Author: K.D.Brainin

Bridge to Health –  Sian Smith

When considering their birth plan, more and more women are choosing to include the use of water at some stage.

In fact, around 30% of women now plan to use this method either for birthing their baby or as a natural way to reduce some of the intense sensations (pain!) associated with labour.

Here are some of the reasons why:

Water is relaxing!

Being able to bob around in a large pool of warm water is the perfect environment to help you stay calm and relaxed, in a situation most would normally consider pretty stressful.

For many, sliding into a warm bath is the ‘go to’ choice of relaxation after a hard day, so what better way to help you through one of the most physically demanding and memorable experiences of your life?

Additionally, a calmer birth may be less stressful for your baby, as moving from an environment of warm amniotic fluid to one of warm water is a gentle way of introducing them to their new surroundings.

Water is a natural pain reliever

The relaxing effects of water help encourage the body to produce its own pain-fighting substances.

This is beneficial both for Mum and baby; for Mum staying relaxed helps stimulate her natural production of oxytocin (the’ love hormone’ that helps the uterus contract) and endorphins, the ‘feelgood’ hormones that help work as a natural pain reliever.

For baby, a happy and relaxed Mum is more likely to birth quickly with a reduced need for medical intervention.

It reduces stress and anxiety

It is not just the water that helps to relax you. With a waterbirth, often the entire surroundings are altered to create a calming ambience e.g. dimmed lights and hushed voices.

This enables you to go into your own world much more easily than if in a harshly lit room with strange people popping in and out.

Additionally, this type of relaxation helps encourage deep abdominal breathing, preventing you from becoming tense which may make contractions feel more intense.

It reduces the risk of perineal tearing

The warmth of the water helps to promote increased blood flow to the vagina and perineum (the area between the vagina and anus that is susceptible to tearing during childbirth).

This increases flexibility of the tissues and can reduce the likelihood of tearing when birthing the baby’s head.

It allows you to adopt a more ‘active’ birth position

A reason that some women choose a water birth is that it allows you to retain some control throughout the labour process –being aware of the contractions and sensations your body is experiencing, with a reduced chance of medical intervention.

Additionally, the sensation of ‘weightlessness’ that being in the water provides, enables you to move around much more freely than your body has allowed you to for a while!

You are free to adopt almost any position that feels comfortable for you.

The classic image of a labouring woman is that of her laying on her back with her legs in stirrups.

Whilst this is the case for many, it is actually a fairly difficult way to birth your baby as you have to work against gravity to push the baby’s head UP and over the lowest part of the spine – the coccyx.

The best way to counteract this is to work with gravity and adopt a more ‘active’ squatting or modified squatting position.

Being in the water allows you to stay in these positions for longer, as you can lean against the side of the birthing pool for support.

Remaining fit, healthy and active will also help you have as smooth a pregnancy as possible.

Your Osteopath can advise you on exercises that are suitable throughout pregnancy, specifically core, pelvic and lower limb strengthening exercises that will help you be able to adopt active birth positions and use the correct muscles to birth your baby as efficiently as possible.

It is safe!

Of course, water births are not suitable for everyone – the main criteria is that Mum and baby must be healthy, the baby must be in a head-down position, and the pregnancy must be between 37 and 42 weeks.

But as the majority of pregnancies are healthy, a water birth can offer a natural and more in control option to the labour choices a woman has.

And finally, one of the most frequently asked questions regarding waterbirths appears to be ‘will my baby drown underwater?’… to which the answer is no!

The baby receives all of its oxygen via the placenta and hormones circulating through the baby ensure this occurs until the baby is lifted out of the water.

It is also known as the ‘foetal dive reflex’ and allows babies to be underwater for short periods of time up until around 6 months old.

Excerpt from article published by Big Birtha who provides information and support for bigger mums and mums to be.

All women are more buoyant and supported by water, it’s one of the reasons swimming and aqua aerobics are particularly good forms of exercise while pregnant.

But the benefit is likely to be greater for obese women, as fatter bodies are naturally more buoyant.

The buoyancy and support provided by water eases movement, which may make both maintaining an active labour and facilitating access for monitoring easier.

On land, it is cumbersome and difficult for a heavily pregnant woman of any size to quickly move between kneeling, reclining, sitting, leaning, crouching, turning from front to back etc.

In water, it is simple and easy to shift to whatever position is most comfortable/convenient, even midway through contractions.

Being in water also promotes positions which are more agreeable for birthing. Lying flat on your back on a bed is one of the worst positions to be in during labour.

When you are on your back you are working against gravity; actually trying to push the baby out uphill.

It’s only a slight incline, but it’s there.

To add to the problem, when lying down, your body weight is also resting on your coccyx (tailbone), forcing it into the pelvic cavity and reducing space for the baby.

In water, even if you were to float on your back, you wouldn’t be putting the same pressure on your tailbone, and you are far more likely to take an upright position, crouching or kneeling, for instance; positions which on land are uncomfortable to maintain, but not in water.

This frees up your coccyx to keep out of the way.

It is well documented that warm water reduces pain felt by labouring women, and decreases the use of other pain relief.

Given the issues with providing epidural anaesthesia to obese women, it seems sensible that using water; an effective non-pharmaceutical intervention to help with pain should be an attractive alternative?

Obese women are at increased risk of having longer labours, and of moving on to instrumental delivery and caesarean sections for ‘failure to progress’.

Yet immersion in water has been shown to significantly reduce the length of labour in ‘normal’ sized women.

It doesn’t take much of a leap of imagination to consider that water might help to address this problem, at least in some obese women?

BigBirtha.co.uk...

Active Birth Pools are specially designed for to accomodate bigger mothers enabling them to move and benefit from the positions natural to labour and birth.

Various means of entry and exit from the pool as well as emergency evacuation have been considered and designed for to safeguard  over weight mothers and the midwives who care for them.

Professional advice for attending midwives

1. Must be the midwives choice to help mothers in the pool room.
Two midwives present for delivery

2. Adequate education

3. Professional and peer support

4. Familiarity with legal implications

(in UK code of practice 3.3.3. Sections C & D).

5. Record Keeping

6. Health and Safety

7. Rehearse Emergency Procedures

8. Midwife’s Comfort

Preparation of Parents

Aqua natal and other antenatal classes

Midwife explains use of the pool

Discuss:

File notes of parent’s wishes

Parents to agree in advance

However

Midwife on duty must be competent and willing

Midwife’s judgement is paramount. If the midwife is not happy about aspects of progress in the pool and wants the mother to leave the pool, she will agree to do so.

“Midwives are accountable for their own practice”

PREPARING THE POOL ROOM

Portable Pool

1. Position the pool to allow easy access all the way round (consider trolley in an emergency).

Remove all unnecessary furniture.

2. Place blue disposable liner in position

3. Run tap for five minutes before filling the pool.

Put filling pipes over the side of the pool.

Fill pool two-thirds full – temperature 36-37 degrees C

As pool is filling, adjust creases in liner.

4. Maintain temperature to mother’s comfort between 32 and 37 degrees.

With this amount of water, temperature reduces at about 1 degree per hour – check half-hourly). Keep heat retaining cover on pool when not being used.

5. Clean up any spillage – remove unnecessary hose.

6. Equipment Required

Parents’ birth plan

Admission

1. Confirm mother still wishes to use the pool

2. Base line observations

3. Assess strength of contractions

4. Obtain satisfactory CTG

5. Vaginal assessment

Avoid rupture of membranes

AIM – Physiologically normal labour

6. Glycerine suppositories – some offer microlax enema (5 mls). This is not usually necessary.

7. Encourage mother too remain outside pool until mid-labour.

Use:

Aromatherapy Massage

Homoeopathy

Labour – Inclusion criteria

Labour – Exclusion criteria

Caring for the mother and baby in the pool

Labour

Priority – remember too many interruptions breaks the mother’s concentration.

Disturb as little as possible

1. Labour established prior to mother’s entry to pool (4cm onwards)

2. Mother can adopt any position she likes. Frequent changes are good.

3. Adjust depth of water for comfort

4. Lower lights

5. Midwife in constant but discrete attendance while mother is in the pool.

6. Check water temperature regularly Mother comfortable – not too warm or too cold 36-37 degrees at delivery

7. Ensure plenty of fluids – mother, partner and staff – to prevent dehydration.

8. Ventilation and room temperature to comfort.

Observations during Labour

Amniotomy

Usually unnecessary, membranes left intact as long as possible, but can be performed in water.

Pain Relief

1. Warm water may be enough

2. Breathing, visualization, relaxation techniques

3. Massage – holding – partner in pool optional (bathing trunks to be worn)

4. Homoeopathy

5. Essential oils by inhalation – Lavendar, Clary Sage or Marjoram

6. Verbal support – partner participation

7. Opitons – N20 + 02 (Entenox) – Pethidine (not to exceed 50 mgm)

Elimination

1. Inclusion of toilet in pool room preferable

2. Mother usually empties her bladder without being aware of it.

Birth in water

Exclusion Criteria

Second Stage in the pool

If contractions slow down in second stage, the mother should leave the pool – if contractions are effective birth may occur under water.

Two midwives present

Second stage initiation usually self-evident. Vaginal examination not necessary as a routine.

Guidance, support – sometimes suggest different position. Do not actively encourage pushing if progress is normal. (if progress is not satisfactory – advise mother to deliver on dry land).

