Dr. Rebecca Dekker – 00:00:00:
Hi, everyone. On today’s podcast, we’re going to talk with Liz Nutter about waterbirth from the expert clinician’s perspective.
Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to today’s episode of the Evidence Based Birth® Podcast.Â
Are you interested in getting more involved here at EBB? Well starting next week we have an incredible opportunity for you to try out all of our best pro member resources at Evidence Based Birth® for free. We will be sending out an email soon to everyone who subscribes to our free newsletter with a link and instructions on how you can participate in a 30 day free trial EBB pro membership. It opens for enrollment on Tuesday, July 16th and closes on Thursday, July 25. We have some important trainings happening live for our pro members this July, including a special live training all about the evidence on doulas and a bonus recording we’re giving to everyone all about the evidence on the flu shot during pregnancy. So, if you’re interested go to ebbirth.com and make sure you’re signed up for the free newsletter subscription to get the notification when it comes out. I can’t wait to see so many of you at the trainings later this month, and with that let’s get to today’s episode and I’d like to introduce our honored guest, Dr. Liz Nutter. Â
Dr. Nutter served in the United States Army and retired in 2021 as a Lieutenant Colonel. She is a proven nursing leader with more than 20 years of nursing and healthcare leadership experience. Dr. Nutter is a board-certified nurse midwife and is recognized as a national expert in waterbirth and hydrotherapy evidence-based practice. She was named a fellow in the American College of Nurse Midwives in 2020 and was the United States Army Surgeon General’s Consultant for Women’s Health Nursing from 2017 to 2020. She is now an assistant professor at St. Martin’s University in Lacey, Washington State, where she teaches childbearing nursing, transition to nursing practice, and nursing foundations for nursing students. Liz, welcome to the Evidence Based Birth® Podcast.
Liz Nutter – 00:01:35:
Thank you for having me. I’m so excited to talk to your audience today.
Dr. Rebecca Dekker – 00:01:40:
Yes. And you were an integral part of peer reviewing the EBB Signature Article on waterbirth. And you gave us so much good feedback this time. And I was just wondering if you could, you know, take us back to your role in the United States Army and talk a little bit about, you know, how your role evolved there and how it influenced your perspective on women’s health and childbirth.
Liz Nutter – 00:02:06:
Oh, absolutely. It was really an honor. As women started growing in service membership, the military recognized, oh, we have a little bit of work to do in this area. And so I was really fortunate to be able to give guidance to our three-star general at the time, General Dingle. And we were able to talk about the issues from obstetrics to gynecologic perspectives in the military. And evidence is my passion. And I brought evidence to the table, the big thing that I started was in the Army, every six months, we had to do a physical fitness test and we had to do height and weight. And we had to be within standards within six months after delivery. And it was really difficult for many service members to meet those standards. So I dug into the evidence and was able to really present. You know, we can lose weight, we can get ready for a physical test, or we can breastfeed our children, but we can’t do all three. Really, the evidence showed we could do two out of the three. So I was able to bring that to the table and start the conversation. And I’m really happy to report that we were able to push that out to a year. So now service members have the option in the military to… really breastfeed as long as they want to, not have to worry about getting back into physical fitness peak condition within six months, and they have a year to be able to meet those standards. So that was a huge win. The other thing that we were able to start working on was getting maternity leave pushed out to 12 weeks instead of six weeks postpartum. So that was another huge win so that women could be home with their children and have that 12 weeks of really protected time that was paid, which is a huge, amazing benefit in the U.S. And then really the last thing too was we recognized that there were service members that unfortunately were having miscarriages and losses in their second and third trimester, and they weren’t getting enough time to really grieve the loss of their children. So we were able to put in a standardized protocol to really support those women in having protected time that they could have time. So those were the big three major things in my tenure that I was able to bring forward and work with teams to get those policies all passed.
Dr. Rebecca Dekker – 00:04:33:
Yeah, so it makes me wonder then these really important projects you’re working on to improve maternal health rights for women and childbearing people in the military. Some of that must have been… like enlightened by the work you did as a midwife prior to that. So were you a midwife attending births of active duty military members then?
