Guidelines for a safe water birth

Barbara Harper 2006

The aim of this guideline is to provide a review of information on labor and birth in water and to suggest possible strategies to minimize the potential hazards to mothers and infants.

It can also be used to promote the maternal and infant benefits, which may arise from choosing this type of birth experience, but are not easily quantifiable.

It is written with the belief that clinically sound, evidence based guidelines improve quality of care.

These recommendations are not intended to dictate an exclusive course of management or treatment.

They must be evaluated with reference to individual client’s needs, resources and limitations unique to the place of birth and variations in client choices.

Rationale

The therapeutic properties of warm water immersion have been known for centuries. Baths, showers and whirlpools have been used for comfort during labor for many years. Over the past two decades the use of warm water immersion for the birth of the baby has aroused interest in many countries and an increase in the number of women requesting this option for both hospital and out-of-hospital births is occurring.

Waterbirth International has reviewed the best available evidence and offers this guideline to assist midwives and women in their decision making process around the use of water immersion for labor and birth. The body of evidence is small but growing.

Evidence

Maternal and neonatal outcomes after water immersion for labor and birth have been assessed in two large surveys over a four year period in England and Wales (Alderdice, Renfrew & Marchant, 1995; Gilbert & Tookey, 1999) Researchers reviewed 4693 and 4032 births, respectively, where water immersion was used and found no difference in outcomes for women and their newborns compared to a cohort group of low risk women who did not use water.

The perinatal mortality rate for these births was comparable to other low risk births in the UK. (Gilbert and Tookey 1999). This study tried to estimate mortality and morbidity rates for babies delivered in water.

The data collected was compared to other sources of data providing similar estimates for babies delivered conventionally to low-risk women. They examined adverse outcomes, which were reported over a two-year period between 1994 and 1996 from approximately 4,000 births in water. 1500 consultant pediatricians were surveyed and asked to report any cases of baby deaths associated with waterbirth. None of the five perinatal deaths recorded among the waterbirths was attributable to delivery in water.

Admissions to special care baby units were slightly lower for the water-born babies than admissions for other low-risk babies. This was a landmark study in providing significant reassurance about the safety of waterbirth.

Other researchers (Burns 2001; Lenstrup et al, 1987; Rush et al,1996; & Waldenstrom et al, 1992) have made similar outcome reports. A recent Canadian randomized control trial reported women experienced less pain after water immersion than their non-immersion counterparts and over 80% of the water immersion group said they would use the tub in subsequent labors (Rush et al, 1996).

There have been a few highly controversial reports in the literature, especially in the journal Pediatrics on the negative effects of water immersion for babies. “Water Birth: a near drowning experience (Nuygen et al, 2002) suggests that every case of waterbirth should be evaluated as a possible fresh water drowning. The authors’ conclusions that the use of water for labor and birth may contribute to adverse outcomes should be viewed with considerable caution.

There are several methodological problems with this case study and these results are not congruent with the findings of many large trials. It is clear more research is needed into this form of care. But opinion pieces should be viewed at just that, opinion and not referred to as scientific or medical evaluation of the evidence.

In the absence of a substantial body of evidence on the use of warm water immersion for labor and birth, the potential advantages and disadvantages, which follow, are primarily derived from experience. This guideline will be updated as more evidence becomes available.

Eligibility

Water immersion for labor and birth should be available to all clients who request it, who have been screened and who have discussed the risks and benefits with their care provider. Some practices may choose to use a standard informed consent form for the use of warm water immersion.

Water Immersion Defined

Water immersion must be defined at providing a depth of water which enables the mother to sit in water that covers her belly completely and comes up to her breast level or kneel in water on her haunches which comes up to just below her breast level.

Any amount of water less than this does not constitute true immersion and will not create the buoyancy effect and produce the chemical and hormonal changes which enhance a more rapid labor. After an initial immersion of approximately thirty minutes the body responds by releasing more oxytocin, but only if the body experiences deep immersion, leading to buoyancy.

When to enter the bath in labor

It has been reported in the literature that labor slows down or stops if the woman enters the bath too soon. Guidelines were established to prevent a woman from entering the bath before the start of active labor, by definition: established labor pattern, dilation of the cervix to 4cm or greater and the need to concentrate during the contraction.

We argue that observation has led us to believe that a woman should be given the opportunity to use immersion as soon as her body and her brain have the desire to bathe. Women have been observed in very early labor relaxing, letting go of fear and progressing quickly to an active and pushing phase of their labor.

Using the water effectively often requires a “trial of water,” to see how the mother will respond. It has been noted with the advent of underwater continuous fetal monitoring that contraction patterns once thought to space out and become less frequent were in fact exactly the same in or out of the water. The mother’s response to those contractions in the water was vastly different from the response on the bed, thus making everyone believe that they were less intense.

The chemical and hormonal effects of immersion take effect after no less than twenty minutes and peak around ninety minutes. It is therefore suggested that a change of environment, such as getting out and walking be recommended after about two hours of initial immersion. The midwife can make an evaluation of the mother’s condition at that time.

Getting back in the water after thirty minutes will reactivate the chemical and hormonal process, including an sudden and often marked increase in oxytocin.
Dianne Garland, registered midwife, lead waterbirth researcher in England and the author of, ” Waterbirth: An Attitude to Care,” says the following:
” Just as labors can be slower or stop out of water so is true of water. Changes to the woman’s body are normal in labor and each of us will tolerate different lengths of first and second stage. Just as we all deal with different amounts of fatigue and stress, so each woman is individual and should be treated as such in labor.

The point of this with water labor and waterbirth is that as each woman is an individual, so her labor should be cared for, within the normal parameters set by ourselves as autonomous practitioners. Or within the maternity units where we work. Fundamental changes to normal practice may need to be made in units where active management of labor prevails.”

Summary of benefits for labor and birth in water

• Facilitates mobility and enables the mother to assume any position which is comfortable for labor and pushing
• Speeds up labor
• Reduces blood pressure
• Gives mother more feelings of control
• Provides significant pain relief
• Promotes relaxation
• Conserves her energy
• Reduces the need for drugs and interventions
• Protects the mother from interventions by giving her a protected private space
• Reduces perineal tearing
• Reduces cesarean section rates
• Is highly rated by mothers – typically stating they would consider giving birth in water again
• Is highly rated by midwives
• Encourages an easier birth for mother and a gentler welcome for baby

Theoretical Potential Disadvantages

• Decrease in uterine contraction strength and frequency, especially if entering the bath too soon
• Neonatal water aspiration
• Maternal hyperthermia may contribute to fetal hypoxemia
• Neonatal hypothermia
• Cord immersion in warm water may delay vasoconstriction, increasing red cell transfusion to the newborn and promoting jaundice
• Blood loss estimation and assessment not accurate
• Maternal and Neonatal infection may be increase – not supported by the evidence
• Risk of acquiring blood born infection or sustaining back injury for caregivers
  

  Recommended Criteria for the use of a water pool

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

  Contraindications for birth in a water pool

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

  Absolute contraindications

• Pre-term labor
• Excessive vaginal bleeding
• maternal fever> 100.4, or suspected maternal infection
• Any condition which requires continuous fetal heart rate monitoring
• Untreated blood or skin infection
• Sedation or epidural
• Fearful Attendant
• Inflexibility in the client
  

  Controversial contraindications