Crowning: manual support of perineum and control of head not usually needed, due to softening effects of water.

Baby born from front. Head delivered – with next contraction body is delivered. Slowly raise the baby to the surface of the water without delay. Baby face up under water, face down when lifted up. Mother assists or is given baby and welcomes baby with head above water but body below water to minimize heat-loss by evaporation (water level may need adjustment so mother can sit comfortably and hold baby like this)

Baby born from behind into water. Do not bring baby to surface from behind mother. Pass baby, face up, through mother’s legs and invite mother to reach down and receive the baby herself and then hold the baby’s head above, body below water surface level.

If mother stands up or baby is born above the water surface, ensure that the head does not resubmerge. Pass baby to mother (between the legs if from behind), she can then sit down in the pool with baby’s body submerged and head above the water level.

Midwife checks apex beat and cord pulsation, Apgar and blood loss observation.

Mother and father welcome baby, take photographs etc.

First sucking takes place.

Third stage in water

Exclusion Criteria:

First contact between mother and baby undisturbed if possible.

Discreet, unhurried observations

Placenta:

A physiological third stage is logical after a natural birth.

Use oxytocic drugs only if blood loss is excessive

Emptying a portable pool

Dealing with Emergencies

If in doubt – Get her out!

Cord around neck

Remember: NEVER cut the cord prior to underwater delivery

Once out of water, the baby’s head must not be allowed to resubmerge, as breathing may have initiated already.

Shoulder dystcoia

Episiotomy Procedure

Episiotomy is rarely needed for a water birth

Only done if baby is stuck or in an emergency where mother cannot leave the pool.

Not difficult to do in the pool

Woman Collapsing in Pool
(this rarely happens if guidelines are observed)

Call for assistance.

Do not empty pool – if possible fill to maximum as buoyancy aids removal of mother from pool.

If partner is present, ask him to support woman but do not lift.

Midwife maintains airway until assistance arrives.

Assistance Arrives

Baby slow to breathe

Please note: This is copyrighted material. But you’re free to forward it to anyone you like, as long as you don’t make any changes or profit from its use.

Michel Odent’s groundbreaking report “Birth Under Water” that was published in the Lancet in December 1983 is widely regarded as the seminal moment in time when the use of water for labour and birth entered our consciousness.

I’d personally like to thank Michel for being the inspiration that led me to begin to create and develop water birth pools in 1987 and for facilitating the birth of my son Theo at home in 1988.

Keith Brainin – Founder & Director Active Birth Pools

Birth under water – Michel Odent

Originally published in the Lancet: 1983

Centre Hospitalier Général de Pithiviers, PIthiviers 45300, France

The 100th birth under water in our hospital in June provided my team with an opportunity to summarise our experience of the use of water in an obstetric unit.

Since a report on birth under water in 1805,1 the subject has been rarely broached in the medical literature.

In Pithiviers, a hospital which is, in other respects, a conventional state hospital,2 a small pool has been installed close to the homely birthing room.

This pool is large enough (2m in diameter) and deep enough (about 0.7m) to make it easy for a woman in it to change her posture.

Many parturients feel and irresistible attraction to water. We don’t advise women to try the pool; we simply offer the pool as a possibility.

The water is ordinary mains tap water, at a temperature of 37 °C. The water is not sterilized, and contains no chemicals or additives on any sort.

We tend to reserve the pool for women who are experiencing especially painful contractions (lumbar pains, in particular), and where the dilation of the cervix is not progressing beyond about 5cm. In these circumstances, there is commonly a strong demand for drugs.

In most cases, the cervix becomes fully dilated within 1 or 2 hours of immersion in the pool, especially if the lights are dimmed.

It is possible to check the fetal heartbeat regularly with a small ultrasound stethoscope or with a traditional obstetrical stethoscope. Most women choose to leave the water in the second stage.

We believe that the warm pool facilitates the first stage of labour because of the reduction of the secretion of nor-adrenaline and other catecholamines; the reduction of sensory stimulation when the ears are under water; the reduction of the effects of gravity; the alteration of nervous conduction; the direct muscular stretching action; and peripheral vascular action.

Other factors, however, are difficult to rationalise. We have found, for example, that the mere sight of water and the sound of it filling the pool are sometimes sufficient stimuli to release inhibitions so that a birth may occur before the pool is full.

We have observed that water seems to help many parturients reach a certain state of consciousness where they become indifferent to what is going on around them.

Although nearly all the women who enter the pool leave it before birth, the process of delivery can sometimes be so extraordinarily fast under water, that some parturients do not leave the pool at the second stage.

Birth under water is therefore not exceptional in our unit, although it may not be intentional. During the second stage, immersion in warm water seems to help women to lose inhibitions. Most women cry out freely during the last contractions.

When the birth happens under water, the newborn infant is brought gently to the surface and placed in the mother’s arms. This is always done within seconds but without rushing (I am present at the pool for every underwater delivery).

Our experience confirms that the newborn’s first breathing is triggered by contact with the air and the sudden difference in temperature.

There is no risk of inhalation of water. It is useful to remember that in the human species carotid chemoreceptors are thought to be insensitive at birth, and very likely play no part at the time of the first cry. 3,4,5 Only 2 newborn infants out of 100 needed suction of the upper respiratory tract and a short period of manual ventilatory support.

At the time of first contact, most mothers are in a vertical position, kneeling in the water.  They hold the baby in their arms in such a way that skin-to-skin and eye-to-eye contact are as perfect as possible.

An early demonstration of the rooting reflex is almost the rule, and a first sucking 20 min after the birth is common.

Water seems to facilitate the development of the mother-infant relationship. We cut the umbilical cord and help the mother leave the pool just before expulsion of the placenta.

We consider that there might be a risk of water embolism if the mother were to stay in the pool after this time. In 100 underwater deliveries there were 2 manual removals of placenta (our general rate is less than 1%).

All the presentations were cephalic. In breech presentations, our strategy is to use the first stage as a test before deciding on either a vaginal delivery or a caesarian section: in these cases we prefer not to interfere with drugs or with a bath.

Among the 100 women who gave birth underwater, there were 43 primipara, 37 secundiparas, 14 para 3, 2 para 4, one para 5, one para 6, and one para 7.

The youngest was 19 and the oldest was 43. The average age was 28. The lowest birth weight was 2.15kg and the highest was 4.40 kg, we did not perform any episiotomies.

All the tears (of which there were 29) were first degree. We had no infectious complications, even where the membranes were already broken.

There were no perinatal deaths. One infant was transferred to a paediatric unit one day after the birth with groaning and respiratory failure, symptoms which were diagnosed as subarachnoid haemorrhage after delivery in the posterior position at 37 weeks.

Only one infant was jaundiced and required phototherapy (15mg/dl bilirubin on the second day). One of the infants born under water died suddenly some weeks later, although it was previously considered to be perfectly healthy.

We have found no risk attached either to labour or to birth under water, and in any hospital where a pool is in daily use, a birth under water is bound to happen now and then.

Compared with the supported squatting position in the birthing room, we have found that the end of the second stage of labour can be more difficult under water, particularly for primipara, but immersion during the second half of the first stage of labour is helpful, particularly for parturients having painful and insufficient contractions.

It should be possible for any conventional hospital to have a pool situated close to the birthing room and operating theatre.

The use of warm water during labour requires further research, but we hope that other experience would confirm that immersion in warm water is an efficient, easy, and economical way to reduce the use of drugs and the rate of intervention in parturition.

REFERENCES

1. Embry M. Observation sur un accouchement terminé dans le bain. Ann Soc Méd Prat Montpellier 1805; 5: 13.

2. Gillett J. Chilbirth in Pithiviers, France. Lancet 1979; ii: 894-96.

3. Girard F, Lacaisse A, Dejours P. Lestimulus O 2 ventilatoire à la période néonatale chez l’homme. J Physiol (Paris) 1960; 52: 108-09.

4.  Purves MJ. The effects of hypoxia in the newborn lamb before and after denervation of the carotid chemoreceptors. J Physiol 1966; 185: 60-77.

5.  Purves MJ. Chemoreceptors and their reflexes with special reference to the fetus and newborn. J Devl Physiol 1981;  3: 21-57.

 

Water births are largely considered safe — but are there potential microbiological risks? And what are the best recommendations to eliminate any possible dangers?

Dr Jimmy Walker clarifies some of the advice outlined in an upcoming ‘back to basics’ book* aimed at training and education on the potential microbiological risks from water in healthcare facilities.

Water births have long been considered a safe way of giving birth for women who are not expected to have complex deliveries, with the literature backing up this record to show that rates of neonatal infections are no greater in water births than conventional bed births.1,2,3,4

However, this doesn’t mean there are no risks at all. Rare instances of adverse events have occurred, including microbial neonatal infections caused by a range of organisms that have included Legionella, the cause of Legionnaires’ disease, and Pseudomonas aeruginosa — although these have largely been related to home births.

There are several routes for potential contamination of water during a water birth:

Water supply

If either of the above organisms were found in a pool, this would indicate either contamination in the water system or at the tap outlet. If only a tap outlet were colonised, the contamination may be diluted to negligible levels in the pool once that tap is run. However, running a tap when there is biofilm build-up, either in the last two metres or further back in the system, would continue to release microorganisms leading to microbial concentrations in the pool water that could lead to infections.

