the body exposed and out the baby cannot choke in the entroitus the baby cannot move the muscles that would stimulate a gasp they are frozen until respiration begins on the outside of the womb out the outside of the birth pool at the outside of the of the bag of waters mild hypoxia is normal it causes a bradycardia in second stage as the baby's born on the bed it's slightly apnick it's it's apnick it's not going to take a breath however the bradycardia and the apnea the baby has to swallow first and swallowing is the very first reflex before respiration begins and swallowing can get all those fluids from the baby's oral pharynx into the baby's gut where it needs to jump start the microbiome so look at this baby this picture came from one of the clients of gloria lemay a longtime midwife in vancouver bc and when she sent it the mother sent it to me she said welcome my little alien what the baby's doing is swallowing just think lucy lemon lips it's swallowing you're going to see that on every single baby on the planet just don't put a hat on the baby the hat might get wet in the water and and there there's no need to have a hat when the when the baby is in the sanctuary and the sanctuary of the mother's chest so the the second one so we've looked at at the intercostal muscles stopping we've looked at the swallowing reflex and now pulmonary resistance there's a low arterial and pulmonary artery pressure caused by low circulating blood volume in the uterus in the womb only 8% of the cardiac volume goes out to the lungs the rest gets circulated through the the placenta so this creates a pulmonary resistance and every single of the lr space is filled with fluid and the presence of that lung food is an important inhibitor now remember that amniotic fluid is actually produced in the kidneys and the lungs and that lung fluid has to leave those spaces 50 million aviolar spaces in the newborn lung it has to leave before respiration can even begin and so we know that every single cell is inflated by extra blood that comes from the placenta and it opens up the cell it sucks out basically it it allows the fluid to leave the cell and go into that network of capillaries and as judith mercer put in her article which i posted on idm i want you to read judith mercer's article on neonatal physiology of the newborn the establishment of neonatal respiration is based on the adequate flow of blood into the lung bed into the lung bed so you need perfusion before ventilation can even happen and that's why we must leave the cord impact on every single baby on the planet not just water birth but every baby the baby has a two to three minute head start literally the head is down the breach baby and the water baby have a delay because the face and that's what we're going to look at next what what causes the inspiration the trigeminal nerve or the fifth cranial nerve around the nose and the mouth on the face interpret the presence of gravity two kilos per square millimeter it interprets the the presence of atmospheric oxygen carbon dioxide nitric oxide nitrogen it says hello baby you're on planet earth change the ph of your cerebral spinal fluid which is going to send a signal to the brain to close the the shunts in the heart and blood is going to pull pour into the lungs remember eight percent cardiac output going to the lungs prenatally now we require 55 percent and the only place that the baby is going to get that much blood is from the placenta so once pulmonary circulation begins those lung cells are recruited via the capillary erections and the pulmonary fetal fluid is sucked out or resorbed and that fluid contains all kinds of chemicals that now increases the blood volume by 20 percent and is going to maintain the the the cardiac system and the pulmonary system it's just such a perfect perfect anatomy that was designed and what isn't taken out by this lung exchange is affected by the lymphatic system over the next 72 hours and stimulated by breast crawl skin to skin and self attachment breastfeeding as the baby sucks it's actually taking fluids out of its lungs this is absolutely amazing and and is another reason why we need to leave the baby alone so delayed cord clamping means extra lung perfusion babies born in water and breach babies need more time to establish good perfusion the transfer of blood from the placenta to the baby begins during second stage airborne babies have a two to three minute head start okay and water babies and breach babies have a lower apcar in one minute at one minute but they always have a better apcar at five minutes so this was the most important part of what we need to look at when we're taking care of women in water so wait for white and the ideal is placental you can deliver the placenta in the water but the next best is to wait a minimum of three minutes and yes this baby says I have to swallow before I can breathe remember that and the next baby says I need to put 55 percent of my blood in my lungs before I can take a breath so please give me time to do that and as we're looking at neonatal transition vigorous babies do not need suctioning they don't need stimulation they don't need hats or wrapped up in blankets and they certainly don't need cord clamping so practice keen observation and please respect the baby's ability to transition from womb to room in his own way and in his own time you can tell if you have a good baby or not and we've got an adjusted apcar scoring that that takes into consideration the swimming movements that babies make and if you see a swimming baby on expulsion in the water you've got a good baby to start with if you have a heart rate that's higher than 100 you've got a good baby to start with they might be a little slow coming up to establishing regular respirations but but yes we sing perfusion perfusion every baby needs perfusion leave the cord alone let the baby get all the blood it needs and then you'll have an apcar of 12 if so midwife training in Spain this year I'm going to be in Madrid and Tarragona in just a few weeks so join us if you haven't signed up already and look at the heart rate look at the presence of breast sounds put your stethoscope on listen if the baby's not crying they don't cry a lot in the sanctuary but check for graduating color and are the eyes open and blinking and just relax don't panic give that baby that extra minute severely hypoxic babies are going to be in trouble in utero we don't birth those babies in water and just a couple of other things yes we can deliver the placenta in water just look at her picture this was 20 minutes after birth and that's pretty much how it goes three to four contractions placenta is out the night before last the the placenta dropped out onto the floor of the tub conception chili I'll be back in in Chile in November Barbara we do have to finish in the next 20 minutes so you can take some questions sorry okay super super super research we have plenty of research absolutely we're we're almost done and I'm just going to slide through right these and just one that I want to point out was the midwives alliance of North America 35 percent of the out-of-hospital births were in water it's a low risk low intervention birth happening and the UK accepted waterbirth early on and it's everywhere how can you tell if a woman has bled in the water the color of the water if it's merlot that's a postpartum hemorrhage so this is just phenomenal I want to just get back to here we go one more slide reflexes reflexes and behavior let the baby move down never go in to rescue a baby have the mother stand up and get onto the bed and if in doubt move the mother if you if you want the baby to move move the mother change the shape of the pelvis you'll find more information on my website about doing this with the water and and join one of my certification classes we do teach them online and the next online certification is in July so um proposal position one knee down one foot down mother guided she knows when to push she knows her body she lifts the baby up and off we go eye to eye wires the baby's brain so think about what interventions you're using and how much hands-on you practice currently and yes the perineum can be intact as above so below let her sing the baby out ah a tight jaw is a tight perineum a relaxed jaw is a relaxed perineum so and I just want to reassure you that we don't see infections and you can bring the baby out or the mother out by lifting her with an emergency um an emergency lift and they're available from all over the world and you can see how to get them on my website we don't sell them but I think water birth solutions does so thank you thank you thank you I know that that was fast in the end and um um they there are all kinds of things that I know you're talking about I have ignored you completely on the other side um so let's have some questions and um and uh we'll we'll take this next few minutes uh to uh to answer those so Jane take it away thank you so much Barbara that was so inspiring uh for a first kickoff um we actually uh we don't really have a lot of time because we actually have to go over to the uh the other room because we have uh the next talk I'll just see if there's a quick talk but everyone's saying thanks to you we've got the recording would you be okay uh I think your powerpoint will be on the website but you're you're good with uh folks contacting you Barbara if you'd like to say your your uh information again I will type it in the public chat if you'd like to see your contact information um uh Barbara at waterbirth.org um my website is waterbirth.org and um uh I'm on uh WeChat um oh WeChat is from China and um my um uh my um um WhatsApp is my phone number and I'm putting that in right now seven nine seven five there we go so um uh you can contact me on