Active Birth Pools News

March 2022

New midwifery research and studies

Water birth in Sweden – a comparative study

Waterbirth in low-risk pregnancy: An exploration of women’s experiences

Water birth: a national retrospective cohort study of factors associated with its use among women in England

A systematic meta-thematic synthesis to examine the views and experiences of women following water immersion during labour and waterbirth

The perceptions and experiences of women who achieved and did not achieve a water birth

Midwives’ experience of their education, knowledge and practice around immersion in water for labour or birth

Factors influencing water immersion during labour: qualitative case studies of six maternity units in the United Kingdom

Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study

An economic evaluation of water birth

February 2022

The Active II Water Birth Pool – innovative design makes our pools safer and more user-friendly 

Launch of the revolutionary Venus II Water Birth Pool

These pools are the same width as the original models but slightly longer and marginally more expensive.

Space and budget permitting I suggest you consider the Active and Venus II Water Birth Pools as your first choice.

They are game changers that make a real difference to the experience of all concerned.

January 2022

Launch of Resource and Educational Centre

A comprehensive collection of publications covering all aspects of water birth, design, build and setting up of a water birth facilities. A one of a kind resource that is the product of our 35 years of dedication to serving the needs of mothers and midwives.

Categories:

Alternatively  – use the search field in the top right of the page to find the information you’re looking for.

December 2021

Active Birth Pool installed to create water birth facility in the Midriff Hospital in Dubai.

November 2021

“Freedom of Movement” now has over 11,000,000 views on YouTube

The simple, short video shows how mothers instinctively relate to our pools and move naturally to find the most comfortable, supportive and beneficial positions. Watch on YouTube

 

 

Educational Centre – for mothers, midwives, healthcare professionals, planners and builders

Right from the start we have made education an important part of who we are and what we do.

Browse through the categories below or use the search engine to find the information you’re looking for.

Educational Videos

“Freedom of Movement”

The simple, short video has garnered over 11,000,000 views on YouTube.

It shows how mothers instinctively relate to our pools and move naturally to find the most comfortable, supportive and beneficial positions.

Entering the pool  – the Active Birth Pools approach

The extra-wide rim and step unit make simple and safe for mothers to get in and out of our water birth pools.

Educational videos for midwives

Active Birth Pools sponsored these educational videos for All4 Maternity to help midwives gain knowledge and understanding about the use of water for labour and birth.

Emersion in water in labour and birth – Part One
Emersion in water in labour and birth – Part Two
For more videos + foreign language productions visit our YouTube Channel

Dealing with emergencies

Active Birth Pools give midwives safe, practical options for dealing with emergencies.

The evacuation a collapsed woman is potentially hazardous and poses risk of injury to mother and midwife.

If the need for an emergency evacuation arises the midwife should:

  1. summon help
  2. stabilise the mother
  3. turn the taps on to raise the water to rim level.

The buoyancy of the water reduces the relative weight of the mother by approximately 33% making it easier to move her and effect safe evacuation.

Midwives should float/move the mother onto a seat or support and hold her safely until help arrives.

Basics:

  1. The mother should be screened to ensure that she meets the inclusion criteria prior to entering the birth pool.
  2. Continuous risk assessment is essential to reduce the incidence of emergencies in the pool.
  3. At the first sign of a contraindication the mother should be asked to get out of the water and assisted from the pool for monitoring and care.
  4. If the mother is unable to leave the pool under her own power or has collapsed an emergency evacuation will need to be conducted.
  5. A trolley should be available
  6. for the mother to be moved onto.
  7. Care must be taken that proper lifting techniques are employed to avert strain & injury.

Example 1: Emergency evacuation utilising the labour support seat

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The mother has been moved onto and held on the labour support seat

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The midwives guide the mother onto rim by sliding her up the side of the pool

Once on the rim she can be easily transferred onto a trolley

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Example 2) Emergency evacuation utilising the safety seat

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The mother is moved into position under the safety seat

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The midwives glide her up the side of the pool

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Onto the safety seat,

and then onto the rim for transfer onto the trolley

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Active Birth Pools are portable hoist compatible

Manual Handling advisors may insist that women are evacuated from the birth pool with a hoist and that this facility is provided for.

Active Birth Pools are designed to accommodate a portable hoist should the need arise.

Clinical Guidelines – Royal Cornwall Hospital

Clinical Guidelines – Royal Worcester Hospital

Guideline for the Management of Women Requesting Immersion in Water  – Norfolk and Norwich University Hospitals

Operational Policy and Clinical Guidelines – Abbey Birth Centre

Birthspace: An evidence-based guide to birth environment design – Queensland Centre for Mothers and Babies

Use of water for labour and birth – Hywel DDA Local health Board

Guidelines for use of pool during labour and delivery – East Cheshire NHS Trust

Guiding principles for midwifery care during normal labour – Barking, Havering and Redbridge NHS Trust

Waterbirth care during labour for low risk women – Sandwell and West Birmingham Hospitals

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Birth of the water baby – Michel Odent

In 1977, a state hospital near Paris began quietly changing the way women gave birth.

Obstetrician Dr Michel Odent believed that childbirth had become too medicalised and he wanted a more natural approach.

So he introduced a pool to ease the pain of labour and eventually some babies were even born in the pool.

Witness speaks to Dr Odent about the innovation that has become a revolution using the power of water.

Watch the video – Birth of the water baby

 

 

Better births

The keyword that defines our approach to design is ‘Active’.

If we look up the definition of ‘Active Birth’  we get, “Childbirth during which the mother is encouraged to move around freely and assume any position which feels comfortable”.

Active Birth Pools provide mothers with the space and depth to move freely in the postures natural to labour and birth.

As she moves, she intuitively discovers features that provide support and make her more comfortable.

Other birth pools have elaborately moulded interiors that can be described as an “obstetric chair in a bath”.

These birth pools typically have very little floor space or room to move.

As Sheila Kitzinger wrote in her article ‘The clock, the bed, the chair’ published in 2003:

“Even a recent innovation, the birth pool, does not always permit free movement. In theory, a pool allows a woman, supported by water, to move unencumbered.

Or so it might be thought.

Though published research often refers to mobility as an advantage of being in a pool, some pools are elaborate constructions with seats, handgrips and foot-rests, and movement in them is restricted.”

The pool dictates the position the mother should be in by placing her in a semi-recumbent posture with hand holds and foot rests to fix the arms and legs.

Mothers are positioned in the classic lying back with legs wide-open position but happen to be immersed in water.

The seats in these water birth pools are typically tilted backwards. The mother is immobilised in a position with her pelvis tilted upwards resulting in her  pelvic outlet being up to 30% smaller.

This puts pressure on the sacrum which flexes upward, into a curved position that restricts the diameter of the pelvic outlet inhibiting the baby’s descent.

The birth canal is placed in an “uphill” orientation, forcing the mother to push upward against gravity to give birth to her  baby.

These seats and moulded fittings greatly reduce the space the mother has to move in and restricts her ability to use the positions most beneficial.

The benefits of labouring in water are largely negated. The possibility of a physiological labour and natural birth is greatly reduced.

By contrast the Active Birth Pool gives mothers plenty of room to move with an unobstructed floor area that measures 1200 x 800mm.

A water birth pool should have features and design elements that support the mother as she changes position rather than dictate the position she is in.

Mothers experience maximum advantage of the benefits that water offers to help increase the likelihood of a physiological labour and natural birth.

‘Freedom of Movement video’ 

To see how mothers benefit from complete freedom of movement click on the link above.

This short home made video shows how the mother relates to the pool and the natural flow of movement that ensues. It has been hugely popular on YouTube.

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Water Birth Pools: The economic reality and impact

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

The use of water for labour and birth

Health Times: Karen Keast

Water is a life force in more ways than one – it covers more than 70 per cent of our earth and we drink it to survive.

When it comes to using water for childbirth, water birth is still a contentious issue that divides healthcare professionals and organisations alike.

The fact that it’s contentious at all surprises some of Australia’s leading midwives, writes Karen Keast.

There are legends of Egyptian pharaohs being born in water and of South Pacific women giving birth in shallow seas.

The first written report of a water birth in the western world occurred in France in 1803, when a mother experiencing a long and difficult labour was helped to give birth in a tub of warm water.

In the 1970s, Igor Tjarkovsky, a boat builder, investigated the therapeutic benefits of water and installed a glass tank in his home for women to use for childbirth.

French obstetrician Michel Odent went on to pave the future of water birth.

After a mother, using water to ease the pain of her labour, accidentally gave birth in the water, he went on to install a plastic paddling pool in a hospital so more women could enjoy the benefits of water birth while reducing their need for painkillers.

Only a small proportion of women in Australia choose to give birth in water each year although the exact number of water births is not known.

Griffith University Professor Jenny Gamble, a practising midwife of 30 years, says water births have come a long way in Australia but there is still a long way to go.

Professor Gamble recalls when a new maternity wing opened up at a Brisbane hospital, the then director general who was touring the facility instructed the plugs from the tubs to be removed.

“In his own way, he was saying water births might be a bad thing,” she says.

“Those days are gone. Water has become more accessible to women. There’s quite a lot of evidence to say that water is safe for women.