This is a highly unlikely scenario that would only occur if water maintenance has been neglected enough to allow conditions for microbial growth to develop: for example where pipes have not been lagged properly causing the hot water to become cooler and the cold pipe to become warmer, creating ideal temperatures to enable growth of Legionella bacteria, for example.

Bodily fluids, birthing ‘debris’ and maternal contamination

As part of the birth process, water in birthing pools will inevitably be contaminated by bodily fluids and ‘debris’, such as placenta, some of which will be caught in strainers. Pool water can also be contaminated by faecal matter and any P. aeruginosa the mother may be carrying (P. aeruginosa can occur naturally on the skin of healthy individuals), although newborns are unlikely to be at risk from maternal ‘flora’.

A clear protocol is essential for drainage of the pool, cleaning and also disinfection to remove this contamination. All accessories must also be cleaned and thoroughly disinfected — or be single use.

If contamination is not properly dealt with, then any remaining residues will encourage microbial growth that could lead to potentially dangerous contamination of the next user’s water.

 Drains

The role of drains as a source of healthcare associated infections (HAIs) and potential reservoirs of antibiotic resistant organisms is now being regularly documented, with carbapenem-resistant Enterobacteriaceae (CREs) a particular concern.

Single use plugs and strainers are now most commonly used, with a large access valve for nurses and midwives to retain water in the bath. However, because birthing pools are usually located at floor level, the gradient of the drainage pipework may not be sufficient to remove the material caught in the drain. Although such an event has not yet been reported, this creates the potential for biofilmbuild-up over time, to a level that may be difficult for disinfectants to penetrate and possible contamination of the pool as soon as it is filled.

Birthing pool design

Birthing pools could be improved to prevent this backflow scenario from the drain, with designs that ensure efficient drainage of contaminating material and valves and drains that are easy to disinfect.

There are also examples of birthing pools where the pool is filled via a wall tap that enters the pool at a level where the water could flow back into the tap. This again has the potential for back contamination of the tap, with bacterial colonisation reaching even further back into the system in contravention of the water fitting directive.

Birthing pools should be designed with taps that are well above the pool’s edge and which are fitted with suitable backflow protection.

Some birthing pools also have an associated showerhead for cleaning the pool after use. However, this is also inadvisable as the flexible hose and shower head may become contaminated when they are suspended in the water. This could not only lead to backflow and contamination of the supply, but also, the contaminated hose and shower head could introduce harmful bacteria to the pool if they are not cleaned and disinfected appropriately or replaced between uses.

In addition, because water births are not always considered appropriate, there may be a prolonged period when the pool is not used. Where this is the case, a flushing regime is essential to minimise water stagnation, biofilm build-up and microbial proliferation in the water supply.

Resolving issues

Maternity units are well aware of the risks and must carry out their own risk assessments, but it is important that they are assisted in this by appropriate members of the hospitals’ water safety groups (WSGs – see p 10-12), who can provide additional specialist knowledge e.g. from microbiologists and the estates team.

Health Building Note 09-02 provides regulations and recommendations for birthing pools

References

1. Thoeni, A. et al “Review of 1600 water births. Does water birth increase the risk of neonatal infection?” J Matern Fetal Neonatal Med 17: 357–361, 2005. “https://doi.org/10.1080/14767050500140388″doi.org/10.1080/14767050500140388
2. Neiman, E. et al “Outcomes of water birth in a US hospital-based midwifery practice: A retrospective cohort study of water immersion during labour and birth”, J Midwifery Womens Health 65:216–223, 2020. “https://doi.org/10.1111/jmwh.13033″/doi.org/10.1111/jmwh.13033
3. Bovbjerg, M.L., Cheyney, M., Everson, C. “Maternal and newborn outcomes following waterbirth: The midwives alliance of North America statistics project, 2004 to 2009 Cohort, J Midwifery Womens Health 61:11–20, 2016. “https://doi.org/10.1111/jmwh.12394″doi.org/10.1111/jmwh.12394
4. 4. Taylor, H. et al “Neonatal outcomes of water birth: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal 101(4):357-365, 2016. doi.org/10.1136/archdischild-2015-309600

There have been accounts of women labouring and giving birth in water mostly amongst peoples living near a source of shallow warm water such as the South Pacific islanders.

In most traditional societies the rituals and practices of childbirth have, until recent times, been a matter of secrecy and handed down through generations of women.

There are oral traditions of similar practices among the Maori, the Indians of Central America, and the Ancient Greeks and Egyptians.

In 1805, the first account the use of water in Europe was documented.

A French woman, who had laboured for two days before being encouraged to get into a warm bath by her enlightened doctor then progressed to give birth to a healthy baby within an hour.

Sadly, for millions of women at the time there was no recognition of the importance of this event.

Aside from this, there are no accounts of a tradition of childbirth in water in Europe or other northerly regions.

The reason for this may be a simple matter of climate and plumbing.

Only with the widespread availability of artificially heated water and portable and installed birthing pools in comparatively recent times, has giving birth in water become a real option for women anywhere in the world.

Waterbirth was pioneered in the 1960’s by the Russian researcher Igor Tjarkovsky.

Using a large aquarium he installed a glass tank in his own home in Moscow in which many mothers gave birth .

Stunning photographs of these extraordinary births were published in the west and inspired the first water births.

For today’s generation of mothers, the key figure in the use of water for labour and birth is the French obstetrician Michel Odent.

In 1977 Odent installed a pool in the hospital at Pithiviers , not with the idea of promoting birth in water, but primarily as an additional option for pain relief and rest during long or difficult labours.

He has said ‘the reason for the birthing pool is not to have the baby born in water but to facilitate the birth process and to reduce the need for drugs and other interventions.’

Odent published his findings in the Lancet and his recommendations in this article provided the basis for the first midwifery guidelines for waterbirths.

Odent, M.  Birth under water.  The Lancet. December 24/31, 1983. pp 1476-1477

Inspired by news of what was happening in Moscow and France, the earliest waterbirths in the West took place at home in pools that were often improvised by the couples themselves and attended by independent midwives.

The parents created birthing pools using any large waterproof container they could find – including refuse skips, cattle troughs, inflatable paddling pools or garden ponds lined with a plastic sheet.

This happened simultaneously in several parts of the world and began to cause ripples in the world of obstetrics.

When reports and images of the first waterbirths were published, the world looked on in amazement.

The women who chose this way of birthing and their attendants were variously regarded as crazy, deluded, foolhardy or inspired.

The medical establishment rallied to condemn or at least call the practice into question, citing theoretical risks of infection and fears of the baby drowning.

Such fears have been largely appeased by the work of Dr Paul Johnson, neonatal physiologist at the John Radcliffe Hospital, Oxford.

His research on the mechanisms that trigger breathing in the newborn provided scientific confirmation of the safety of birth underwater at body temperature for babies who are not at risk.

He described how the baby is protected against the possibility of breathing while underwater in the few seconds between emerging from the birth canal and being lifted out of the water.

This response is known as the ‘dive reflex’.

Johnson, P.  Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology, vol 103, no 3, March 1996. pp 202-208

In 1999 Ruth E. Gilbert and Pat A. Tookey of the Institute of Child Health, London, published a hugely important study in the BMJ that effectively provided the ‘green light’ for labour and delivery in water.

It was a study of the outcomes for all babies born in water in the UK in a two-year period between 1994 and 1996.

A total of 4,032 waterbirths were included in the study (about 0.6 per cent of all deliveries).

All 1500 consultant paediatricians in the British Isles were asked if they knew of cases of perinatal death or admission to special care within 48 hours of labour or delivery in water.

The study showed that there was no increased risk to health for babies born in water as compared with babies born to other low-risk women on land.

Since then a burgeoning of interest in the use of water in labour in the UK has led to the development of a unique concentration of knowledge and expertise within the mainstream maternity system.

Positive encouragement to the use of water in labour and childbirth has come from the Royal College of Midwives, which recommends that midwives should develop the knowledge and skills to assist women at a waterbirth .

Water labour and birth is an option which is limited to ‘low risk’ women having an uncomplicated birth following a healthy pregnancy.

In the UK the issues of safe practice have been addressed by the health authorities, Royal College of Midwives, midwifery supervisors and one or two obstetricians.

A significant body of research studies and several important surveys have been undertaken.

Development has been more carefully and diligently monitored than many of the obstetric procedures that are widely used.

Against this backdrop, more of the managers of maternity services in the UK are increasingly being persuaded that the option of using water in labour and for birth should be available to all women.

The extent of the use of birth pools in the UK increased.

Pools are now used in hospitals as well as independent birth centres, some of which specialize in waterbirths, and in the community at home births with both independent and NHS midwives.

The Edgware Birth Centre in North London is an example of a new type of forward-thinking NHS birth unit.

Typically 70 per cent of women who give birth at the centre use water during labour and 50 per cent give birth in water.

Since it’s inception outcomes show far fewer interventions than for low-risk births at a conventional hospital birth unit.

This is a model of care which would transform our maternity services if widely adopted.

In October 2000 the UK’s Royal College of Midwives estimated that 50 per cent of maternity units provided facilities for labour or birth in water.

The usage of pool varied between 15 and 60 per cent, which may be an indicator of the significance of the role of the midwife in supporting and encouraging women to consider the use of water.

Since then the number of UK hospitals and birth centres with installed pools has risen to closer to 60 per cent.