Liz Nutter – 00:04:58:
Active duty military members, spouses, and then dependents. So under the Affordable Care Act, dependents, so meaning daughters, service members up to the age of 26 could have deliveries in TRICARE, which is the military health care network. So active duty members like myself, I was delivering and then spouses and then some of their children as well. So those were the populations that I supported taking care of in the military. And then also in my role. It was midwifery, but also our labor and delivery nurses that were on active duty. So giving strategic support on what does labor support look like and also deployability. Labor nurses have an amazing skill set that they bring to the table when it comes to deployment opportunities. Because we circulate in the operating room, we’re familiar with triage, emergency management. There’s a lot more that labor and delivery nurses brought to the table when it came to the strategic mission for military readiness. So really making sure that the Surgeon General was able to leverage the skill set of the labor and delivery nurses was really important too.
Dr. Rebecca Dekker – 00:06:14:
Okay. So what led you to specialize in waterbirth? And were you doing waterbirths in military settings?
Liz Nutter – 00:06:22:
Yeah. So that’s kind of a two-part question. So I’ll start first with, were we doing waterbirth? So, yes, we were doing waterbirth in the military. Madigan Army Medical Center in Washington State was the first medical center to offer waterbirth. I was really fortunate that when I was a midwifery student, I was able to train with those midwives. And so I learned waterbirth when I was in midwifery school at Joint Base Lewis-McChord. Fast forward, I decided to go get my doctorate in nursing practice. And I actually started with a completely different project in mind. After I had completed my first semester and done my entire literature review on my other topic, I got a phone call from the obstetrician consultant to the Surgeon General saying, you know, hey, Liz, I hear you’re in your doctoral program. I want to do some waterbirth research to demonstrate our great outcomes that we have. And I said, well, that’s awesome. But at this point, we had four military treatment facilities, MTFs, that were doing waterbirth, and they were all using different protocols. So I said, our data won’t be valid because there’s no standardization to the protocol. So I said, why don’t you allow me some time to talk to my faculty and see if they’ll let me change my project? And fortunately, my faculty was totally supportive and said, you’ve got two weeks of break. If you can do the entire literature review and get caught up so that you’re not behind, we’ll support you. We think this is really important work. So I spent the two weeks and I changed my project. And it was, I love supporting women in all options, but I really find waterbirth to be a magical experience for the birthing family, for the nurses that are involved, for me as a provider. And I really believed in military families being able to have that as an option. And I wanted to get our data out there because we had awesome data. So that’s how I became involved. And that’s where really my journey began was a phone call from the colonel saying, let’s get our data out there. And I said, yes, but we have to do step one first.
Dr. Rebecca Dekker – 00:08:33:
I still think some of our listeners might be a bit shocked, amazed, surprised that the military has this reputation of not offering too many options to birthing families, that waterbirth has actually been an option in some facilities for a while. And you mentioned the protocol. So how are the different military institutions doing waterbirth? I’m assuming not all of them offered waterbirth. It was probably just where people were comfortable doing it, the clinicians.
Liz Nutter – 00:09:02:
Yeah. And really it was where our midwifery teams were, right? So not all military hospitals have midwives. There were only 54 active duty midwives. So not a lot. We have a lot of government midwives. So they’re civilians that work in our military treatment facilities and the active duty midwives come on and they’re the leadership. So not a ton of us were on active duty. And so not all military treatment facilities offered it, unfortunately. And I think we’re going to get into this a little bit in 2014. ACOG came out with a committee opinion that was- Rebecca, you and I talked about this a lot back in 2014, was not based on evidence. It was very poorly written. There was literally one study that was on laboring rats in cold water that they used as a citation to support their opinion against waterbirths being a safe practice.
Dr. Rebecca Dekker – 00:10:04:
Right. And they didn’t look at any of the many studies on actual people.
Liz Nutter – 00:10:09:
Yes, exactly. And so in 2014, when ACOG came out with that, the Army unfortunately said, you know what, ACOG is the gold standard. I use that in air quotes. And ACOG says this is not a safe practice. So at this point, we’re going to suspend our waterbirth program. But we do support hydrotherapy. So up until the point of actually delivering the baby in water, we still do in military treatment facilities, but the waterbirth process was suspended in 2014. It is something now that I am passionate about getting back into military treatment facilities because… The midwifery community responded with a vengeance with the 2014 committee opinion opinion. And to ACOG’s credit, they did go back and… I was fortunate. I was on the waterbirth working group with the American College of Nurse Midwives. And I used my doctoral work and we co-authored the American College of Nurse Midwives model practice template that’s really based upon the evidence that is really now our national standard in the United States. So I was able to take my work from my doctoral program and pull it forward. And then we worked with multiple organizations to have conversations around the table. What does this look like if you have a home birth? What does this look like if you’re in a birth center? What does it look like from the RN perspective? And we all sat around the table and then the model practice template came out of this. So because I was on that working group, Lisa Kane Low at the time was the president of the American College of Nurse Midwives. And we had no idea that this committee opinion was coming out in 2014.