“More and more hospitals are putting in big tubs and there’s a range of deep tubs. It’s coming but it’s all too slow.”

Advocates of water birth say its benefits include the relaxing effect of warm water and feelings of weightlessness, buoyancy and ease of movement which help to alleviate pain naturally.

Western Sydney University Professor Hannah Dahlen, a privately practising midwife and spokesperson for the Australian College of Midwives, says evidence shows water immersion may also help improve blood flow in the uterus, lower blood pressure, provide less painful contractions and result in shorter labours and fewer interventions.

Professor Dahlen last year published a study in the Journal of Midwifery examining the outcomes of 6144 Australian women who had normal vaginal births in a birth centre over a 12-year period.

Her research compared women giving birth in water with those who gave birth in six other positions out of the water – kneeling or all fours, squatting, side lying, using a birth stool, standing and, the most common birth position in the country – semi-seated.

Professor Dahlen found those who gave birth on a birth stool had almost a one-and-a-half time’s higher rate of major perineal trauma and more than twice the rate of haemorrhage after delivery compared with water birth.

There was no difference in major perineal trauma and haemorrhage after delivery between women who gave birth in water and those who had a semi-seated position.

While those babies born in a semi-seated position had a four-and-a-half time’s higher incidence of five minute APGAR scores less than seven.

APGAR scores, which rate the newborn’s breathing effort, heart rate, muscle tone, reflexes and skin colour, of less than seven at five minutes after birth indicate medical intervention was needed to resuscitate the baby.

“Some studies have shown better outcomes but basically I found no difference to other birth positions,” she says.

“There was no evidence of harm. We want to do more research in Australia.

“We have no evidence to date that it’s harmful but we need more and more evidence to show it’s safe.”

Professor Dahlen says a water birth also provides women with a sense of protected space.

“They talk about how they felt there was a barrier; they felt it was a cocoon where they could feel safe,” she says.

Professor Dahlen says one common concern about water births is that the baby could drown but she says babies are born with a diving reflex, or bradycardic response, that causes them to hold their breath under water.

Professor Dahlen says despite mounting evidence proving the benefits of water birth, they still remain contentious in Australia.

“I have never understood it. I find it fascinating that water is so scary.”

Professor Gamble agrees.

“We’re talking about water, just water – not epidurals, not heavy duty drugs,” she says.

“Thank goodness hospitals are moving towards increasing their remodelling of their maternity suites to include tubs but quite frankly it’s a lot of fuss for something as simple as warm water.”

Professor Gamble says water births are common practice at planned home births, and are used during labour or active birth.

“Some women want to get in and get out for birth, some want to labour in the water and some hop in just for the birth – anything goes.”

Perhaps, most importantly, Professor Dahlen says water births are not about the baby.

“That’s what people get wrong,” she says.

“It’s about the mother and if you have a really happy and relaxed and stress free mother you actually have a baby that’s advantaged – they are born and very placid.

“They don’t often cry – they come up and blink.

“They are breathing fine. They come up all lovely and warm and then go to their mother’s chest.

“I really love water births.”

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A way to make labour shorter, easier and more comfortable

“Introducing a deep pool of water to the birthing room is a way to make your labour shorter, easier and more comfortable.

It increases your sense of privacy and helps to make your baby’s entry to the world gentle and free from trauma, whether the birth occurs in or beside the pool”

Janet Balaskas – “Water Birth”

During your labour relaxing in a deep pool of warm water can be a wonderful aid.

It’s using a pool mainly for this reason – even if you are not planning a water birth.

A birth pool may help you to manage pain effectively in labour and considerably reduce your need for medical pain relief.

Studies have shown that fewer epidurals are needed when women use a water birth pool.

You are supported by the buoyancy of the water.

This allows you to relax easily and more deeply.

This helps you to cope with contractions and rest more comfortably in between them.

By saving energy you’re less likely to become tired or exhausted.

It’s easier for you to use upright or squatting positions in water than it is on land and to move freely from one position to another as you explore what works best for you.

You are likely to have an increased feeling of privacy and security in the pool.

If you enter the pool at the right time (5-6cms dilation) you can expect a boost in the secretion of the hormone oxytocin.

This will stimulate strong contractions.

The ‘oxytocin wave” when you enter the pool in strong labour lasts for approximately two hours.

You are likely to dilate rapidly during this time.

You may choose to have your baby in water

Welcoming your baby in water can be a joyous and wonderful experience.

However, you may choose to leave the pool for the birth itself.

It’s best for you to keep an open mind, rather than to have a fixed plan to give birth in water, even though the idea may be very appealing.

If you progress well in the pool during labour, or if your birth happens soon after you enter the water, you may wish to stay in the pool for the birth.

Your baby can be born under water without increased risk provided there is good midwifery care and there are no known complications.

Your baby is gently brought to the surface before taking his first breath.

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The history of Water Birth

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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Nothing helps mothers cope with pain in labour more effectively

Water birth pools play a vital role in helping mothers experience physiological labour and natural birth.

Nothing helps mothers cope with pain more effectively.

If mothers are not going be reliant on analgesia for pain relief they need other options.

Mothers who enter a pool of warm water in established labour find that they are better able to cope with the pain.

Immersion in warm water has been unequivocally proven to be of great benefit both physiologically and psychologically.

Women have a greater sense of fulfillment and accomplishment and babies experience a non-traumatic birth.

Aside from the obvious benefits to mothers and babies, midwives experience greater job satisfaction and hospitals save money & optimise resources.

Nearly a third of women benefited from the use of a water birth pool in the UK in 2014 (National Maternity Survey 2014).

With up to 60% of mothers open to natural birth now is the time to consider making this safe, effective, low cost option more widely available.

On land mothers contend with the force of gravity which limits movement as labour progresses and they tire.

Many women do not have the fitness to maintain upright postures for lengths of time. (Gupta JK, Hofmeyr GJ, Smyth R 2007).

Mothers who are overweight or obese are often unable to cope with the physical demands.

The transition from the land to water helps revive & energise mothers giving them a new lease on life and sense of purpose.

The buoyancy of water supports the mother reducing her relative weight by approx. 33% (Archimedes Principle).

This allows her to move in ways not possible on land.

To explore and benefit from the postures natural to labour & birth .

The calming, relaxing effect of the warm water promotes the flow of oxytocin.

This powerful hormone plays a huge role in childbirth.

It causes the uterus to contract and triggers the ‘fetal ejection reflex’.

Immersion in water has a beneficial physiological effect on hormone secretion, including oxytocin surges which can advance dilation and stimulate contractions (Odent 2014).

Setting up a water birth facility

Hospitals in the United Kingdom have been evolving clinical guidelines for the use of water for labour and birth for over 3o years.

The protocols for operational policy that they’ve developed are widely regarded as the benchmark standard internationally.

Below a collection of guidelines and publications to help you create a water birth facility.

Clinical Guidelines – Royal Cornwall Hospital

Clinical Guidelines – Royal Worcester Hospital

Guideline for the Management of Women Requesting Immersion in Water  – Norfolk and Norwich University Hospitals

Operational Policy and Clinical Guidelines – Abbey Birth Centre

Birthspace: An evidence-based guide to birth environment design – Queensland Centre for Mothers and Babies

Use of water for labour and birth – Hywel DDA Local health Board

Guidelines for use of pool during labour and delivery – East Cheshire NHS Trust

Guiding principles for midwifery care during normal labour – Barking, Havering and Redbridge NHS Trust

Waterbirth care during labour for low risk women – Sandwell and West Birmingham Hospitals

Waterbirth Guidelines – Midwifery Led Unit, Wirral Hospital

Choosing a Water Birth – East and North Hertfordshire

Birthing pool use of labour and delivery – Wansbeck General Hospital

Water birth and use of water in labour guideline – Buckinghamshire Healthcare

Water for labour and birth guideline – Northern health and Social Care Trust

Immersion in water during labour and birth – NHS Forth Valley

Intrapartum care midwifery led unit – Wirral Women & Children’s Hospital

Guidelines for water birth within the hospital and at home – Dartford & Gravesham NHS

Disinfection and Sterilisation policy (infection control) – Basingstoke and North Hampshire NHS FT

The buoyancy of water helps mothers benefit from upright positions

Studies have shown that upright labour positions are associated with a reduced second stage, fewer episiotomies or instrumental intervention in contrast to mothers labouring on their backs.

Many women also feel empowered in an upright position, and experience a sense of control over their labour.

On land women need to contend with the force of gravity that limits their ability to assume upright postures especially as labour progresses and they feel tired.

Many women do not have the fitness or stamina to maintain upright postures for lengths of time.

The transition from the land to water helps revive and energise the mother giving her a new lease on life and sense of purpose.

The buoyancy of water supports the mother reducing her relative weight by approx. 33% (Archimedes Principle) allowing her to easily explore the full range of beneficial upright positions in comfort and move in ways that were not possible on land.

The space, depth and design features of Active Birth Pools allow women to move freely to find and be supported in the upright positions that are most comfortable and beneficial for a physiological labour to unfold.

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Michel Odent – the birthing pool test

This article first appeared in Midwifery Today, Issue 115, Autumn 2015.