However, that does not necessarily mean that the pools are being fully or enthusiastically utilized or that the pool is always available.

It’s not uncommon for women to be discouraged from using them or to be told that trained midwives are not available.

Sometimes stringent protocols around the use of a pool can limit it’s usefulness and frustrate both mothers and midwives.

Women who want to use a pool are often also told that this may not be possible if the pool is already in use.

It’s time for such problems to be addressed and for all women to have the possibility of using a birth pool wherever they choose to give birth.

Water birth is one of the greatest innovations in childbirth of our times and can no longer be regarded as a passing fad.

The use of epidurals today has reached epidemic proportions and contributes significantly to the high caesarean and intervention rate and is also very costly, requiring a high level of expert attendance.

The simple expedient of a pool of warm water is by now a proven way to confine the use of epidurals to those women who really need them and improve safety and quality of the birth experience.

 

 

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I wrote this article a few years ago.

It seems particularly relevant now.

Recent news has highlighted the restrictive financial environment that maternity units will be expected to operate in.

Yet, at the same time midwives are charged with the important task of improving the quality of care and services.

David Cameron has said, “The whole aim of these NHS reforms is to make sure we get the value for the money we put in.”[1]

In the same article, Stephen Dorrell, former Health Secretary commented that, “In real terms, the NHS budget was being broadly maintained, but we’re having to find ways of doing more with the same amount of money.”[2]

The only way of improving maternity services is by optimising facilities, saving money wherever practical and normalising childbirth to a far greater extent.

Studies have shown that women who are supported during labour need to have fewer painkillers, experience fewer interventions and give birth to stronger babies.

After their babies are born, supported women feel better about themselves, their labour and their babies.

A focus on normalising birth results in better quality, safer care for mothers and their babies with an improved experience.

Increasing normal births is associated with shorter (or no) hospital stays, fewer adverse incidents and admissions to neonatal units and better health outcomes for mothers.

It is also associated with higher rates of successful breastfeeding and a more positive birth experience.

These changes benefit not only women and their families but also maternity staff.  Midwives are able to spend less time on non-clinical tasks and more on caring for women and their babies.

Psychologically speaking, and in particular for first time mothers, the less intervention and a more hands on approach with one-to-one support means that mothers will leave hospital feeling held and therefore far better prepared for motherhood.

This again has a domino effect, not just on the welfare of the infant, but also circumventing the need for costly government and LA interventionist approaches in particular for younger mothers post-partum.

What increases the likelihood of normal births?

It is also known that some factors help to facilitate straightforward birth without evidence of additional risks, including one-to-one support, immersion in water for low-risk women, planning for a home birth, care from known midwives, more extensive training of junior doctors, employment of consultant midwives focusing on normality, and support on the labour ward from consultant obstetricians[3].

How can midwives make a case for purchasing birth pools?

The need for more water birth facilities is evident.  The problem is that financial controllers are under pressure to save money.

They will not be easily convinced of the necessity unless you clearly stress that purchasing pools should not be viewed as a cost but rather to make the case that they are a valuable investment and will enable your unit to optimise resources, improve the quality of care and yield a return of significant financial savings.

A birth pool is a simple, inexpensive piece of medical equipment that can have a major impact on the quality of care and cost of having a baby.

The bed is no longer the primary focus of the room: having birth pools in hospitals and delivery suites facilitates pain relief encourages relaxation and therefore confidence and promotes mobility along with soft furnishings such as beanbags.

Importantly, this results in significant financial savings! 

Our cost study has revealed that savings of up to £700.00 per birth can be achieved.

For example, St Richards Hospital in Chichester has three of our birth pools as well as our soft furnishings.

They recently reported their first successful VBAC in the pool for a woman who had previously had twins by c-section.

Depending on complications, a c-section costs between £1,370 and £1,879 in contrast to a normal delivery that is usually between £735 and £1,097.[4]

The experience of hospitals that have birth pools demonstrates that the cost of installing a pool is soon recouped by the savings achieved through reduced use of medical methods of pain relief and shorter hospital stays.

Wherever possible, women should have the opportunity to labour in water, as this is often far more comfortable.

The NHS has advised hospitals to ensure facilities are in place for this: three pools for 1,000 births a year is seen as adequate provision[5].

[1] BBC: 19/01/11
[2] BBC 19/01/11 taken from BBC Radio 4 Today programme
[3] Hodnett ED, Gates S, Hofmeyr GJ, Sakala C.  Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub2
[4] NHS Institute, 2009
[5] NHS Guidelines on Childbirth 26 September 2007

Please note: this has been written for midwives by a midwife. If you’re pregnant – it’s worth scanning down the page as it’s full of really beneficial information. But, there is a lot of technical information and research that will mainly be of interest to professionals.

I am a practising Midwife, working at the Birth Unit at the Hospital of St. John & St. Elizabeth, a small private unit in North London. It has a” low risk” criteria for booking & delivery and our unit has international recognition for water birth and offering complimentary therapies, as well as offering traditional birthing methods, facilitating client choice (D.O.H 1993).

We currently deliver about 400 women a year and over 60% of women use the pool at some point during their labour and about 30% actually deliver in water.

Waterbirths have always been seen as normal Midwifery practise, the midwives working here have gained confidence and competence in using water for their clients, by on going support in education and by debriefing with colleagues and reflecting on practise, this has been invaluable and meets post registration education and practice (PREP) needs. We are currently taking part in a collaborative Audit of Waterbirth with other units offering Waterbirth.

I am fortunate to work with visionary Obstetricians who support and advocate water for Labour and birth and empower Midwives in normal physiology of labour, We offer Midwifery Led Care (70%) and Consultant Led Care. (30%). There is a great sense of teamwork and mutual respect; clients seek out our unit because of our philosophy of care and the option of using a pool.

We have two pools from the Active Birth Centre and have put a lot of energy into making the birth environment as home-like as possible within a hospital setting, soft colours, dimmed lights, beanbags, birthing ball’ s, floor cushions rocking chairs and aromatherapy burners combine with the safety net of modern obstetrics should the need arise .

Water provides the midwife with an extra dimension, a great resource to enhance her skills in addition to the kind, warm, sympathetic and motherly presence that is so essential to the woman in labour.

Having met many Midwives, and many visit our unit to observe our practise and hopefully, witness a waterbirth and have the opportunity to skill- share with colleagues, there is great discord. Many are disillusioned with the Midwifery profession as a whole, such Midwives are disappointed by the cascade of interventions in their own units, having lost faith in the birthing process and the women’s ability to labour naturally.

Now, I am not saying that our unit is superior to any other, or that we only have women who only want Waterbirth and natural birth. We try to offer the optimal outcome for childbirth, if interventions are required they are very justified. We have an open, honest approach with our clients and try to address the realities of labour and birth in our classes, so whatever the outcome is a waterbirth, vacuum/forceps or caesarean section, it is hopefully a positive birth experience.

Most of what I am going to tell you is from my own 14-year experience of waterbirth, and from the evidence and research that is available, although there is still little. And a lot is anecdotal.

Many Midwives and Mother’s have enthusiastically supported the use of water in labour for birth. Many of the women I have cared for find the use of water so appealing—the soothing nature of immersion in water, the comfort of floating and moving freely, in contrast to being immobile on a bed, under bright light’s and electronically monitored. Immersion in water was popularised as a formal method of analgesia by Michele Odent in the 1970’s (Beake 1999).

It always brings a smile to the faces of women who are shown around our labour room prior to booking, they are often drawn to the pool with interest and curiosity and are keen to learn how and when we use the pool, this has an amazing effect on some women, who relax and are eager to anticipate the birth of their baby, they let go of fears so commonly inhibiting many women today, they begin to trust and some women begin to heal from previously bad birth experiences, knowing that they have a voice, good support and an environment conducive to a positive birth .

When a woman is able to labour in water, she receives positive affirmation that the birth is under her control, and that her values and her preferences are important. She is also likely to have the constant presence of a midwife whose attention is focused on her and her needs.

   In 1992, the House of Commons Health Committee report on the maternity services recommended that all hospitals should provide women with “the option of a birthing pool”.

Due to lack of research on labour and birth in water at this time, the Department of health was prompted to fund a survey, so the National Perinatal Epidemiology unit (NPEU) was commissioned to undertake a survey on labour and birth in water.

219 heads of midwifery in England and Wales were sent questionnaires in 1993, the outcome was that there was no evidence to suggest that labour and birth in water should not continue to be offered as an option. Questions remained about the possible benefits and hazards and called for further research.

Labour and birth in water is now widely available throughout the National Health Service. In 1995 nearly half of all units in England & Wales were reported to have installed birthing pools.

This appears to be the case as we start the new millennium. The number of births in water in various units is still generally low; therefore exposure to this type of care for most professionals is limited. As with all aspects of midwifery care, the use of water during labour and birth requires evaluation of associated benefits and risks, yet there are no large, collaborative, randomised controlled trials to date (Nickodem, 200)

The United Kingdom Central Council (UKCC) produced a position statement on waterbirths in October 1994 recognising the need to support the Midwife and that it welcomed the recommendation those women should have choice concerning the method of delivery.

The Position paper 1a (RCM Dec 2000) clarifies the Royal college of Midwives position and recommendations for it’s members stating that all units should develop guidelines and policies on the use of water in labour and birth. supervisors of midwives should help ensure midwives acquire and sustain skills and competence and suggests midwives audit and evaluate their practise and ensure their record keeping of labour and births in water is accurate.