Dr. Rebecca Dekker – 00:11:58:
So you were doing all this work and had no idea?
Liz Nutter – 00:12:01:
No clue that ACOG and AAP, so the American Academy of Pediatrics, and ACOG wrote this committee opinion together. So Lisa and I got on the phone and we were like, what happened? So we had some conversations and presented a lot of facts that this was not evidence-based. And they went back to the table and to their credit, they did review actual evidence. And came forward with a new committee opinion and they still cited that they didn’t believe that waterbirth should be an option for birthing people. However, because we had talked with them from the American College of Nurse Midwives, they knew we were working on this protocol. And they did give us some support in the fact that they said, we recognize that birthing women, birthing people will choose this as an option. And if you’re going to do it, you need to do it with somebody that’s trained. You need to do it when there’s protocols in place. You need to do it making sure that there’s infection control standards. And so that was about as far as they could come to meet us in the middle ground.
Dr. Rebecca Dekker – 00:13:09:
Yeah, I don’t think they’ve ever come any farther past that. But what you’re saying is. The midwives were blindsided. And it also sounds like ACOG did not contact any midwives to give input on their statement, basically banning a practice that was led by midwives.
Liz Nutter – 00:13:28:
Correct. Correct. You know, and I think there was a misconception that waterbirth only occurred in out-of-hospital birth. ACOG was kind of surprised when we talked about the fact that certified nurse midwives were offering waterbirth in the U.S. That kind of caught them off guard. They didn’t think that was happening. So I think it was almost a political move on ACOG’s part to take a stance against out-of-hospital birth.
Dr. Rebecca Dekker – 00:13:58:
Oh, I see. So they were trying to put down the certified professional midwives in the U.S. and the certified nurse midwives also got like… you’re naughty for doing this.
Liz Nutter – 00:14:12:
Right.
Dr. Rebecca Dekker – 00:14:12:
And that just shows how little they knew about waterbirth.
Liz Nutter – 00:14:16:
And when you swat at the hornet’s nest, midwives we’re feisty, right? So we came about with a vengeance in the amount of excellent research that has come out of that like, was like a war cry. So when I did my doctoral work and reviewed every single study, so at the time when I did my review in 2013, there were 91 research studies that had been conducted on waterbirth. And I looked at published studies, doctoral dissertations, what we call gray literature, so things that aren’t published in peer-reviewed journals. So I really looked at the entire body and there were 91 studies at the time. And the evidence was really clear then that like, if you do this based upon the evidence, you have great outcomes. And now, holy cow, so many more studies and just supporting what was in the early literature, but we have great data now in the U.S., that says it’s safe at home, it’s safe in birth centers, it’s safe in hospitals. When you know what you’re doing and you risk appropriately women before they get in, and then that we’re cognizant during the process. Midwives, we’re experts in looking at birth as normal. And then we’re experts in recognizing when we really need to look with a little deeper eye to make sure that mom and babe are tolerating the labor process. And the literature is consistently showing that we are really good at risk assessment, and that we get our moms and our babies out when we’re concerned, and they don’t deliver in the water.
Dr. Rebecca Dekker – 00:16:04:
Right. And I think, you know, as we’ve both seen, and if any of you have read the updated Signature Article on Waterbirth or any of Dr. Nutter’s research. The research on the benefits is actually growing from when I first started reading the research that you’re talking about from 10 years ago.
Liz Nutter – 00:16:20:
Yeah.
Dr. Rebecca Dekker – 00:16:21:
I think there’s more benefits that have been documented than we knew about back then.
Liz Nutter – 00:16:25:
Yeah.
Dr. Rebecca Dekker – 00:16:25:
I think midwives always knew it was helpful for their clients. Um, I remember a midwife telling me, I don’t do waterbirth because it’s easier for me. She said, it actually makes my job harder. I do it because it makes birth easier for my clients. And I always thought that was a really interesting perspective and kind of like the selflessness of that.
Liz Nutter – 00:16:50:
Yeah, you know, I can appreciate that, but let me share with you a different perspective.
Dr. Rebecca Dekker – 00:16:56:
Okay.