There are many reasons to avoid last-minute cesarean sections that are decided at a phase of real emergency.

They are usually preceded by signs of fetal distress and they are often performed in poor technical conditions.

Furthermore, they are associated with negative long-term outcomes.

For example, according to an American study, women with a full-term second stage cesarean have a spectacular increased rate of subsequent premature births (13.5%) compared to a first-stage cesarean (2.3%) and to the overall national rate (7–8%) (Levine et al. 2014).

There are also serious reasons to avoid prolonged pharmacological assistance during labor, since the probable long-term effects of its different components (particularly drips of synthetic oxytocin) have never been evaluated through valuable scientific studies.

When a woman enters the pool in hard labor, there is an immediate pain relief, and therefore an immediate reduction in the levels of stress hormones.

Since stress hormones and oxytocin are antagonistic, the main short-term response is usually a peak of oxytocin and therefore a spectacular progress in the dilation.

We must add reasons to avoid, when it is possible, prelabor cesareans.

Apart from impaired lung maturation, it appears that the state of stress deprivation associated with “birth without labor” has a great variety of effects on the child, such as a lack of maturation of its olfactory sense (Varendi, Porter and Winberg 2002), which is a guide towards the nipple as early as the hour following birth (Odent 1977; Odent 1978).

Low levels of specific informational substances in the blood of stress-deprived neonates suggest effects on metabolic pathways and development of certain brain structures (Hermansson, Hoppu and Isolauri 2014; Simon-Areces et al. 2012).

It appears also that the milk microbiome and the gut flora of infants are disturbed in a specific way after birth by prelabor cesareans (Azad et al. 2013; Dogra et al. 2015), which is the mode of medicalized birth that disturbs breastfeeding more than all others (Prior et al. 2012; Zanardo et al. 2012).

Unexpectedly, it has been revealed recently that the risk of placenta previa in subsequent pregnancies is statistically significant only if the cesarean has been performed before the labor starts (Downes et al. 2015).

Finally, we are reaching a phase in the history of midwifery and obstetrical practices when an in-labor non-emergency cesarean appears in many cases as the best alternative to drugless childbirth.

In such a context, we understand the need for a new generation of tests in order to decide early enough during labor that the vaginal route is acceptable, without waiting for the phase of real emergency (Odent 2004).

The Basis for the Birthing Pool Test

The birthing pool test is the typical example of a tool adapted to futuristic strategies. It is based on a simple fact.

When a woman in hard labor enters the birthing pool and gets immersed in water at the temperature of the body, a spectacular progress in the dilation is supposed to occur within an hour or two.

If the already well-advanced dilation remains stable in spite of water immersion, privacy (no camera!) and dim light, one can conclude that there is a major obstacle. There is no reason for procrastinations. It is wiser to perform right away an in-labor non-emergency cesarean.

In the early 1980s, I had already mentioned in a mainstream medical journal (Odent 1983) the reason why we originally introduced the concept of birthing pools in the context of a French state hospital.

I had also described the most typical scenario: “We tend to reserve the pool for women who are experiencing especially painful contractions (lumbar pain, in particular), and where the dilatation of the cervix is not progressing beyond about 5 cm. 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…” At that time, I could only refer to most cases.

Afterwards, I analyzed the outcomes in the rare cases when the dilation had not progressed after an hour or two in the bath. I realized that finally a cesarean had always been necessary, more often than not after long and difficult first and second stages.

This is how I started to tacitly take into account what I had not yet called the birthing pool test.

More recently it happened that I mentioned the birthing pool test during information sessions for doulas.

This is how I learned from a series of reports about births in London hospitals.

It is obvious that many long and difficult labors with the usual range of drugs preceding an emergency cesarean would be avoided if the birthing pool test had been interpreted.

One of these anecdotes is particularly significant.

A woman in hard labor arrived in a maternity unit with her doula while the dilation of the cervix was already well advanced.

Soon after, she entered the birthing pool.

More than an hour later, the dilation had not progressed.

The doula, who was aware of the birthing pool test, was adamant that this woman could not safely give birth by the vaginal route.

A senior doctor was eventually called and diagnosed a brow presentation.

A brow presentation is difficult to diagnose in early labor and is incompatible with the vaginal route. In this case, the doula knew that a cesarean would be necessary, although she could not explain why.

The birthing pool test implies that an internal exam has been performed just before immersion so that, if necessary, a comparison will become possible after an hour or two.

This is an important practical detail, because midwives who are familiar with undisturbed and unguided births in silence, semi-darkness and privacy usually can follow the progress of labor with other criteria than a repeated evaluation of the dilation of the cervix.

Today, we can offer a physiological scenario explaining why immersion in warm water (set to the temperature of the body) makes the contractions more effective during a limited period of time.

When a woman enters the pool in hard labor, there is an immediate pain relief, and therefore an immediate reduction in the levels of stress hormones.

Since stress hormones and oxytocin are antagonistic, the main short-term response is usually a peak of oxytocin and therefore a spectacular progress in the dilation.

After that, there is a long-term complex response, which is a redistribution of blood volume.

This is the standard response to any sort of water immersion.

There is more blood in the chest (Norsk and Epstein 1988).

When the chest blood volume is increased, certain specialized cells in the atria release a peptide commonly called ANP (atrial natriuretic peptide) that interferes with the activity of the posterior pituitary gland (Gutkowska, Antunes-Rodrigues and McCann 1997).

We can all observe the effects of a reduced activity of our posterior pituitary gland after being in a bath for a while: we pass more urine.

This means that the release of vasopressin—a water retention hormone—is reduced.

In fact, the chain of events is not yet completely clarified (Mukaddam-Daher et al. 2002).

We have recently learned that oxytocin—the love hormone—has receptors in the heart (!) and that it is a regulator of ANP (Gutkowska et al. 1997).

In practice, we need to remember that the immediate peak of oxytocin following immersion in warm water will induce a feedback mechanism and eventually the uterine contractions will become less effective after an hour or two.

References:

  • Azad, MB, et al. 2013. “Gut Microbiota of Healthy Canadian Infants: Profiles by Mode of Delivery and Infant Diet at 4 Months.” CMAJ 185 (5): 385–94.
  • Dogra, S, et al. 2015. “Dynamics of Infant Gut Microbiota Are Influenced by Delivery Mode and Gestational Duration and Are Associated with Subsequent Adiposity.” MBio 6 (1): e02419–14.
  • Downes, KL, et al. 2015. “Previous Prelabor or Intrapartum Cesarean Delivery and Risk of Placenta Previa.” Am J Obstet Gynecol 212 (5): 669 e1–6.
  • Gutkowska, J, J Antunes-Rodrigues and S McCann. 1997. “Atrial Natriuretic Peptide in Brain and Pituitary Gland.” Physiol Rev 77 (2): 465–515.
  • Gutkowska, J, et al. 1997. “Oxytocin Releases Atrial Natriuretic Peptide by Combining with Oxytocin Receptors in the Heart.” Proc Natl Acad Sci USA 94 (21): 11,704–09.
  • Hermansson, H, U Hoppu and E Isolauri. 2014. “Elective Caesarean Section Is Associated with Low Adiponectin Levels in Cord Blood.” Neonatology 105 (3): 172–74.
  • Levine, LD, et al. 2014. “Does Stage of Labor at Time of Cesarean Affect Risk of Subsequent Preterm Birth?” Am J Obstet Gynecol 212 (3): 360 e1–7.
  • Mukaddam-Daher, S, et al. 2002. “Regulation of Cardiac Oxytocin System and Natriuretic Peptide during Rat Gestation and Postpartum.” J Endocrinol 175 (1): 211–16.
  • Norsk, P, and M Epstein. 1985. “Effects of Water Immersion on Arginine Vasopressin Release in Humans.” J Appl Physiol 64 (1): 1–10.
  • Odent, Michel. 1977. “The Early Expression of the Rooting Reflex.” In Proceedings of the 5th International Congress of Psychosomatic Obstetrics and Gynaecology, Rome 1977. 1117–19. London: Academic Press.
  • ———. 1978. “L’expression précoce du réflexe de fouissement.” In Les cahiers du nouveau-né, vol. 1–2, edited by E Herbinet. 169–85. Paris: Stock.
  • ———. 1983. “Birth Under Water.” Lancet 2 (8365–66): 1476–77.
  • ———. 2004. The Caesarean. London: Free Association Books.
  • Prior, E, et al. 2012. “Breastfeeding after Cesarean Delivery: A Systematic Review and Meta-analysis of World Literature.” Am J Clin Nutr 95 (5): 1113–35.
  • Simon-Areces, J, et al. 2012. “UCP2 Induced by Natural Birth Regulates Neuronal Differentiation of the Hippocampus and Related Adult Behavior.” PLoS ONE 7 (8): e42911.
  • Varendi, H, RH Porter and J Winberg. 2002. “The Effect of Labor on Olfactory Exposure Learning within the First Postnatal Hour.” Behav Neurosci 116 (2): 206–11.
  • Zanardo, V, et al. 2012. “Impaired Lactation Performance Following Elective Delivery at Term: Role of Maternal Levels of Cortisol and Prolactin.” J Matern Fetal Neonatal Med 25 (9): 1595–98.