The council (UKCC) recognised concerns raised by Midwives, mothers and consumer groups about the potentially difficult relationships which may arise between a woman’s autonomy, a midwifes professional judgment and accountability and that of local policy in relation to waterbirths as a woman’s chosen method for the delivery of her baby.

Midwives need the support from their Supervisor of Midwives when faced with such dilemmas. .Supervision was written into the MIDWIVES Act 1902 and has remained a statutory requirement until this day. The Supervisor of midwives is responsible for maintaining identifiable objectives, setting standards, ensuring competent practice, supporting staff and identifying training needs as well as fostering a supportive environment for birth and supporting change..

She is an advocate for clients and a supporter of Midwives , supporting women in their choice of care, and Midwives providing that care, She is a resource for learning material and experience, encouraging on going education.

Consequently schools of midwifery and study days/workshops were introduced to offer sessions on labour and birth in water for midwives offering the opportunity to discuss practical and clinical issues thus helping midwives to acquire new skills and update themselves .I am continually surprised at how much I continue to learn despite my many years of experience of waterbirth. This facilitates PREP’s statement of lifelong learning.

Birth in water is considered a “normal birth” and as such midwives have a responsibility to reflect and re-visit their Midwives Rules and The Midwives code of practise (UKCC 1998)The code is very clear that we ensure we are competent in skills acquired in our training and after registration and in maintaining those skills and that as a midwife we are accountable for our own practise in whatever environment we are practising.

Rule 40 : The responsibility and sphere of practise (UKCC 1998)

It is the wording of this rule that both enables the Midwife’s autonomy and at the same time delineates its boundaries.

It states:-

1. A practising Midwife is responsible for providing Midwifery care to a mother and baby during the antenatal, intranatal and postnatal periods.

2. Except in an emergency, a practising midwife shall not provide any midwifery care, or undertake any treatment, which she has not, either before or after registration as a midwife, been trained to give, or which is outside her current sphere of practise.

3. In an emergency, or where a deviation from the norm, which is outside her current sphere of practise, becomes apparent in the mother or baby during the antenatal , internatal or postnatal periods, a practising midwife shall call a registered medical practioner.

REFERENCES:

Maxwell B Water & Birth- Legal Implications Hunter Valley Midwives Association June 1997 vol 5 no 3

Keane H. the Waterbirth Experience, A Supervisors Perspective January 1995

Street D Waterbirths; Client Choice versus legal implications Nursing Times November % 1997 vol 93 no 45

United Kingdom Central Council position statement on waterbirths 1994

Royal College of Midwives Position Paper The use of water during birth July 1994

I have tried to address the most commonly asked questions that midwives ask and are concerned about regarding labouring and giving birth in water .I have included some practical tips from my own experience.

I would like to stress that the midwives clinical judgment, intuition and common sense is paramount.

Q. WHAT SHOULD THE TEMPERATURE OF THE WATER BE IN THE FIRST STAGE AND SECOND

STAGE OF LABOUR?

A. Labour 32°c- 36°c

Birth 36°c- 37°c

Measure hourly & record in the mother’s records. Record temperature in second stage. Bath thermometers are inexpensive to buy and can be cleaned following individual use.

This range of temperature is said to enhance uterine activity and prevent the baby from initiating respirations.REF:- Catherine Charles. BJM March 1998, vol 6, No 3.

O’dent Michelle, The Lancet. December 1983, pg 1476-1477

Johnson. P birth under water: To breathe or not to breathe J Obstet Gynaecol 1996

Q. WHAT IS THE RECOMMENDED TIME TO ENTER THE POOL?A It is recommended that the ideal time to enter the pool is when labour is well established and the cervical dilatation is 5cms or more. Getting into the pool too early may slow the process down. But if this should happen then leaving the pool & adopting upright positions will help.

However, I feel a degree of flexibility is required, and women reviewed individually, for some women having an intense labour experience, it may benefit from entering the pool earlier. In some cases I have known this has been of benefit and the woman has relaxed enough to “let go” and surrender to the birth process and has consequently made good progress.

I am amazed to witness the effect water can have on some women, from not coping “on land” to total submission, often the sound of “Ahhhh”! is heard as the woman steps into the pool, this has a wonderful effect on everyone!

REF:_ Odent M Use of water during labour- updated recommendations. MIDIRS, Midwifery Digest, March 1998, vol 8, No 1, Pg 68-69.

Odent M can water immersion stop labour? Journal of Nurse- Midwifery, vol 42, No 5 Sep/Oct 1997 pg 414-416

Eriksson, M Mattsson, L-A, Ladfors, L, Early or Late bath during the first stage of labour a randomised study of 2O0 women, Midwifery, vol 13, No 3 September 1997. Pg 146-148.

Boulvain M & Wesel S Neurobiochemistry of immersion in warm water during labour: The secretion of Endorphins, cortisol and prolactin.

Q. WHEN TO LEAVE THE WATER?

A I think here the midwife needs to review the nature of the labour and any risk factors .If in doubt get the mother out!

In my experience women will be asked to leave the pool for the following reasons:-

• Concern over the condition of the baby, changes in the fetal heart or meconium stained liquor
• When there is failure to progress in labour first or second stage.
• In second stage , when a large for dates baby is suspected to birth on land
• If the water becomes heavily soiled
• Maternal request, when further analgesia is required.
• In 3rd stage if there is excessive blood loss .or where there is a low haemoglobin estimation and the need for active management of 3rd stage.

Q DOES THE MIDWIFE GET INTO THE TUB?A No, with carefully designed pools, providing good access this is not necessary, apparently Michel Odent stepped into the pool in his socks, when his first waterbirth took him by surprise!:

In my experience I have never known it.

TIP. Midwives attending a waterbirth are best to wear light cotton trousers and top that can easily be changed should they get wet. Birth attendants are easily able to touch, massage and assist the mother in the pool.

Water spillage can occur as the woman steps out of the pool, or leans over the pool, try to clear up any water as soon as possible to prevent slippage, I usually have a towel or floor mat near by. A non-slip bathmat is also a good idea.

Q. HOW OFTEN SHOULD THE FETAL HEART BE MONITORED?

Prior to entering the pool the fetal heart will have been monitored and found to be normal, depending where the labour is taking place i.e. home or Hospital. Unit protocols should be followed.

In my unit a cardiotocograph (CTG) will have been performed on admission and repeated 4-6 hourly unless a deviation from the norm is detected.

Everyone with a portable acqua dopper sonic-aid devise can hear fetal heart tones.

In order to exclude fetal heart decelerations it is important to listen to the fetal heart immediately at the end of a contraction and from time to time during a contraction.

During the first stage of labour every 30 mins

During second stage of labour after every contraction or every other one.

Follow your instincts, if any concern asks the woman to leave the pool and commence continuous fetal heart monitoring.

All observations and events should be clearly recorded in the mother’s records, this is an integral part of midwifery practise.Q. WHAT IS THE H:I:V: RISK RELATED TO WATERBIRTH?

A. H.I.V is a very fastidious virus, meaning that it has a very hard time surviving outside of its preferred environment. It is thought that the water would provide a barrier to transmission due to the dilution effect of the water.

It is becoming increasingly more routine to offer antenatal H.I.V. screening of women

Some NHS trusts have denied women access to use the pool until screening tests showed they were H.I.V. negative, this is certainly controversial.

However birth attendants should adhere to universal precautions. ( Guidelines have been issued about universal precautions for the protection of health-care workers (D.O:H. 1990)

Wearing gloves is essential:_

TIP

• I advice wearing a half size smaller to provide a watertight fit
• Gauntlets are available, but my colleagues and I do not find them to be very user friendly! The latex is rather thick..
• I have known Midwives to cut off the fingertips of the gauntlets and wear them over regular gloves for better protection.
• Obviously cuts and abrasions on the hands should be covered with suitable plasters.
• Keep hands out of the water as much as is possible a “minimal touch” delivery technique is advocated.

REF:- Garland D, Jones K Updating the evidence BMJ June 1997 Vol 5, No 6.

No hepatitis or HIV test, no waterbirth Modern Midwife October 1995

Harley J. The use of water during labour & Birth. RCM Dec 1998, Vol 1, No 12.

Tedder, Prof R.S, Ridgeway, Dr G Blood-borne viruses, Labouring pools and birthing pools January 1996

Q. WHAT OBSERVATIONS ARE REQUIRED?

Observations as per normal practise of maternal temperature, pulse and blood pressure should be done prior to

Entering the pool and can easily be performed in the pool.

The use of the new GENIUS ear thermometers make’s life much easier. Monitoring maternal temperature ensures

That she is not over or under heated.

If there is a concern with the blood pressure it can be recorded in between a contraction with the mother either

Kneeling over the rim of the pool or sitting on the rim of the pool supported.

I have seen blood pressures lower due to the benefits of the mother relaxing in the water; this can be very helpful for

The woman who has mild hypertension.

Listening and observing the woman are very important skills that the midwife should follow.

WHAT ABOUT VAGINAL EXAMINATIONS?

Vaginal examination can easily be performed in the water with the mother lying, kneeling or squatting, supported by her partner. If a proper assessment is needed then the woman should be asked to leave the pool. In my practise I have found that the need to perform vaginal examinations in water is less. Evidence suggests that most women will deliver, for primigravida 4-5 hours, for multips 2-3 hours.