Liz Nutter – 00:16:56:
So, especially as a hospital birth midwife. So when I would bring waterbirth to a new practice in the military, a lot of the nurses were really apprehensive because… intermittent auscultation is what the evidence says for low-risk women, which is what really waterbirths should be reserved for women that are low-risk, right? That’s really clear. We don’t have the data yet on different high-risk populations. And so I always encourage my PhD researchers out there, like, go for it. Please do some research. I know where the gaps are in the research, right? We need to look at women that have BMIs that are over 30, right? That technically are high-risk.
Dr. Rebecca Dekker – 00:17:40:
Yeah, they get excluded.
Liz Nutter – 00:17:41:
But I can say, like, really, if you think about it from a logical approach, the ability to have mobility and weightlessness, and it’s probably protective in supporting a vaginal birth for those birthing persons, right? But we need the data to show it. And so I always stand behind what have my PhD colleagues done to support what the evidence says? And that’s what I stand on, right? Because I feel really confident that if I was to have an outcome that was suboptimal, and I needed to demonstrate that I was practicing within what we know is the standard, I would always lean back on the evidence. And that’s there. And it just says low-risk women, right? So coming back, intermittent auscultation is what the evidence shows that our low-risk women should be having in labor and not continuous electronic fetal monitoring. You could get me on a whole soapbox about that. Maybe that’s another podcast. But so we do intermittent auscultation, and we listen to the babies. And if we hear something, we get them out. And I always say, when in doubt, risk them out. So the nurses didn’t feel super comfortable with intermittent auscultation because it’s a skill. And they’ve gotten really used to continuous electronic fetal monitoring and being able to see what’s going on. And they don’t trust their ears as much. So I wouldn’t teach them how to do this. So yes, it’s up front. It was more labor intensive for me as a midwife, right? Because I was doing all of the monitoring where normally my nurses.
Dr. Rebecca Dekker – 00:19:10:
Oh, but where normally the nurses would do it. So you would have to do the intermittent auscultation and listen to the heart tones.
Liz Nutter – 00:19:15:
Exactly. So I would do it. But then once they felt comfortable, they would start taking it over. And I would take those early adopter nurses on that were like, okay, I can do this. I trust Liz. Like, let’s do this. The best thing happened. We were at the board one day reporting off in the morning, and I had a patient that wanted to do a waterbirth. And this nurse came forward and she says, oh, I’ll take the waterbirth, where normally it had been, no, no way. I’m not taking the waterbirth. And one of the nurses said to her, well, why do you want the waterbirth? And she says, well, this woman’s going to go unmedicated no matter what. The water does the work for me because I don’t have to do double hip squeeze. I don’t have to massage. I don’t have to like really be super physically present because the water does the work for me. I just get to be there and like have conversations with her. And so I was like, super powerful. And then I saw this culture change in that unit where the nurses were like, okay, I’ll try this out to the point where I even had an obstetrician say to me, can I come watch one of your waterbirths? Like I just keep hearing these women that have had these experiences say how magical it was. And I was like, yeah, if the patient’s okay with it, totally. And I brought her in, she stood in the corner and after the delivery, I look over and she literally has tears rolling down her eyes. And she said to me out at the nurse’s station, that was one of the most beautiful births that I’ve ever witnessed. I see the magic in this now.
Dr. Rebecca Dekker – 00:20:46:
I think that’s a big part of why we still don’t have enough waterbirth in hospitals, because once you’ve seen one or two and you witness the transformation and how it makes birth so much easier for most people. It would seem like a no-brainer to offer it to anyone who wants it. But so many of these hospitals that still have bans or de facto bans or say you have to get out during the pushing phase, they’ve literally never, these physicians and administrators have never seen a waterbirth. Right.
Liz Nutter – 00:21:19:
And all they have to go off of, right, is ACOG’s committee opinion. And because in the U.S., they kind of say ACOG’s the gold standard. And I’m like, not when it comes to midwifery, not when it comes to unmedicated birth.
Dr. Rebecca Dekker – 00:21:33:
Yeah.
Liz Nutter – 00:21:34:
They’re not the experts. Midwives are the experts in supporting physiologic birth. And that’s what the research is so clear about. If you want a physiologic birth, meaning giving birth with your own power without… you know, Pitocin without all these interventions with normal blood loss after delivery. Waterbirth is the answer for an unmedicated experience. And while that’s not right for everyone, for the people that want that, this is the best opportunity that I have to fully support them in a hospital environment. Because they just, I’m always in awe in women that give birth unmedicated in a hospital because we throw so many barriers at them. I’m just like… this is a protected, sacred space in a hospital when you birth in the water.