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How a simple pool of water revolutionised childbirth – Michel Odent

The birth of the water baby -…

In 1977, a state hospital near Paris began quietly changing the way women gave birth.

Obstetrician Dr Michel Odent believed that childbirth had become too medicalised and he wanted a more natural approach.

So he introduced a pool to ease the pain of labour and eventually some babies were even born in the pool.

Witness speaks to Dr Odent about the innovation that has become a revolution using the power of water.

Click here to view the video.

On a personal note, I’d like to thank Michel for inspiring me to develop Active Birth Pools.

As he said:

“When asked about the history of birthing pools in hospitals, I mention two key events:

1) In the 1970s when I bought a deep inflatable blue paddling pool and found a convenient space in the maternity unit to install it.

2) The day when Keith Brainin realised that special bath tubs might be designed and commercialized to meet the needs of labouring women.”

A landmark in the history of water birth – Michel Odent

August 21, 1999 should be remembered as a landmark in the history of water birth.

On that day the British Medical Journal published an unprecedented study about “the perinatal mortality and morbidity among babies delivered [sic] in water” (1).

This study is authoritative for several reasons:

  • The conclusions are based on large numbers: the authors traced the 4,032 babies born
    under water in England and Wales between April 1994 and March 1996.
  • The authors belong to a prestigious department of epidemiology and public health
    (Institute of Child Health, London, United Kingdom).
  • The report has been published in a respected peer review medical journal.

Methods

In order to convince anyone of the seriousness of this study, all midwives should be aware of the sophisticated methods used by the London epidemiologists.

Several inquiries were combined in order to eliminate the effects of under-reporting.

From April 1994 to April 1996, all 1,500 consultant pediatricians in the British Isles were surveyed each month by the “British Paediatric Surveillance Unit” and asked to report whether or not they knew of any births that met the case definition of “perinatal death or admission for special care within 48 hours of birth following labour or delivery in water.”

The findings were compared with reports to the confidential inquiry into stillbirths and death in infancy (a mandatory notification scheme).

At the same time a postal questionnaire was sent to all National Health Service (NHS) maternity units in England and Wales in 1995 and again in 1996 to determine the total number of deliveries in water during the study period.

Results

The main results can be easily summarized and remembered.

There were five perinatal deaths among 4,032 births in water; that is a rate of 1.2 per 1,000. In the context of the United Kingdom this rate is similar for low risk deliveries that do not take place in water.

Furthermore, none of these five deaths were attributable to delivery in water: one stillbirth was diagnosed before immersion; another stillbirth occurred after a concealed pregnancy and unattended homebirth with no previous prenatal care; one baby died aged three days with neonatal herpes infection; one died aged thirty minutes with an intracranial hemorrahage after precipitate delivery; and another one, who died aged eight hours, was found to have hypoplastic lungs at postmortem examination.

There were thirty-four babies admitted for special care; that is a rate of 8.4 per 1,000.

Rates of admission for special care of babies born to low risk primiparous women are significantly higher than for babies born in water.

Birth in water may have caused water aspiration in two babies.

Comments

Compared with well known anecdotes, such as one case of neonatal polycythemia reported in The Lancet in 1997(2), this survey of more than 4,000 babies born (rather than delivered!) in water has been paradoxically ignored by the media, the medical circles and the natural childbirth movement as well.

However, it undoubtedly represents a landmark in the history of the use of water during labour.

From now on midwives should not be the prisoners of strict protocols.

Updated flexible guidelines should accept that “in any hospital where a pool is in daily use a birth under water is bound to happen now and then”(3).

Midwives are far less anxious and invasive wherever a birth under water is considered acceptable if the woman does not have the time or is reluctant to get out of the water during a powerful “fetus ejection reflex.”

The first effect of this study should be to change the focus.

An opportunity is given to recall that the main reason for the birthing pools is to facilitate the birth process and to reduce the need for drugs and other intervention.

In order to control the current epidemic of epidurals the point is to divulge a small number of simple updated recommendations in order to make the most effective use of birthing pools.

Updated recommendations

The main recommendations are based on the fact that immersion in water at the temperature of the body tends to facilitate the birth process during a limited length of time (in the region of an hour or two).

This simple fact is confirmed by clinical observation and by the results of a Swedish randomised controlled study suggesting that women who enter the bath at five centimetres or after (“late bath group”) have a short labour and a reduced need for oxytocin administration and epidural analgesia (4).

Physiologists can offer interpretations.

The common response to immersion is a redistribution of blood volume (more blood in the chest) that stimulates the release by specialized heart cells of the atrial natriuretic peptide (ANP).

The inhibitory effect of ANP on the activity of the posterior pituitary gland is slow, in the region of one to two hours (5).

When a woman is in labour this inhibitory effect is preceded by an analgesic effect that is associated with lower levels of stress hormones and increased release of oxytocin.

Furthermore it is partly via a release of oxytocin that the redistribution of blood volume stimulates the specialized heart cells.

The first practical recommendation is to give great importance to the time when the laboring woman enters the pool.

Experienced midwives have many tricks at their disposal to help women be patient enough so that they can ideally wait until five centimetres dilation.

A shower, that more often as not implies complete privacy, is an example of what the midwife can suggest while waiting.

The BMJ survey clearly indicates that many women stay too long in the bath (the average time was in the region of three hours for women who gave birth in water!).

One reason is that many of them enter the bath long before five centimetres.

The second recommendation is to avoid planning a birth under water.

When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of long second and third stages.

There are no such risks when a birth under water follows a short series of irresistible contractions.

The recommendations regarding the temperature should not be overlooked.

It is easy to check that the water temperature is never above 37° C (the temperature of the maternal body).

Two cases of neonatal deaths have been reported after immersion during labor in prolonged hot baths (39.7° C in one case) (6).

The proposed interpretation was that the fetuses had reached high temperatures (the temperature of a fetus is 1° higher than the maternal temperature) and could not meet their increased needs in oxygen.

The fetus has a problem of heat elimination.

At the dawn of a new phase in the history of childbirth one can anticipate that, if a small number of simple recommendations are taken into account, the use of water during labor will seriously compete with epidural anesthesia.

Then helping women to be patient enough and enter the pool at the right time will appear as a new aspect of the art of midwifery.

Michel Odent, MD founded the Primal Health Research Centre in London and developed the maternity unit in Pithiviers, France, where birthing pools are used. He is the author of ten books published in twenty languages. Two of them—Birth Reborn and The Nature of Birth and Breastfeeding—were published originally in the United States. His most recent book is The Caesarean.

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Using Water During Labor and Birth 

Originally published by Jessica Vogtman: November 27, 2016
Humans have an integral relationship with the element of water.
It runs through our veins, we are born of it, and it is necessary for our survival.
We are drawn to it for escape, adventure, release, and cleansing.
As a woman is preparing to give birth, water is a means of release from the weight of her growing belly, and the means to ease her aching muscles.

Water is a great coping tool in labor, whether through a shower or tub. (For the sake of this paper we will only be mentioning the use of a tub.)

The use of water in labor can aide in pain management by increasing relaxation, decreasing strain on muscles, and creating freedom of movement.

The mother’s ability to relax her muscles during labor can affect the length of labor and the intensity of contractions.

The more a mother fights and tenses her muscles the worse contractions may feel.
Especially in active labor, the mother may need as many coping strategies as possible.
The birthing tub offers a great respite, and a simple way to relax.

Version 2

The birthing tub is often called, “The midwife’s epidural”, for its effectiveness (Drichta, Owen p. 257).

The warmth of the water helps to ease the pain felt from contractions, relaxing muscles of the pelvic floor and back, and creates a mental space that creates privacy (Drichta p. 258).

It is recommended to maintain water temperature at 96-98 degrees.

Using higher temperatures could cause increased blood pressure, dehydration and lethargy (Drichta p. 258).
The bath is also deeply engrained as a place of mental release in daily routines.

Our bathtubs are typically places of retreat to relax, and the mental association during labor holds true.

Labor is a physically demanding process.

From hours of walking, lunging, squatting, intense contractions, and the possibility of little sleep can make for a grueling marathon on the mother’s muscles.

The warmth of the tub eases both the pain of the contractions and the work of her remaining muscles (Drichta p. 257).

Being in a large tub that covers her belly, the mother is buoyant and freed from the gravity of dry land.

Her pelvic muscles are relaxed and her cervix will continue to dilate, often with more ease as she relaxes.

A mother that is able to relax and mentally release her tension, will have an easier time laboring than a mother that is fighting each contraction.

Being weightless allows the mom to assume positions that could be too taxing on land, such as deep squats using the side of the pool, that will help baby to descend and turn.

She’s able to easily move from one position to the next in response to her labor, while remaining warm and relaxed.

The ease of movement allows the mother to find her own rhythm and coping responses that she would not have had if she was limited to a bed.

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Her ability to move through labor gives the mother more control and autonomy during the birth.

She’s able to push in the position that suits her, catch her own baby, and bring baby to chest without outside help or others manipulating her body. She has full confidence and control.

Relaxation, decreased strain on muscles and freedom of movement are gained for the birthing mother with the use of water during labor. The three work together as a pain management strategy, addressing both mental and physical tension that could hinder a birth.