I have always found women to be co-operative and eager to please and will move, change position to help if it is necessary.

If the woman is deep in the water, I have found my examination not to be so accurate and depending on what the indication for examination may request that she leaves the pool.

REF. Warren C Why should I do vaginal examinations? The Practising Midwife June 1999 vol 2, No 6 pg 12-13

Q. HOW DO YOU CONDUCT THE 2nd STAGE OF LABOUR IN THE WATER?

The emphasis should be on the normal mechanism of labour.

Midwives will need to adapt their practise and technique to the position the mother adopts.

Equipment required and useful for a waterbirth’-

• Warm towels, for mother & baby
• Large sanitary towel
• A bath robe
• A delivery pack & cord clamp, sterile gloves
• Mirror
• TorchSieve/bucket/fish net needed to sift out any debris
• Bath thermometer
• Non-slip bath mat
• Water to drink for everyone
• Evian spray & lip salve
• Waterproof sonic-aid.
• Resuscitation equipment checked and near by.
• Syntometrine or syntocinon at hand should it be needed.
• Call bell that is easily reached, ours are fixed over the pool or emergency numbers if at home.
• A low stool, birth ball beside the pool for midwife and partner.

Never leave the woman alone. It is important to remind the mother of the importance of keeping her bottom under the water during delivery

Many units advocate the presence of a second midwife at the time of delivery this is helpful not only for practical reasons, but also an opportunity for midwives to skill-share and observe a waterbirth.

Check the temperature of the water it should be 36-37°c

It is very easy to observe progress; some suggestions may be required if pushing is ineffective. changing position, more upright to aid gravity.

Be prepared for the unexpected! I have known women to stand up out of the water at the last moment, if the baby’s head is delivered above the surface of the water then the delivery is conducted out of the water until full expulsion, then she can sit down into the water with her baby.

A part from the face, keep the baby immersed in the water to ensure that body temperature is maintained.

Michele Odent (1984) noted that women spontaneously leave the pool in second stage to birth their babies, whatever their previous intention had been.

If second stage progress is slow then leaving the pool, so the woman can maximise her pushing power is recommended.

Delivery of the head is technically a “hands off” procedure; this is achieved when there is a good rapport between woman and midwife. A mirror is useful to help see the advance of the baby’s head also I have found some women and partners like to see and this encourages them to progress further. .

The head may crown in full view, alternatively the midwife may use her hand to gently feel the advance of the head, this can be helpful, not to “guard the perineum” as in traditional birthing, but in order to determine if maternal efforts need to be gentler, and not so forceful to minimise perineal trauma and give some direction. The midwife will know if this is necessary.

Minimal intervention is needed, there should be no hurry, when the baby’s head is born, wait for the next contraction, I remember with the first few waterbirths I assisted finding myself holding my breathe! Being anxious and keen to deliver the baby up to the surface of the water, 2-3 minutes can pass, so remain calm!!

The baby is born completely under water and in a slow gentle movement brought to the surface, a movement that will generally take between 5-7 seconds.

The baby’s well being should be monitored throughout and ascultating the fetal heart immediately after a contraction will ensure you detect any late decelerations, if any concern the woman is asked to leave the pool.

I have seen baby’s open their eyes under water.

Usually the baby is handed directly to the mother, but be prepared, as I have had occasions when the mother has needed a few minutes before receiving her baby.

Checking the umbilical cord for pulsation reaffirms that the baby is still receiving oxygen via the placenta; this gives a good indication of the baby’s condition. Often water babies do not cry and are very peaceful so feeling the cord is reassuring.

Q WHAT IF THE CORD IS TIGHT AROUND THE NECK?

It is not necessary to feel for the cord prior to the birth of the shoulders, once the head is born. Feeling for the cord causes discomfort for the mother. If the cord is around the baby it is simple to rotate the baby’s body under the water to disentangle the cord. If the cord is so tight that it might adversely affect the baby late decelerations will be obvious and the woman will be asked to leave the pool.

NEVER CLAMP & CUT THE UMBILICAL CORD UNDER WATER. This is risky and time-consuming sine it could trigger respiration or stimulate the baby. If the cord was that tight you would of detected decelerations of the fetal heart rate prior to delivery.

Q WHAT ABOUT THE RISK OF THE CORD SNAPPING?

This is very rare, but some cases have been reported.

Delivering the baby gently to the surface of the water and avoiding being to hasty will help prevent excessive tension on the cord.

These suggestions may help. –

• Ensure that the water is not unnecessarily deep.
• Have cord clamps ready
• Deliver baby gently and away from the mother, it is then possible to view length of cord
• If any concern or for a short cord, pull the plug or ask the mother to lift herself up

REF: -Gilbert R E. Tookey P A Perinatal mortality & Morbidity among babies delivered in water: surveillance study

And postal survey B M J 1999, 319 483-7.

Anderson Tricia Practising Midwife Umbilical cords & underwater birth. The practising Midwife February 2000 vol 3 no 3 no 2 p12

ESTIMATING BLOOD LOSS IN WATER?

The amount of blood lost during and after delivery is difficult to estimate in the water, due to the dilution effect of the water.

With experience, midwives become better at gauging this, but if bleeding seems excessive then the woman should be helped to leave the pool.

Observing the mother will make you aware of any ill effects. If a mother feels faint she should leave the pool or the water should be drained

It has become common to estimate blood loss as less than or greater than 500mls. In my experience, I am surprised how often the water is clear following the birth, usually due to little perineal trauma.

Midwives must follow their intuition and gut feeling on this, if in doubt get the woman out!

Use a sieve or fish net to collect any blood clots.

In the case of a post partum haemorrhage I would suggest the following will need to be done;

• Pull the plug, call for help
• Administer syntometrine intramuscular
• Help the mother out of the pool to lie down either on a floor mat or on the bed if it is close ask the partner/colleagues to help you
• Wrap in warm towels or robe and rub up a contraction.
• Deliver the placenta if not delivered
• Estimate the blood loss
• Site an intravenous infusion if required and take blood for x-matching
• A syntocinon infusion may be requested
• Check the bladder is empty
• Record observations of maternal pulse & blood pressure and observe maternal condition

FAINTING

Should a mother feel faint while in the pool it may be best that she leaves the pool, the room often gets heated up with the vapour from the water, perhaps she has overheated. practical suggestions like opening a window, the use of a fan, drinking cold water or tepid sponging may help, and getting her to breathe slowly. Check her pulse and blood pressure. A glucose sweet or energy drink may also help. Rescue remedy and homeopathic arnica are useful.

IS IT SAFE TO DELIVER THE PLACENTA IN THE WATER?Yes, in the absence of complications the mother may remain in the water. A physiological third stage of labour is conducted unless there are contra indication e.g. low haemoglobin estimation.

Always have syntometrine available.

Unit to unit policies will differ on this, but in my own unit we wait for the umbilical cord to cease pulsating prior to clamping and cutting the cord, unless there is a concern. Sometimes the placenta is delivered prior to the baby being separated. Michel Odent (1993) suggests that the umbilical cord should be cut 4-5 minutes after the birth to reduce the risk of polycythemia.

In my experience, if you ask the woman to bear down with the next contraction she feels the placenta is often expelled with ease. Using upright positions assists gravity.

Remember “hands off” and no fiddling with the cord as this can cause undue bleeding.

The third stage can average 20-40 minutes. I have known it to take longer and leaving the pool is advisable, often this helps and the placenta is birthed easily.

In the absence of bleeding and if the mothers condition is satisfactory, be patient, putting the baby to the breast obviously will help.

Giving a homeopathic remedy like Arnica or pulsitilla in a 200-potency ca help.

TIP Have warm towels available and a large sanitary towel. As well as a bowl to catch the placenta.

In my own experience I have found mothers quite keen to leave the pool if the placenta is slow to be birthed.

Fathers are asked if they would like to cut the cord as a symbolic gesture. Often the Dads can enjoy their first cuddle with their baby while the placenta is being delivered.

WHAT IS THE CONCERN REGARDING WATER EMBOLISM?

This is a theoretical risk of introducing water into the uterus as the placenta is delivered, in theory allowing water to enter the mother’s bloodstream through the blood vessels at the placental site.

Back in 1993 Michel Odent raised the question of water entering the vagina and uterine cavity if the placenta is delivered while the woman was still in the water. Since that time many water births have occurred and many placentae have been born into water, without any incidence of water embolism.

In reality, immediately after birth, the vaginal walls touch one another, even if there was a tear so that the vagina is a potential cavity rather than an actual one. So it is extremely unlikely to happen.HOW DOES THE BABY BREATHE?

It is commonly believed that the stimulus to breathe is from the baby’s face coming into direct contact with the cool air and this only occurs when the baby is brought to the surface of the water.

This is one of the main concerns that I hear Midwives and parents expressing about the possibility of the baby inhaling water at the moment of birth.

When the head emerges underwater the chest is in the mother’s pelvis and water cannot be inhaled because the lungs do not expand. The baby continues to receive oxygen via the umbilical cord, therefore the umbilical cord SHOULD NOT BE CUT prior to full expulsion and birth of the baby.

It is important to instruct the mother to keep her bottom under water during delivery, if for some reason the mother lifts herself up and this does happen, then the delivery is conducted above the surface of the water.