Dr. Rebecca Dekker – 00:22:29:
When you’re in the tub.
Liz Nutter – 00:22:30:
Yeah. Yeah.
Dr. Rebecca Dekker – 00:22:31:
It creates a natural barrier and safe, cozy nest to give birth in, basically.
Liz Nutter – 00:22:38:
Exactly. And there’s a lot of qualitative research that says… birthing persons say? It is a safe space. The water almost acts as a barrier to intervention. But I want to go back. You said something about administrators. And I’ve worked with lots of people in consulting roles and getting practices started, not having practices shut down where administrators have come threatening to turn down the waterbirth practice that’s been thriving with no bad outcomes. And what I’ve been able to support those midwives in is… I actually believe that hospitals by saying, oh, you can labor in the tub, but you must get out for delivery, you actually put your organization at a higher risk. So let me explain. When you say waterbirth is an option. What I recommend is your team has some sort of training, that there’s drills that you do so that everybody is aware. How do we manage this as safe as possible and understand some very rare but potential risks and how we would manage them? But when you say you can only labor, but you have to get out of the tub, your entire team loses the skill of safely delivering a baby into the water. Because it’s not a, when will a baby come out into the water? It’s going to happen, right? Sometimes birth happens really fast and it’s safer to deliver them in the water. But what if something happens? Now you have an entire team that has lost all the training. Where if you just say, We’re trained. We do the full scope. We do waterbirth. We know how to manage this. You actually mitigate risk. So that has been something that I’ve really supported nurse midwives and bringing to the front when they’re talking to administrators. It’s like, we actually are putting our organization more at risk when we say we’re doing just hydrotherapy and not allowing for delivery in the water, because that is when risk can occur, is when your team’s not trained.
Dr. Rebecca Dekker – 00:24:48:
I’ve talked with parents in my hometown of Lexington, Kentucky. The hospitals do not support waterbirth. They do support water labor. And sometimes parents are like, well, I just won’t get out of the tub. And the risk you run with that is since the nurses and the clinicians there are not trained in waterbirth, if there was some kind of emergency, they would be really, I would be worried about how they might handle it. They might panic, you know, or do something that doesn’t help. The other thing that I see sometimes here is… They use it like a threat. Like you have to get out a certain point or we’ll pull the drain on the tub, which to me. Seems like a sort of violation. I don’t know if you have, have you seen that or heard of that, but it like gives me chills when I hear people make that threat.
Liz Nutter – 00:25:38:
Yeah. You know, and to be totally honest, when the military made the decision to stop waterbirth, I was panicked. I literally was getting women out of the tub earlier because I had this fear of if I facilitate a birth in water.
Dr. Rebecca Dekker – 00:25:56:
And if it happens accidentally.
Liz Nutter – 00:25:57:
Right. Because it, and I make a decision as a clinician that it’s safer for me to actually deliver this baby into the water than getting her out of the tub. I’m going to get in trouble. Right. So I ended up, and it just took time for me to get comfortable with when was the right time to pull women out. Right. When it was hydrotherapy only. But I remember the first couple, once this ban came into effect, I was getting them out way earlier.
Dr. Rebecca Dekker – 00:26:26:
And I was like, they weren’t getting the full benefit.
Liz Nutter – 00:26:29:
No, they weren’t. Right. And the messaging, right? Especially right when it happened, we had all these women and all these people that were ready.
Dr. Rebecca Dekker – 00:26:39:
They are planning it.
Liz Nutter – 00:26:40:
They were prepared, they were going to have this waterbirth. And then we’re like, actually, no, you can’t do that anymore. Well, why not? Well, you know, this is what’s going on politically. And it really, it’s politics.
Dr. Rebecca Dekker – 00:26:53:
It is, yeah. It’s not about evidence and it’s not about safety. And like you said, it doesn’t even really help lower risk for the facility. So it is political. And it was, I think, you know, oppression of midwifery led options.
Liz Nutter – 00:27:08:
Yeah, definitely.
Dr. Rebecca Dekker – 00:27:10:
So Liz, you said they shut down waterbirth when this statement come out. Did the hospitals, the military facilities where you were practicing and where you had colleagues practicing waterbirth, did they ever start allowing it back again?
Liz Nutter – 00:27:24:
No. As of right now, it’s hydrotherapy only.
Dr. Rebecca Dekker – 00:27:27:
Okay.
Liz Nutter – 00:27:28:
Yeah.