The birthing tub is used at its greatest advantage during late stage active labor through transition.

It is recommended that for every hour spent in the tub, the mother spends at least thirty minutes out of the tub.

This is to ensure that contractions do not slow down, as can sometimes happen.

Often contractions may just feel less intense, but are still actively working.
According to Water BirthInternational, “Getting back in the water after thirty minutes will reactivate the chemical and hormonal process, including a sudden and often marked increase in oxytocin.” (Harper p. 2)
As with other labors, hydration is of the utmost importance. Keep a drink with a straw nearby so the mother can drink at will.

The birth can be completed in the water as well, depending on location (some hospitals only allow laboring in the tub) and as long as the labor is not having any complications (ex:meconium, shoulder dystocia).

Works Cited

Drichta, Jane E., CPM and Owen, Jodilyn, CPM. The Essential Homebirth Guide for Families Planning or Considering Birthing at Home. 2003. Simon and Schuster.

Harper, Barbara. “Guidelines for Safe Waterbirth.”Waterbirth International. p. 2

Jessica Vogtman has lived in Maryland since 2003, and has been a Carroll County resident since 2006. She graduated with a bachelors degree in Biology and Chemistry from Notre Dame of Maryland University. Upon graduation, she worked as a zookeeper at the Maryland Zoo in Baltimore, where she became immersed in natural living. Jessica developed her passion for birth during her first pregnancy in 2012, and spent the following years educating herself on natural birth and birthing techniques. She is currently certifying as a doula with Birth Arts International.
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Research offers reassurance for expectant mothers considering a water birth

Giving birth in water is associated with a reduced risk of excessive bleeding and perineal tearing for mothers and with babies born in water being less likely to need specialist care, a new study has found.

In a paper co-authored by De Montfort University Leicester (DMU)’s Dr Tina Harris and published by the BMC Pregnancy & Childbirth journal, researchers showed that the likelihood of key maternal and neonatal complications associated with waterbirths was low.(Image: Hu Chen/Unsplash)

The observational study, which involved an analysis of 46,088 low and intermediate risk vaginal births across 35 NHS Trusts in England, showed that 6,264 (13.6%) were recorded as delivering their baby in the water.

Of those 6,264 babies born, the research highlighted that there was no association between waterbirth and specific adverse outcomes for either the mother or the baby.

More specifically, the paper outlines there was no association between those women who chose to give birth in water and four common concerns, including:

  • Severe perineal tear for mothers
  • Excessive bleeding for mothers
  • Babies born with a low Apgar score (the Apgar score is a test given to newborns soon after birth to check a baby’s heart rate, breathing, and other signs to see if extra medical care or emergency care is needed)
  • Babies requiring neonatal care after birth.

“Immersion in water during labour is associated with a number of maternal benefits however for birth in water the situation is less clear,” explained Dr Harris, who is an active researcher at DMU’s Centre for Reproduction Research.

“While we can’t say there is no associated risk, what we can report from this study is that the association with each of these concerns and waterbirths is a positive one.

“These are four common birthing factors that expectant mothers may be concerned about and we found an association of reduced risk for all four.”

The research provides further evidence for NICE (The National Institute for Health and Care Excellence) on risks associated with waterbirths.

The study also explored the characteristics of those women who gave birth in water and found that women living in deprived areas are half as likely to have a water birth than those living in affluent areas and that younger women and women from black and minority ethnic backgrounds were also less likely to have a waterbirth.

“Most NHS Trusts do have a birthing pool  so all women should have access to giving birth in water, but our study has revealed that some women, from socially deprived areas and from the BAME community, are less likely to have a waterbirth. So we want to understand why that is,” continued Dr Harris.

“Hopefully this research will give women more information and reassurance to help them with their decision on whether or not to have a waterbirth. It’s important that pregnant women have access to as much information as possible to make an informed choice.”

As well as being an Associate Professor in the Faculty of Health and Life Sciences at DMU, Dr Harris is also a registered midwife with an NMC (Nursing and Midwifery Council)-recognised teaching qualification and in 2016, she was appointed Senior Clinical Lead (Midwifery) for the National Maternity and Perinatal Audit at the Royal College of Obstetrics and Gynaecology.

Posted on Friday 4th June 2021

Evidence on the safety of water birth

9 February 2015

Evidence Based Birth – Rebecca Dekker

In April 2014,  waterbirth—an alternative method for pain relief in which a mother gives birth in a tub of warm water—made national headlines.

The event that pushed water birth safetyinto the spotlight was a joint Opinion Statement from the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), denouncing the practice.

In their opinion statement, ACOG and the AAP firmly admonished that waterbirth should be considered an experimental practice that should only occur in the context of a clinical research study.

Their conclusion, which echoed a previous AAP Opinion Statement from 2005, was based on their opinion that water birth does not have any benefits and may pose dangers for the newborn.

In response, the American College of Nurse Midwives (ACNM),(Midwives 2014) the American Association of Birth Centers (AABC), and the Royal College of Midwives (RCM) all released statements endorsing waterbirth as a safe, evidence-based option.

Meanwhile, the AABC released preliminary data from nearly 4,000 waterbirths that occurred in birth centers all over the U.S., supporting water birth as safe for mothers and infants.

Despite the response from midwifery organizations and the AABC, hospitals all over the U.S. began suspending or shutting down their waterbirth programs.

At St. Elizabeth’s Regional Medical Center in Lincoln, Nebraska, mothers and families organized rallies and started a change.org petition to bring waterbirth back.

All of this controversy left us with these questions— Is the ACOG/AAP statement based on a complete and accurate review of the literature?

What is the evidence on waterbirth?

Is it safe?

Does it have any potential benefits or harms for mothers and infants?

These are the questions we will address in the Evidence Based Birth article on the evidence on waterbirth.

This article was published July 10, 2014, by Rebecca Dekker, PhD, RN, APRN
© Evidence Based Birth, All Rights Reserved.

Click here for a copy of Rebecca Dekker’s paper on the safety of water birth

The growing trend of birth in water…

Milli Hill explains why more and more women, including celebrities like Maia Dunphy and Rebecca Adlington, are choosing a birth pool.

More and more women are saying yes to water birth; thanks in part to the many celebrities who are extolling it’s virtues, including broadcaster and wife of Johnny Vegas, Maia Dunphy, and Olympic swimmer Rebecca Adlington, both of whom are planning to have their babies in a birth pool in the next few weeks.

ficore-birthing-pool

As so many women are discovering, there’s literally nothing not to like about water birth. I’ll admit, though, that when I first heard about the trend in 2007, I was sceptical.

I was pregnant with my first, and maybe I already felt daunted enough by the idea of giving birth, without adding in another whole set of anxieties and ‘unknowns’. I was definitely in the “Why would you do that?” camp.

This scepticism is common, explains Beverley Turner, birth expert and LBC presenter. She used a birth pool in all three of her own births and now encourages pregnant women on her London based antenatal course, The Blooming Bunch, to give it a try:

“It’s hard to explain the benefits of water birth in words. You can read all about how it’s great for pain relief, how it helps you to move and find comfortable positions, how it supports the perineum and can prevent tearing, and how it makes your chances of a normal, natural birth more likely.

But ultimately, this can all seem academic – it’s only when you slide your labouring body into the warm water that you really ‘get’ it.”

Water birth is often spoken of in terms of being a ‘pain relief option’, but I’m not sure – having finally let my scepticism be washed away during the birth of my second child – that this entirely does it justice. It’s true, when you get into the pool, the warmth and the weightlessness seems to ‘take the edge’ off the contractions.

Research supports the idea that being in water helps with labour pain: one study found that water birthing mums rated their pain as not only lower than women giving birth on dry land but lower than land birthers who had had epidurals.

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Another study, however, found that there was no difference in pain levels between women giving birth in water or on dry land. If you’re pregnant I’m sorry to have to break the news that, no matter where women in the study gave birth, their general view seemed to be: It Hurts.

However – and this is where it gets interesting – what the researchers did find was that the water birthers remembered birth as less painful, once it was over.

I think this shines a light on the aspect of water birth that so often gets missed – perhaps because it is hard to measure or quantify: women’s experience.

Women who have water births – whilst they may still feel as much pain as their contemporaries on the bed – enjoy their births more. Yes, you heard correctly, whilst it may or may not ‘hurt’ – they enjoy it.

In these times of increasingly high medical intervention in birth, water birth removes you from this stereotypical ‘one born every minute’ reality. You are – quite literally – in a different element. You are upright, active, mobile and out of easy reach – the absolute opposite of being immobilised on your back on a bed.

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The balance of power in the birth room, for several decades at least tipped strongly in favour of the midwives and doctors, is upended. We try to explain why women enjoy it so much by saying, “It’s great for pain relief”, but the real reason is this: water birth puts women back in charge.

“The most amazing thing was that I was in my own space, with no invaders”, Hannah Roe, a midwife who gave birth in water last November told me. “I called all the shots, it really felt like my territory. Midwives could only listen in when I truly consented (ie floated over to them!) and birth was completely ‘hands off’.