Dr Paul Johnson’s work “Birth under water”-“To breathe or not to breathe” (1995) concludes that if the onset of labour is spontaneous, no drugs are administered a baby born with it’s cord in tact, into warm water not asphyxiated,

Is inhibited from breathing. Surfacing into cooler, dryer air provides the stimulus for the baby to start to breathe.

Therefore it is important to detect fetal heart decelerations, particularly late decelerations and hypoxic babies as hypoxia inhibits breathing in the fetus, except if very severe, when gasping occurs.

The entrance to the larynx is bristling with chemoreceptors, water in the larynx causes the diving response.

REF: Johnson P Birth under water- to breathe or not to breathe British Journal of Obstetrics % Gynaecology, vol 103, no 3 March 1996 pg202-208

Letter Birth under water- To breathe or not to breathe, MIDIRS Midwifery Digest (Jun 1997) 7:2 pg 201

Eldering G, Selke, K Water birth- A possible mode of delivery? Waterbirth Unplugged books for midwives Press 1996

WHAT ABOUT THE PERINEUM?

Technically conducting a waterbirth is a “hands off procedure”

Water softens the tissues and allows it to stretch so those deep tears are very uncommon under water.

I believe in a slow gentle delivery of the head using the maternal breath, obviously some women need more guidance than others, this is where having continuity of carer, building a relationship between client and professional, having trust all helps.

Visibility will depend on what position the mother chooses to use, the use of a mirror and torch will help if the mother is squatting or kneeing.

I have never performed an episiotomy in the water, but I have known colleagues who have, with the mother floating supported in the water. In my unit we do not advocate performing episiotomy in the water.

For occasions when the head is crowning for longer than usual, just changing position to being more upright or to even stand up has aided delivery and gravity.

SUTURING Often after a waterbirth if sutures are required it is best to wait an hour before inserting them as often the perineum is water logged, in reality an hour passes fairly quickly.

SHOULDER DYSTOCIA & WATERBIRTH

This is an avoidable tragedy and the detection of risk factors prior to birth would warrant a land birth.

RISK FACTORS: – Exclusion for birth in water

Large for dates baby

Poor progress in first stage, early second stage of labour

Previous history.

Midwives “gut feeling”

This is an emergency situation and medical aid should be called. In the event of the shoulders being difficult to deliver, the midwife will call for help and I would pull the plug and help get the mother out of the pool, just the movement of standing up or lifting her leg over the edge of the pool as getting out could be enough to deliver the baby, she will need help to physically do this, enrol her partner & colleagues.

Then adopt a supported squat position or MRoberts position, lean mother onto a beanbag for support.

Apply supra-pubic pressure; follow your unit’s protocol.

Shoulder dystocia drills are recommended as good practice for staff to feel competent and confident in dealing with this emergency situation, we cover the “what if” situation related to waterbirth in our play stations.

Remember record keeping relating to shoulder dystocia is very important.

E.g.

Not time of perineal phase of the second stage of labour

Note first indication of the shoulder dystocia

Note sequence of events i.e. 1st attempt at delivery

Episiotomy attempted or reasons for not performing

Positions used to facilitate delivery

Manoeuvres used to facilitate delivery

Note time between delivery of the head and the completion of the delivery of the

Baby.

Details of any resuscitation if required.

TWINS & WATERBIRTH

This is usually contra-indicated and stated in unit protocols and guidelines, however there are reports of twin births in water I have actually delivered twins in water but it was not planned, this was a muligravid mother who had a quick, easy delivery of the first twin in water, she left the pool for the second twin as we thought it to be a breech presentation, but actually after an examination it was a head presenting, all was normal, the mother asked to get back into the pool, there was no reason why she should not and with the next two contractions her second twin was born .I had the support of the attending obstetrician.

HOW DOES THE MIDWIFE LOOK AFTER HER BACK?

The health and wellbeing of midwives is very important. In the National Survey on waterbirths (1995), out of 8255 reports of women using water in labour, seven members of staff were reported to have suffered back problems. It is recommended that each Midwife attends an annual moving and handling course and must adhere to the recommendations.

I try not to lean over the pool, I usually pull a stool or chair next to the pool or sit on a birth ball or kneel at the side of the pool. Leaning over the pool unnecessarily is hard on your back. so keep bending over the pool to a minimum and wipe up any excess/spilt water from the floor to prevent falls/slipping.

We do manual handling sessions related to caring for clients in the pool, to look at ways of being kinder to ourselves and taking care of our backs and posture.

Make sure your knees are bent and try to be more conscious of your posture when leaning over the pool.

With care and good postural habit, stress on the spine can almost be avoided. Keeping fit and supple with simple yoga based exercises can help

If you have a back problem or a concern you should discuss this with your manager and occupational health department.

SUGGESTED READING: –

RCM 1999 Handle with cares, a midwives guide to preventing back injury.

RCM 1998 health & Safety representatives handbookRECORD KEEPING

“Record keeping is an integral part of nursing, midwifery and health visiting practise. It is a tool of professional practice and one which should help the care process” (UKCC 1998 Guidelines for records and record keeping).

Good record keeping is paramount and a mark of the skilled and safe practitioner (UKCC 1998)

• Keep accurate, consistent notes and write events as soon as possible after an event, providing current information on the care and condition of the client
• Write clearly in black ink
• Accurately dated, timed and signed with your signature printed along side the first entry
• In relation to waterbirth, record temperature of water, time of entering , leaving the pool and mother’s and baby’s condition
• Record any discussions or plans of care that takes place with the involvement of the client.GUIDELINES FOR THE USE OF WATER IN LABOUR.

For the first time, guidelines have been produced on the best available evidence for good practice when assisting with labour and birth in water, for use in hospital or home.

The guidelines are intended to reinforce good midwifery practice, and to suggest ways in which a midwife can best, and most safely support a woman who labours and may give birth in water. (Burns E & Kitzinger S Midwifery Guidelines for use of water in labour 2000 )

Each unit will have a guideline/protocol and criteria for Midwives to follow related to the use of water for labour and birth.

Here is an example of our own guideline: -CRITERIA FOR USE OF WATER IN LABOUR

• An uncomplicated pregnancy of at least 37 weeks gestation.
• Established labour- preferably when the cervix is greater than 4cms dilated( contractions usually peak within two

Hours of entering the pool therefore entering the pool too early may slow down the labour).

• No specific indication for continuous monitoring of labour
• The mother must be attended by midwife/labour partner at all times and must be aware that she will be requested

To leave the pool should complications arise, two midwives must be in attendance during the birth of the baby.

   WOMEN SHOULD BE URGED TO LEAVE THE POOL IF:

• Excessive fear, anxiety or loss of control exists
• There is significant blood loss at any time
• Augmentation with syntocinon is required.
• If there are significant abnormal changes in the fettle heart rate
• If moderate to thick meconium stained liquor is present
• If the contractions stop or significantly slow down
• If there is lack of progress after pushing for greater than an hour in the second stage
• If the woman has an abnormal rise in blood pressure
• If assistance is needed to deliver the head or the shoulders(help the mother to stand up for the first attempt to deliver to be made)

A new study shows that birthpools can ease the pain of labour.

So why, asks Janet Balaskas, are some women denied access to them?

(Observer newspaper January 28, 2004)

In the late 1970’s most women laboured in large consultant units, semi reclining in bed, strapped to electronic foetal heart monitors and subject to an avalanche of routine obstetric interventions. Of course any sensible women is only too grateful for modern obstetric care when there are problems.

However we only have to look at the statistics our hospitals today (22% of babies in the UK were born by Caesarean section in 2002 [www.birthchoices.com]), to see the heritage of this complete misunderstanding of the nature of birth physiology and the kind of environment and care women need to support it.

It’s not surprising that women the world over rebelled against the medical model. When I founded the Active Birth Movement in the 1980’s in North London it was about women reclaiming the right to labour and give birth in upright positions and in an environment which is more conducive to a natural birth.

Active Birth turned women from passive patients, recipients of a medicalised birth to active birth givers. Gradually, this has been influencing change in the provision of midwifery care and birthing rooms that are designed to facilitate more women being able to be mobile and to have a natural active birth.

While at first the freedom to move and choose comfortable upright positions was paramount – the possibility of getting into a pool of warm water in such an environment adds a number of benefits which can no longer be ignored by the managers and providers of maternity services.

News this week of a study by Southhampton General Hospital confirms what women and midwives all over the world have been saying for two decades about the benefits of using a birth pool during labour.

One of the main reasons that women choose to use water during their labour is for pain relief. There is no doubt from what women themselves and experienced midwives say, that immersion in water can provide dramatic relief of discomfort for a high proportion of women and an alternative to the epidural.

The Southhampton study involved 100 first time mothers who were making slow progress in labour and revealed that those who were given a chance to use a birth pool progressed better than those getting standard care. Less than half (47%) needed an epidural, compared to 66 % of those who did not use a birth pool.

This finding is not entirely new. A review of three randomized control trials found that there was a significant decrease in the use of medical pain relief in the women who used a birth pool in labour – indicating,

Nikodem, V.C.,  Immersion in water during pregnancy, labour and birth, The Cochrane Library, Oxford,1998, issue 1.

Other studies have confirmed the pain relieving effects of water.

For example a clinical audit of waterbirths carried out in five birthing units in England, reported a dramatic reduction in the use of analgesic drugs such as pethidine amongst pool users.