Dr. Rebecca Dekker – 00:27:29:
So in a way, it’s like… 10 years ago, we stepped backwards and have yet to step forward.
Liz Nutter – 00:27:36:
Yeah.
Dr. Rebecca Dekker – 00:27:37:
Can you talk a little bit about some of the research that you’ve seen, some of the trends and findings that have come out in the last 10 years since that negative opinion came out from ACOG in 2014?
Liz Nutter – 00:27:48:
Oh, yeah. There’s been some amazing, amazing research. And as you showed in your update, right? And I was so excited when you reached out because I literally had just gotten done doing the full review myself for the training program that I put together. And I was like, oh, this is perfect. It’s right on. So, Burns, Ethel Burns, is in the UK. She’s a huge waterbirth researcher. She’s done a ton of literature and meta-analyses and systematic reviews. She’s got a new one out. And it’s stable. It says the same things. It says waterbirth is a safe option for birthing persons when you have providers that know what they’re doing. And we have optimal maternal outcomes and optimal fetal outcomes. We’ve had Bovbjerg, who did an amazing study in the United States in birth center birth. So this was, it’s really like a hallmark article that looks solely at out-of-hospital birth. And we’re looking at a huge number. Over 61,000 participants gave birth in the water in this study. And it looked at out-of-hospital birth experiences. And it showed that the data’s awesome. Actually, lower risk of transfer to hospital settings. So some really strong data showing that. Birthing in water actually in an out-of-hospital environment is really protective. And then we have Vanderlyn who did a systematic review and meta-analysis on hospital birth only. It was really clear with these policies that we put in place using these protocols that are based upon evidence. And so they’re saying, we’re using this evidence-based protocol into this study, and we’re having great outcomes. What I see is not so much that the evidence changed at all. It’s really just supported it. But the one area that really has done a fantastic job of giving us quantifiable numbers for risk. The risk associated with waterbirth is the potential of cord avulsion. So cord avulsion or cord tearing. So when I say avulsion, I mean the cord actually snapping in half when the baby’s born. This could happen for a couple of reasons. It could happen that the cord’s really, really short. And so when we bring the baby up to the surface, there’s too much traction on the cord. And so it actually snaps. Also, it could be that the birthing mom, person gets so excited that they bring the baby up really, really fast and it snaps. I always, when I do waterbirth, verbally reassure and give guidance as the baby’s coming up. Remember, we want to go really slow, right? I need to evaluate the cord. And these are conversations that I have beforehand, but I always reinforce it at the time of delivery. I don’t know how short the cord is. So just slowly bring the baby up.
Dr. Rebecca Dekker – 00:30:53:
Right.
Liz Nutter – 00:30:53:
So we have really strong numbers now that show that the risk, so for every 10,000 waterbirths that are done, you could expect 20 cases of cord avulsion. So this is what the cumulative data shows us. But here’s the important thing. Because we know that it’s a risk. We know how to manage it. So, when we practice based upon the evidence. And we know how to manage it, the data shows no poor sequela, meaning… If the cord avulsion happens. We know it’s a risk. We recognize it. We act immediately. And these babies don’t have poor outcomes. They’re not going to the NICU because they lost too much blood. Because we know it’s a risk. We know how to manage it. We’re trained to be looking for it. We do guidance ahead of time. And that’s really… the only risk that’s been proven in the literature is cord avulsion, cord tears, but we know how to take care of it. We know it’s a risk and then our babies don’t have problems. So that’s really what I’ve seen in the literature over the last 10 years is just more data supporting that it’s a good option, a great option for low risk.
Dr. Rebecca Dekker – 00:32:17:
Right.
Liz Nutter – 00:32:18:
Yeah.
Dr. Rebecca Dekker – 00:32:18:
And I remember when we were creating graphics for social media, Evidence Based Birth®, we had, you know, list the benefits, list the risks, which was basically the cord avulsion, which you just talked about. And then a list of the drawbacks. So, the drawbacks are mainly things like the water got too cold or the staff were not supportive. And so somebody commented, commented like, so you mean the risks are that people might not do a good job?
Liz Nutter – 00:32:42:
Yeah. And like, isn’t that scary? And, you know, one thing that I get really passionate about is I do support, an informed consent. Really talking about waterbirth, right? What are all the major benefits? Meaning your chance of having an intact perineum is significantly higher when you give birth in the water because you have like a thousand little hands supporting the perineum with the water and it’s equally balanced, right? So that’s a huge benefit. You know, the qualitative data shows women are empowered. They feel in control. They have this safe cocoon space. Like they’re weightless. It takes off the back labor, which God as someone who had a back labor, it’s awful. You know, so you have all those benefits. And so I go over all these things when I do the informed consent. I talk about risk of cord avulsion. I’ve never had… a single family, after I give them full informed consent, say, I don’t want to do a waterbirth. They always say, okay. I never have seen a nurse anesthetist or an anesthesiologist give that level of informed consent for an epidural. Never. And it just shows the dichotomy in our culture.