“Aside from the encouragement of my midwives and birth supporters I did it all by myself – touched his head to reassure myself that my cervix was fully dilated and lifted him out of the pool following the birth. It was amazing.”

Birth workers themselves are often fans of water birth. As Sarah Dodge, a student midwife at Kingston University told me, “I absolutely love caring for women who choose water, it allows you to do absolutely nothing apart from watch and listen.

I have learnt so much from doing this.” Doula Claire Morrow-Goodman is equally evangelical: “I love it when a mama-to-be slowly sinks down into the water and that wonderful blissful look that enraptures her face…as a doula I sigh with her”, she told me.

freedom-of-movement

However, there are opponents – in April 2014 the American Congress of Obstetricians and Gynaecologists and the American Academy of Pediatrics issued a joint statement, denouncing water birth as without benefits and potentially unsafe.

This statement has made access to water birth more limited in the USA, although the Royal College of Midwives called it ‘disappointingly biased and partially incorrect’, and researcher Rebecca Dekker has written a review of the available literature on water birth in response, concluding the ACOG statement contained, “major scientific errors”.

Dekker’s review makes fascinating reading for anyone interested in the research on water birth. If you want the short version, however, the basics are this: there is no strong evidence against water birth for low risk women, and more research would be helpful.

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Water VBAC: exploring a new frontier for women’s autonomy

McKenna JA; Symon AG, (2014). Midwifery , vol 30, no 1, January 2014, e20-5.

BACKGROUND: although Vaginal Birth After Caesarean section (VBAC) has been promoted successfully as one means of reducing the caesarean section rate, the practice of VBAC using water immersion (Water VBAC) is restricted.

Very little valid, reliable research evidence is available on this birth method, although initial small-scale audits indicate that Water VBAC has no adverse effect on maternal and neonatal outcomes.

METHOD: in-depth semi-structured interviews were carried out with a purposive sample of eight women who had undergone Water VBAC in one midwife-led unit.

The interviews aimed to explore their reasons for requesting this birthing method, and their experience of the process. An interpretative phenomenological analytical approach was adopted.

FINDINGS: the women pursued Water VBAC for two main reasons: in order to prevent a repeat of the obstetric events that previously led to a caesarean section, and to counteract their previous negative birth experiences.

The women reported improved physical and psychological outcomes from their Water VBAC experience when compared with their previous experience of caesarean section.

Three main themes emerged: ‘minimising’, ‘maximising’ and ‘managing’. Water VBAC entailed an attempt to minimise the medicalisation of the women’s childbirth experience.

This was achieved by limiting medical staff input in favour of midwife-led care, which was believed to minimise negative physical and psychological experiences.

Correspondingly, Water VBAC was perceived as maximising physical and psychological benefits, and as a means of allowing women to obtain choice and assert control over their labour and birth.

The women planning a Water VBAC believed they had to manage the potential risks associated with Water VBAC, as well as manage the expectations and behaviour of friends, family and the health care professionals involved in their care.

CONCLUSIONS: for the women participating in this research, actively pursuing Water VBAC constituted a means of asserting their autonomy over the childbirth process.

The value accorded to being able to exercise choice and control over their childbearing experience was high.

These women’s accounts indicated that information-giving and shared decision-making require improvement, and that inconsistencies in the attitudes of health care professionals need to be addressed.

 

Position statement on the use of water immersion for labour and birth – Australian College of Midwives

Australian College of Midwives – 2013

This position statement should be read in conjunction with the Australian College of Midwives’ (ACM) position statement for midwives caring for women who make choices outside professional advice.

The ACM supports the choice of women to have the opportunity to access water immersion for labour and/or birth. The ACM identifies six key principles for the safe use of water immersion for labour and birth.

Key principles

1. Warm water immersion has been used for relieving the intensity of pain associated with labour. Warm water and buoyancy elevates the release of endorphins and facilitates relaxation.

2. There are many benefits of using immersion in water during labour, including increasing women’s feelings of control and satisfaction, less painful contractions and less need for pharmacological analgesia, shorter labour, less need for augmentation, with no known adverse effects for the woman herself.

3. Women should be provided with unbiased evidence-based information during pregnancy about their options for labour and birth, including water immersion in labour and/or birth, in order to make informed choices.

4. Informed decision-making, informed consent, and right of refusal are accepted principles in Australia. Each and every woman has the right to make informed decisions, including consent or refusal of any aspect of her care. Women must be respected in the choices that they make.

5. Midwives have a primary responsibility to ensure that their decisions, recommendations and practices are focused on the needs and safety of the woman and her baby/babies.

6. There is no evidence of significant increases in perinatal mortality or morbidity although there are some reports of rare complications. There is limited research on the safety of birth in water and most of the evidence that does exist, is restricted to healthy women with uncomplicated pregnancies.

Achieving best practice

To achieve best practice in the use of water immersion for labour and birth, it is necessary for consumers, professional colleges, education providers, health systems, Australian and State and Territory governments and policy makers to work together to:

  • foster a culture of valuing physical, emotional, social, cultural and spiritual safety in all birth environments;
  • provide women with access to water immersion in labour and/or birth;
  • provide the preparation and education required to ensure that midwives are
    competent and confident to care for women who choose water immersion in
    labour and/or birth;
  • ensure that midwives to work to their full scope of practice;
  • develop evidence-based policies that reflect best practice;
  • undertake more research on immersion in water during labour and birth. In
    particular, no trials have been identified that assess the effect of immersion in water during the third stage of labour.

Resources to guide practice

The ACM recommends the use of the following resources to guide midwives in their practice:

  • Australian College of Midwives, National Midwifery Guidelines for Consultation and Referral, 2013. Australian College of Midwives, Canberra.
  • Cluett, E.R., et al., Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. BMJ, 2004. 328(7435): p. 314.
  • Cluett ER, B.E., Immersion in water in labour and birth. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111. pub3. , 2009.
  • Hall, S.M., & Holloway, I. M. , Staying in control: Women’s experiences of labour in water. . Midwifery, 1998. 14: p. 30-36.
  • Miller, Y., Thompson, R., Porter, J., Prosser, S., & Fletcher, R. , Findings from the Having a Baby in Queensland Pilot Survey 2009. 2010. Queensland Centre for Mothers & Babies, The University of Queensland.
  • RCOG/Royal College of Midwives. Immersion in Water During Labour and Birth (Joint Statement No. 1), 2006. Available from: http://www.rcog.org.uk/womens- health/clinical-guidance/immersion-water-during-labour-and-birth
  • Richmond, H., Women’s experience of waterbirth. The Practising Midwife, 2003. 6(3): p. 26-31.
  • Zanetti-Daellenbach, R.A., et al., Maternal and neonatal infections and obstetrical outcome in water birth. European Journal of Obstetrics & Gynecology and Reproductive Biology, 2007. 134(1): p. 37-43.

Date of Issue; 30th May 2013
Date of Review; 29th May 2016

Reasons to consider a water birth

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.

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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.

Exploring breech water birth

Maggie Banks – RM, PhD, ADN, RGON

The paucity of literature on labour and birth in water with breech- presenting babies highlights a need to share (and document) empirical knowledge on the subject to piece together women’s and midwives’ growing experiences.

I was asked recently if leaving a woman in a birth pool to give birth to a breech presenting baby, undiagnosed until on the perineum, was ‘reasonable’ midwifery practice.

The question was qualified in that if the breech baby had been known prior to labour, the birth would definitely not have occurred in water as it is contraindicated in all the waterbirth guidelines in New Zealand.

My initial reaction, though fleeting, was to shrink away and not own my own experiences, knowing that these would be viewed as ‘unreasonable’ given that guidelines were presented as a self-evident truth that could not be argued with, that is, a known breech baby would not be born in water.

The issue of breech presentation and waterbirth is one that I have repeatedly explored in the midwifery and obstetric literature over the years and have found little written on the subject.

What is there usually cites the same source – Herman Ponette, the Belgium obstetrician in Ostend who actively promotes waterbirth with breech babies.1 There is minimal acknowledgement that it occurs in hospitals in the USA and the UK.2, 3

A Google search using the term ‘breech waterbirth’ brings up a handful of consumer stories and the occasional midwifery website which discusses the issue. Of the numerous stories I receive from women and midwives about breech birth, increasingly they involve the use of water.

This article pieces together some knowledge gained from reading, discussions, several of my experiences of, and reflections on, the use of water immersion with breech babies.

Going with the Flow

Initially I had been mindful of Michel Odent’s recommendation of not using deep warm water during breech labour as he warns that the soothing effect of water may mask an unduly painful labour, thereby preventing early detection of what may prove to be a problematic birth.4

My own first experience of using water in a breech labour happened by accident in that the frank breech baby remained undiagnosed until on the perineum. The woman had used the pool unconventionally in labour – she chose to lounge in the pool between contractions and stood during them. Once the breech was diagnosed I asked her to leave the pool and she stood to give birth.

This made me re-look at Michel’s caution. My experience of waterbirth with cephalic presentation had shown me that water immersion only mellows out normal labour pain, not severe or pathological pain, which would indicate the bone on bone painof true disproportion between pelvis and presenting part.

I had to question why this should be any different for a breech presenting baby – and I could not find an answer.