The study cited below found that only 3 per cent of women who used water in labour used pethidine as well, compared to 60 per cent of women who laboured on land. A reduction in the use of such narcotic drugs is welcomed by all concerned, as its is now widely recognized that they can have a depressive effect on both mother and baby’s central nervous system and may lead to a variety of complications.

Garland, D. & Jones, K.  Waterbirth, supporting practice with clinical audit. MIDIRS Midwifery Digest (September 2000) 10:3, pp 333-336

While women need to be aware that using a birth pool can make it significantly easier to manage the pain it does not take away the pain entirely and there will be some women who may still need medical pain relief. Experience has shown that the best time to enter the pool to get the most benefit, is about midway through labour at about 5 or 6 cms dilation.

This is generally around the time that many women choose to have an epidural as labour intensifies. Getting into the pool at this point offers an alternative. Many women find that the support of the water allows them to relax much more deeply, to feel much more comfortable both during and in between contractions and to have an increased sense of privacy.

There is a noticeable calming of stress levels and the abililty of the mother to cope with her labour can be transformed. At the same time the water seems to promote more effective contractions, so dilation may progress more rapidly while the mother is relaxing in the pool.

How water birth originated

There have been accounts of women labouring and giving birth in water mostly amongst peoples living near a source of shallow warm water such as the South Pacific islanders. In most traditional societies the rituals and practices of childbirth have, until recent times, been a matter of secrecy and handed down through generations of women. There are oral traditions of similar practices among the Maori, the Indians of Central America, and the Ancient Greeks and Egyptians.

In 1805, the first account the use of water in Europe was documented. A French woman, who had laboured for two days before being encouraged to get into a warm bath by her enlightened doctor then progressed to give birth to a healthy baby within an hour.

Sadly, for millions of women at the time there was no recognition of the importance of this event.

Aside from this, there are no accounts of a tradition of childbirth in water in Europe or other northerly regions. The reason for this may be a simple matter of climate and plumbing. Only with the widespread availability of artificially heated water and portable and installed birthing pools in comparatively recent times, has giving birth in water become a real option for women anywhere in the world.

Waterbirth was pioneered in the 1960’s by the Russian researcher Igor Tjarkovsky Using a large aquarium he installed a glass tank in his own home in Moscow in which many mothers gave birth . Stunning photographs of these extraordinary births were published in the west and inspired the first water births.

For today’s generation of mothers, the key figure in the use of water for labour and birth is the French obstetrician Michel Odent.

In 1977 Odent installed a pool in the hospital at Pithiviers , not with the idea of promoting birth in water, but primarily as an additional option for pain relief and rest during long or difficult labours. He has said ‘the reason for the birthing pool is not to have the baby born in water but to facilitate the birth process and to reduce the need for drugs and other interventions.’

Odent published his findings in the Lancet and his recommendations in this article provided the basis for the first midwifery guidelines for waterbirths.

Odent, M.  Birth under water.  The Lancet. December 24/31, 1983. pp 1476-1477

Inspired by news of what was happening in Moscow and France, the earliest waterbirths in the West took place at home in pools that were often improvised by the couples themselves and attended by independent midwives.

The parents created birthing pools using any large waterproof container they could find – including refuse skips, cattle troughs, inflatable paddling pools or garden ponds lined with a plastic sheet. This happened simultaneously in several parts of the world and began to cause ripples in the world of obstetrics.

When reports and images of the first waterbirths were published, the world looked on in amazement. The women who chose this way of birthing and their attendants were variously regarded as crazy, deluded, foolhardy or inspired. The medical establishment rallied to condemn or at least call the practice into question, citing theoretical risks of infection and fears of the baby drowning.

Such fears have been largely appeased by the work of Dr Paul Johnson, neonatal physiologist at the John Radcliffe Hospital, Oxford. His research on the mechanisms that trigger breathing in the newborn provided scientific confirmation of the safety of birth underwater at body temperature for babies who are not at risk.

He described how the baby is protected against the possibility of breathing while underwater in the few seconds between emerging from the birth canal and being lifted out of the water. This response is known as the ‘dive reflex’.

Johnson, P.  Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology, vol 103, no 3, March 1996. pp 202-208

In 1999 Ruth E. Gilbert and Pat A. Tookey of the Institute of Child Health, London, published a hugely important study in the BMJ that effectively provided the ‘green light’ for labour and delivery in water. It was a study of the outcomes for all babies born in water in the UK in a two-year period between 1994 and 1996.

A total of 4,032 waterbirths were included in the study (about 0.6 per cent of all deliveries). All 1500 consultant paediatricians in the British Isles were asked if they knew of cases of perinatal death or admission to special care within 48 hours of labour or delivery in water. The study showed that there was no increased risk to health for babies born in water as compared with babies born to other low-risk women on land.

Since then a burgeoning of interest in the use of water in labour in the UK has led to the development of a unique concentration of knowledge and expertise within the mainstream maternity system.

Positive encouragement to the use of water in labour and childbirth has come from the Royal College of Midwives, which recommends that midwives should develop the knowledge and skills to assist women at a waterbirth .

Water labour and birth is an option which is limited to ‘low risk’ women having an uncomplicated birth following a healthy pregnancy. In the UK the issues of safe practice have been addressed by the health authorities, Royal College of Midwives, midwifery supervisors and one or two obstetricians.

A significant body of research studies and several important surveys have been undertaken. Development has been more carefully and diligently monitored than many of the obstetric procedures that are widely used.

Against this backdrop, more of the managers of maternity services in the UK are increasingly being persuaded that the option of using water in labour and for birth should be available to all women.

The extent of the use of birth pools in the UK increased . Pools are now used in hospitals as well as independent birth centres, some of which specialize in waterbirths, and in the community at home births with both independent and NHS midwives.

The Edgware Birth Centre in North London is an example of a new type of forward-thinking NHS birth unit. It has two pools and typically 70 per cent of women who give birth at the centre use water during labour and 50 per cent give birth in water. Since it’s inception outcomes show far fewer interventions than for low-risk births at a conventional hospital birth unit. This is a model of care which would transform our maternity services if widely adopted.

In October 2000 the UK’s Royal College of Midwives estimated that 50 per cent of maternity units provided facilities for labour or birth in water. The usage of pool varied between 15 and 60 per cent, which may be an indicator of the significance of the role of the midwife in supporting and encouraging women to consider the use of water. Since then the number of UK hospitals and birth centres with installed pools has risen to closer to 60 per cent.

However, that does not necessarily mean that the pools are being fully or enthusiastically utilized or that the pool is always available. It’s not uncommon for women to be discouraged from using them or to be told that trained midwives are not available. Sometimes stringent protocols around the use of a pool can limit it’s usefulness and frustrate both mothers and midwives. Women who want to use a pool are often also told that this may not be possible if the pool is already in use.

It’s time for such problems to be addressed and for all women to have the possibility of using a birth pool wherever they choose to give birth. Water birth is one of the greatest innovations in childbirth of our times and can no longer be regarded as a passing fad.

The use of epidurals today has reached epidemic proportions and contributes significantly to the high caesarean and intervention rate and is also very costly, requiring a high level of expert attendance. The simple expedient of a pool of warm water is by now a proven way to confine the use of epidurals to those women who really need them and improve safety and quality of the birth experience.

Giving birth in water can be a wonderful memorable and empowering start to motherhood. At the Active Birth Centre we run a nationwide portable pool hire service and also provide installed pools to hospitals. We get feedback from the women and midwives who use our pools which is largely positive and often glowing. The news from Southampton comes as no surprise to me and is a welcome endorsement of the kind of experiences I have been hearing about for many years.

Women’s comments from questionnaires we send out to women who hire our pools.

‘I waited to get into the pool until I was 6 to 7cm dilated. Once in the pool labour progressed rapidly and just 35 minutes later I felt the urge to push. Our baby was born three and half minutes later. The pain was so well controlled that I couldn’t believe tat the birth of our daughter was imminent, neither could our fantastic independent midwife.

The water was so relaxing; this was my only form of pain relief. This birth was so different from my previous experience when I had our son without access to a pool. It was fantastic that our baby daughter entered the world calm and relaxed with no complications – a wonderful experience for all of us.’ “I felt my body relax immediately on entering the water and simultaneously recognized that I was pushing very comfortably.”

“My birth experience was wonderful overall. Helped by excellent midwives who “managed” the situation very well. I was relaxed and confident in the pool and up to the last ten or so contractions, I felt totally happy and in control… Having the pool gave me my own space and enabled me to decide who and when I wanted physical contact with… The water helped enormously with the pain, mainly due to the ease with which I could move about during contractions and the support it gave me whilst resting…”

” I got in the pool at about 5 cm dilated. The relaxation through my body was immediate and the ‘floating’ weightlessness was lovely. The water made it very easy for me to change positions at the start of a contraction. The contractions were stronger which was a bit of a shock but I could feel and visualize my cervix dilating much more easily”

“The sense of weightlessness in water gave me enormous relief. My birth was a fantastic experience and I don’t think I would have coped so well without the pool.”‘Labour progressed steadily for five or so hours, and then my waters broke with a gush. That was when I felt I wanted to enter the pool, which made me relax completely. My baby’s head was delivered five minutes later and I could see her hair floating. I then “breathed” her out and she swam into my arms. It was a wonderful experience and such a calm entrance to the world.’