Dr. Rebecca Dekker – 00:34:04:
It’s accepted implicitly, like, you know, as a form of pain relief. But if you want this midwife-led form of pain relief, there’s all the scrutiny around it.
Liz Nutter – 00:34:14:
Right.
Dr. Rebecca Dekker – 00:34:15:
Yeah.
Liz Nutter – 00:34:15:
Right.
Dr. Rebecca Dekker – 00:34:16:
Well, Liz, you’re clearly very passionate about waterbirth. Is there anything else with our time that you want to teach us about any other aspects of waterbirth you haven’t covered yet?
Liz Nutter – 00:34:26:
Yeah, I think, you know, my mission is really education based upon the evidence, not just for birthing families, but… midwives. nurses, right? I’m really fortunate that, you know, I’m in education and I say I’m midwifing the next generation of nurses. And… I talk about it. I talk about our culture in the U.S. And how it’s intervention-based and how hydrotherapy is an option to support women that are looking for this in a hospital, out of a hospital, right? It really just comes down to risk management. And most birthing persons are low risk. They should have this as a choice. Like the evidence is so clear that when you have persons that are trained, meaning your providers, your nurses. We’re experts, midwives are experts in risk assessment because if I have a laboring person that they’re not doing well or their fetus is not doing well, it’s my responsibility to promote optimal maternal fetal outcomes. And I’m responsible to consult with my obstetrician. I am an expert in doing this in every birth, whether they opt to deliver fully medicated or even unmedicated out of water, right? Right? That’s what I’m an expert in. That’s what I went to school for was to protect the normalcy of birth. And when it crosses over into an area that risk is starting to come over, I’m responsible for consulting and getting that expert obstetrician that looks at the abnormal and… that’s what we do. And as long as you’ve got someone who’s trained and a team that can facilitate if an emergency arises. Where waterbirth and hydrotherapy is an amazing option for people.
Dr. Rebecca Dekker – 00:36:25:
Agreed. So have you seen any birth workers or healthcare workers or providers have luck in the past few years of convincing their hospitals to begin allowing waterbirth either again or for the first time. Can you tell us about how they got through that process?
Liz Nutter – 00:36:43:
I’ve had the honor of many teams reaching out to me saying, Liz, we need help. Liz, we want to bring this in. What are your recommendations? How do we go about this? I know what my priorities in life are. And I’ve got a little one. He’s six. And as much as I am so passionate about waterbirth, I can’t travel all over the world. And so I sat down and I put together a training program because I wanted to make sure nurses, midwives, physicians, there are physicians that facilitate waterbirth. So I wanted to make sure that there was an option that people had good data in order to do this. And so I put that together and it’s opened up doors. And so I’m able to say, here’s a training package, bring this to the team. And then I’m also able to sit down and put together briefs that they can… share with their administrative teams. And really that one point that we talked about, which is you’re actually increasing your risk to the organization, that has spoke volumes to administrators. They’re so fear adverse that they think they’re protecting their population. But when you present the other side of the coin saying, have you ever thought about that you’re actually increasing the risk? That has been the one thing that has led, and I’ve gotten phone call after phone call after they’ve done the brief saying. That was the key point that flipped them and said, yes. Some facilities still, they’re requiring them to start a research study. So a lot of times we’ll pair hospitals together so that they’re doing a study.
Dr. Rebecca Dekker – 00:38:21:
Right, like an operational study.
Liz Nutter – 00:38:23:
Yes, exactly. So those are the ways that we’re able to really get it going. And again, I used ACOG’s committee opinion where they said, yeah, we support hydrotherapy in the first stage. I’m like, great, a tub in every single labor and delivery room, right? They said it’s safe. So let’s get it there. Because then with time, we have the data. Great, now we’ve got tubs in every room. Now let’s just move over into, this is an option for all birthing persons.
Dr. Rebecca Dekker – 00:38:51:
Right, just take it one more step further.
Liz Nutter – 00:38:54:
Yep, exactly.