With the same woman’s second frank breech baby, this time diagnosed in pregnancy, she again used the pool unconventionally to relax between her contractions, and she birthed standing on dry land.

These two experiences marked a small shift in the use of water during my attendance at breech labour and birth in that water immersion remained available with a known breech. However, I continued to arrange with women that they would leave the pool for birthing.

This request changed following the birth of Heath, a firstborn presenting as a flexed legs breech. His mother had been deeply relaxed in the pool, assuming a wide open kneeling position leaning over the edge of the pool.

When the baby was visible on the perineum and the urge to push was overwhelming I asked the woman to leave the pool as we had prearranged, which she did.

Whereas she had been strong, independently held her own weight, and was powerful in her pushing, once out of the pool, she needed physical support to be in active birth positions and was unable to relax deeply between contractions as she had previously done in the pool.

The baby was born within half an hour of pushing and all was well but it was clear to me that I had intervened in a physiological birth and this had altered the ease with which the woman gave birth.

This birth occurred some months after the 1st International Waterbirth Conference in 1995.

Publication of Paul Johnson’s classic article 5 on the mechanisms that prevent or, conversely, stimulate breathing in the unborn baby during waterbirth would occur the following year but, in concluding his conference write up, Johnson, a Consultant Clinical Physiologist in the O&G Department at the John Radcliffe Hospital in Oxford, wrote:

“…if the onset of labour is spontaneous, and no drugs are administered, a fetus born with its cord intact, into warm, fresh water, not asphyxiated, is inhibited from breathing”6 – a process not dependant on presentation.

Initiation of breathing following waterbirth occurs once the baby surfaces and is exposed to cooler, dryer air and clamping the umbilical cord 6 – again, irrespective of presentation.

Sheila Kitzinger would report his additional comment that “if water births are of psychological and physiological benefit, it is logical that this benefit should apply to high-risk women too”.7

I knew deep water immersion to be a very powerful modality for achieving a relaxed state for the woman, enhancing vasodilation and placental perfusion and, therefore, oxygenation, of the tissues and organs, including the placenta during the normally stressing (not distressing) time of labour.

I had seen women become oblivious to everyone and everything as they sank into the pool. I had come to recognise the depth of sigh on entering the pool that signalled release of pain, fear, social etiquette and conversation – and these observations were irrespective of whether the baby was coming head or bottom first.

The Buoyancy and Warmth of Water

Another dimension was added when I attended a woman with twins, the second baby being a breech presentation. The woman had grown her babies well and began labour spontaneously at 40 weeks.

Due to the heaviness of her abdomen, she was drawn to labouring in water – her bath at home then, when labour was well established and she had travelled to her chosen birth place, the spa bath in the obstetric hospital.

There was a point in her labour where she needed to be more upright than reclining in the spa bath allowed, so we set up my free standing birth pool for her.

With the water up to the level of her breasts she became almost weightless in the pool, and was able to assume her intuitive positioning in a deep squat for the births of both her babies, the second of which had remained breech.

The woman reflected how supportive the water had been and how the upright position engaged her strength and ability to birth well.

Controlling Pelvic Pressure

When vaginal breech birth was a common occurrence 15 years or so ago, epidural anaesthesia was commonly recommended to overcome a premature urge to push. However, discussion with midwifery colleagues indicates a premature urge to push with a term breech baby is rare in woman-controlled positioning.

One woman who did experience significant pelvic pressure from the onset of labour with spontaneous rupture of membranes while having her first baby – a frank breech presentation – provided a piece to the mosaic of the use of water.

She controlled the urge to push by long and slow breathes during contractions and lying on her side on a floor mattress for most of her labour, rising only to crawl to the toilet on her hands and knees. After 12 hours of this, the pressure was overwhelming, even when lying.

While her good progress was evident from the lengthening burgundy buttock crease and her birthing energy, it was not time to use that expulsive energy. A vaginal examination confirmed a thin rim of cervix remained.

While a hands and knees position reduced the pressure, it was not until she lounged in the pool on her abdomen that the pressure again became tolerable. The pool was invaluable for enabling her to resume breathing over the contractions for the next three hours.

In the last hour prior to the birth, the woman commenced her grunting expulsions. As this had not brought her baby to a visible position in that time, I asked her to stand for one contraction to test the power of this feeling.

Simply standing engaged the pelvic pressure enough to bring the baby to almost rumping with the first push.

The second surge saw the baby rumped and progress so the popliteal spaces (back of the knees) were visible. With the next, he was born to the ankles, then descended quickly to wear his ‘perineal hat’ and his head was gently released without perineal trauma. All of this occurred without a contraction as the women responded to the pelvic pressure.

Assessing the Baby

The New Zealand Guideline Group’s best practice evidence-based guideline on breech labour and birth acknowledges that the evidence does not support continuous electronic foetal heart rate (EFM) monitoring by cardiotocography over intermittent auscultation.8

This is because, just as for well women and their babies with no alerting factors, there are no significant differences in standard measures of newborn wellbeing (including cerebral palsy and infant mortality) with continuous EFM in labour for ‘high risk’ situations, which frank or flexed legs breech presentation at term is deemed to be by some.

Only beneficial for its association with a reduced incidence of neonatal seizures, continuous EFM is associated with increased maternal morbidity by way of the accompanying increase in Caesarean and operative birth rates.9

At any given point the midwife needs to know that the baby is coping well with labour by assessment of his movements10 and listening to his heart beat.

As with any other labour for well women and babies, listening can be easily acheived with a Pinard stethoscope (or handheld, waterproof doppler) during water immersion.

Essential Elements of Physiological Breech Birth

Midwives commonly reflect on how their practice changes with attending waterbirths of cephalic presenting babies to become more ‘hands-off ’ during birth.

Confident that the water frequently dissipates urges to explosively push, while also supporting the woman’s perineal tissues and the baby as he is born, the midwife is drawn to a non touch vigilant attendance. This ‘hands off ’ in the absence of problems is the ‘golden rule’ during breech birth.

Maternal effort is an important part of achieving a ‘hands-off ’, spontaneous birth. As with any birthing, the woman needs to be supported to choose positions of comfort in the water which enhance her power and strength – kneeling, squatting, hands and knees or reclining.

Whichever birth position is chosen, the midwife needs to position herself so she can see both the advancing baby and the umbilical cord, and be in a position to palpate the umbilical cord if necessary.

The midwife may need ‘hands on’ for the birth of the head but the support of the water usually ensures gentle and woman- controlled birth of the baby’s head. Due to the reduction in gravity and an accompanying reduction in an urge to push for the head, the woman may need to be reminded to release the baby’s head.

Midwives who regularly attend waterbirths with cephalic presentation frequently reflect that if there is a problem during birth, for example, shoulder dystocia, they will initially try to correct it in the pool.

This avoids delay while utilising the water’s buoyancy so the woman can move easily to adopt very wide open positions that are needed for manoeuvres.

While Pinotte1 notes a reduced need for routine manipulations of the breech baby with waterbirth, in the rare circumstance that a manoeuvre is needed – to bring down stuck arms11 and/or flex, cradle and scoop out the baby’s head12 – these could also initially be done in the pool, again, avoiding delay.

The woman, however, would be asked to get out of the pool if problems were not easily remedied.

The Ongoing Mosaic

For some maternity professionals the issue of vaginal breech birth is no longer worth considering in the wake of the Term Breech Trial13 despite concerns about its methodological flaws.14-17

For others it remains a planned option.18-22 There will, of course, always be undiagnosed breech babies in labour, irrespective of the degree of antenatal scrutiny.

While some consider undiagnosed breech an ‘obstetric emergency’, the manner in which a midwife facilitates
a vaginal breech birth, first diagnosed when birth is imminent, is the sameas if it was diagnosed antenatally and a vaginal breech birth is planned, albeit the latter having obstetric backup available with the birth in an obstetric hospital.

The use of deep water immersion with mal-presentation (read: breech)
is contraindicated in hospital clinical guidelines on waterbirth, and the use of water is absent as a modality in vaginal breech birth guidelines.

Embracing these, giving birth in water to a breech baby would be out of the question for some maternity providers.

Yet others are very specific
 in seeing breech presentation as a positive indication for waterbirth because of the buoyancy afforded to the baby and umbilical cord, both of which are kept warm in the water until surfacing into the cooler air,1,23,24 contraindicated only if the breech labour is not progressive and/
or is complicated.25

Midwifery can have additional knowledge fragments to obstetric knowledge, gained by our deep relationships with women.

Being attentive to women who are called to use water through breech labour and birth and walking side by side with them during this time has added to my understanding of facilitating physiological breech birth.

We need to be able to share the practice wisdom which comes from our experiences, discussions and reflections. We also need to be able to do this without fear of repercussions that may be activated from that disclosure. As a result, we will continue to find ongoing pieces to the mosaic of breech waterbirth.