Dr. Rebecca Dekker – 00:38:55:
Yeah. Any advice you have for parents who are hoping for a waterbirth? Any tips you have for them as they prepare for that experience, assuming they’re giving birth somewhere, they can have one.
Liz Nutter – 00:39:08:
Yeah, assuming that they can give birth in a facility that supports waterbirth. Talk to the, talk to your provider about what does your team do for training? If there’s an emergency, how is that managed? And here’s something that I get a lot of time when I offer training, people say, well, I need to watch a midwife do one. And then the midwife needs to watch me do one. And I say, no, like midwives were expert in birth. And as long as you understand just the very few things like safe water temperature, how do you manage a cord avulsion? How do you manage a shoulder dystocia if it occurs in the water? One of the most common questions that I get from patients that haven’t really read a lot on waterbirth or done a lot of research is like, well, doesn’t the baby breathe underwater? And it can, if you’re not using evidence to support the water temperature. And the other thing is if the baby is in distress. Then we know that it can override the protective dive reflex, which is research that was done way back in the 60s, showing that… fetuses, when they’re in the water, in the amniotic fluid, right, they’re floating in fluid. And if we control the water temperature to the maternal core, when the baby’s born into water, it doesn’t trigger the dive reflex as long as the baby is not compromised. So when we’re listening to the baby’s heartbeat, it’s giving us a lot of information that the fetus is tolerating the experience. And if they’re not, we have to get them out. Again, like I said, when in doubt, risk them out, right? Get them out, take a look, and then I can always put them back in the tub. But I never want to jeopardize the protective physiologic mechanism that the fetus has. When they’re born into water, because if there’s something going on, we have to get them out of the tub. So that way, I just want to give a mom a healthy baby and give her the experience that she wants. And sometimes I always say the baby sets the pace, right? Like I’m there to ensure safety, but ultimately your little one is going to dictate a lot of your labor course. And that’s really hard. I’m type A, a lot of women are type A, and they really want control over the experience and if nothing has taught me anything of being a mother is you learn to kind of let go of some of that control and labor is the first step in that process.
Dr. Rebecca Dekker – 00:41:52:
That is so true. And I love how you talk about being protective of safety because it reminds me of my sister, who’s a family medicine doctor. She used to describe midwives to me as kind of like a lifeguard of the process. And she always aspired as a family medicine doctor to practice similar in that way, you know, watching out for signs of distress. Keeping an eye on safety. And it’s just kind of amusing to think that in waterbirth, you literally kind of are a lifeguard.
Liz Nutter – 00:42:21:
Yeah, I love it. That’s a great analogy. I think it’s awesome. I might have to pull that in and talk with my patients. I’m really fortunate that I drive 35 miles up the road because the only practice in town in this area that does waterbirth is up the road. And so there’s a hospital right down the road and they don’t do it. And so I drive up to Tacoma and I’m really happy to report that I’m in a practice that fully supports birthing in water and an amazing team of labor and delivery nurses that are fully supportive of it. And they’re still my favorite births to this day.
Dr. Rebecca Dekker – 00:42:57:
Do you want to give them a shout out to their unit?
Liz Nutter – 00:42:59:
Yeah. St. Joseph in Tacoma, Washington. They’re amazing, great team and beautiful tubs installed there. So if you’re looking for a waterbirth in Washington, St. Joe’s is where you want to go.
Dr. Rebecca Dekker – 00:43:11:
Yeah, it’s so inspirational to hear that there are places that are supportive of this option. And Dr. Nutter, we wanted to thank you again for all your help on the research article on waterbirth. And we’ll also link to your recent published articles as well as the EBB Signature Article on fetal monitoring in case people want to learn more about the intermittent auscultation that you talked about earlier. So thank you again, Dr. Nutter, for coming on the podcast and sharing your research and and clinician expert wisdom with us.
Liz Nutter – 00:43:43:
It was a pleasure. Thanks so much, Rebecca.
Dr. Rebecca Dekker – 00:43:46:
This podcast episode was brought to you by the book, Babies are Not Pizzas: They’re Born, Not Delivered. Babies are Not Pizzas is a memoir that tells the story of how I navigated a broken healthcare system and uncovered how I could still receive Evidence Based care. In this book, you’ll learn about the history of childbirth and midwifery, the evidence on a variety of birth topics, and how we can prevent preventable trauma in childbirth. Babies are Not Pizzas is available on Amazon as a Kindle, paperback, hardcover, and Audible book. Get your copy today and make sure to email me after you read it to let me know your thoughts.