References:

Ponette H. Breech and twin deliveries in the water. Accessed 20 March 2000. Available at http://www.helsinki. fi/~lauhakan/whale/waterbaby/p6.html
Kitzinger S. Sheila Kitzinger’s letter from England. Birth 1991;18(3):170–171.
Harper B. Waterbirth basics – from newborn breathing to hospital protocols. Midwifery Today 2000;54:9– 10,12–15,68.
Odent M. Birth reborn. Souvenir Press: New York, 1984:103–105.
Johnson P. Birth under water – to breathe or not to breathe. BJOG: An International Journal of Obstetrics and Gynaecology 1996;103(3):202–208.
Johnson P. Birth under water – to breathe or not to breathe. In, Lawrence Beech BA (ed).Water birth unplugged. Proceedings of the First International Water Birth Conference. Books for Midwives: Cheshire, England, 1996:31–33.
Kitzinger S. Sheila Kitzinger’s letter from England: is water birth dangerous? Birth 1995; 22(3):172–173.
New Zealand Guidelines Group. Care of women with breech presentation or previous Caesarean birth. New Zealand Guidelines Group: Wellington, 2004:xxi, 32.
Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858. CD006066.
Banks M. Utilising the unborn baby’s in-labour movements. New Zealand College of Midwives Journal 2003;29:6.
Banks M. Breech birth woman-wise. Birthspirit: Hamilton, New Zealand, 1998:88–89.
Ibid., pp. 90–91.
Hannah M, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicenter trial. Lancet 2000;356:1375–1383.
Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. American Journal of Obstetrics and Gynecology 2006;194(1):20–25.
Kotaska A. In the literature: combating coercion: breech birth, parturient choice, and the evolution of evidence-based maternity care. Birth 2007;34(2):176–180.
Keirse MJNC. Evidence-based childbirth only for breech babies? Birth 2002;29(1):55–59.
Goer H. When research is flawed: planned vaginal birth versus elective Cesarean for breech presentation. Accessed 14 August 2007. Available at http://www.lamaze.org/ Research/WhenResearchisFlawed/ VaginalBreechBirth/tabid/167/ Default.aspx
Goffinet F, Carayol M, Foidart J, Alexander S, Uzan S, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. American Journal of Obstetrics and Gynecology 2006;194(4):1002–1011.
Hellsten C, Lindqvist PG, Olofsson P. Vaginal breech delivery: is it still an option? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;111(2):122–128.
Sibony O, Luton D, Oury J, Blot P. Six hundred and ten breech versus 12,405 cephalic deliveries at term: is there any difference in the neonatal outcome? European Journal of Obstetrics & Gynecology and Reproductive Biology 2003;107(2):140–144.
Giuliani A, Schöll WMJ, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single centre. American Journal of Obstetrics and Gynecology 2002;187(6):1694–1698.
van Roosmalen J, Rosendaal F. There is still room for disagreement about vaginal delivery of breech infants at term. BJOG: An International Journal of Obstetrics and Gynaecology 2002;109(9):967–969.
Charkowsky I. In: Napierala S. Water birth: a midwife’s perspective. Bergin & Garvey: London, 1994:181–182.
Enning C. Personal communication, 2008.
Ponette H. The New Aquatic Maternity in Ostend. Accessed 20 March 2000. Available at http://www.helsinki. fi/~lauhakan/whale/waterbaby/p2.html

MIDIRS: The use of water during childbirth

20 November 2015:

Since the early 1980s use of immersion in water during labour and birth has been increasingly promoted to enable women to relax, help them cope with pain, and maximise their feelings of control and satisfaction1-4.

In 1992 the House of Commons Health Committee recommended all hospitals provide the option of a birthing pool where practicable5. Currently few women give birth in water but the option of immersion or showering during the first stage of labour is commonly available.6-8

Although problems have arise which have been attributed to water use, the results of the most formal evaluations have not clearly associated water use with harmful outcomes for mother or baby 3,9-13.

The lack of robust evidence of harm or benefit means that childbearing women and health practitioners alike are subject to conflicting opinion about the usefulness and safest of water, particularly for birth.

However, a recent observational study over a nine year period concluded that ‘waterbirth was associated with low risks where obstetric guidelines were followed’16.

At present in the UK there is no reliable measurement of the rate of birth in water.
A national survey of maternity units in the UK in 2002 found that 63% (216/342) had a birthing pool8; 67% (228/342) reported having at least one midwife trained to provide support for women giving birth in water and 36% (121/342) said that at least half of the midwives working in their unit were trained to support birth in water.

How is water used during labour?

Water use ranges from informal, for example when a woman in early labour decides to get into her bath at home before going to hospital, to formal use in a specially designed birthing pool. Informal use in a domestic bath or shower is often initiated by a woman herself to help her cope at home before her labour is well established.

Formal use implies either that a woman has actively chosen to use water as part of her plan for labour and/or childbirth or that a health professional, usually a midwife, has suggested use during established labour.

Why water use is promoted

Use of immersion in water during childbirth has largely been driven by pregnant and birthing women17 and supported by midwives. During the first stage of labour it is advocated to shorten labour and help a woman relax and cope with contractions, feel more in control, and to reduce intervention by health professionals3,18-21.

During the second stage, proponents use it to allow perineal tissues to stretch spontaneously, birth to occur with minimum intervention, and to provide the baby with a gentler transition into extra-uterine life. Expectant management of the third stage is likely if a woman is in water.

Limitations on water use

Many health professionals consider that water use during the first stage of labour in uncomplicated pregnancy is unlikely to harm the mother or baby22,23, whilst others have concerns about water use at any point in labour14.

Local clinical guidelines may restrict water use to women considered at ‘low’ obstetric risk7, and other aspects of care may be prescribed, for example when and how to monitor the temperature of the water, the degree of cervical dilatation at which to begin its use24, and whether the immersion is considered safe for all stages of labour6,25.

Problems associated with possible risk of infection or cross infection caused by amniotic fluid, blood, and faeces have been described26-28 and some hospitals have restricted use of birthing pools to women who have tested HIV negative during pregnancy29.

However, at a multi-disciplinary consensus meeting held in London in 1996, it was agreed that mandatory HIV testing for prospective users of birthing pools could be an extreme reaction to the perceived risks and that high standards of pool hygiene would be an appropriate way forward30. Local infection control guidelines should cover the use of water pools25,31 and procedures to minimise risk of cross infection13, 32.

It has been suggested that high water temperature can cause serious changes in feto-maternal haemodynamic regulation and fetal thermoregulation33. It has been reported that fetal tachycardia can be reduced by cooling the water34 and most providers and clinical guidelines specify a temperature range within which the water should be maintained during the first and second stage of labour7,35.

The prospect of a woman giving birth in water can cause anxiety about how to deal with unexpected emergencies such as shoulder dystocia, the need to avoid the baby inhaling water, or being unaware that the umbilical cord has been severed11.

Despite the fact that it denies women choice about birth, one response has been to limit water use to first stage only6. Development of agreed clinical protocols to deal with unexpected complications25 and providing training which allows3 staff to achieve relevant competencies is key to enabling real choice for women about use of water.

There are theoretical risks of increased blood loss, retained placenta, or water embolism, and professional advice is often to conduct the third stage out of water25.

Because water adds to the difficulty of estimating blood loss accurately, it has been proposed that blood loss would be more appropriately estimated as being either more or less than 500ml36 and that the overall physical condition of the woman should be used as the most important indicator to assess the impact of any bleeding37.

In summary, although not universally accepted, first stage water use is less controversial than immersion for the second or third stage of labour22,23,38.

The research evidence

The effects of water use during the first stage of labour on maternal and fetal outcomes have been evaluated in several randomised controlled trials4,9,10,12,13,39 with sample sizes ranging from 60 to 123934.

The use of water has been shown to reduce the rate of augmentation40; however, no trial has been large enough to measure the effect of water use on important neonatal outcomes such as perinatal death or other serious neonatal or maternal morbidity.

In addition, there has often been significant cross-over between study groups4,12, reducing the likelihood of identifying clear differences between women allocated to water use and those not.

A systematic review of eight trials41 indicated a statistically significant reduction in the use of pain relief with no such significant difference in the rate of operative deliveries or in neonatal outcomes.

It concluded that while the use of water in the first stage of labour can be of benefit to some women, there is no evidence at present to support or not support a woman’s choice to give birth in water.

Retrospective comparison has been made of women who have used water with those who have not42,43.

However, there are considerable difficulties in interpreting such studies because of the possibility that the results are inherently biased.

In the same way, findings of cohort studies which suggest benefit for water use in terms of pain relief and increased rate of cervical dilatation44-47, or those which indicate differences in rates of maternal and neonatal infection48-50, are also open to criticism.

A recent study16 compared neonatal and maternal morbidity and mortality for spontaneous singleton births that took place in water or on land.

This was an observational study over a nine year period and data were obtained through standardised questionnaires for 9,518 births, of which 3,617 were waterbirths and 5,901 landbirths.

Statistically significant differences were identified between the two groups; women who gave birth using water were less likely to suffer serious perineal trauma, use no analgesia and have a lower blood loss than women in the landbirth group.

Maternal and neonatal infection rates were the same for both groups, but more landbirth babies had neonatal complications requiring transfer to an external NICU.

During the study, there were neither maternal nor neonatal deaths related to spontaneous labor.

The authors acknowledge the potential bias that could arise from the self-selection issue but argue that this is well accounted for in the analysis.They conclude that waterbirths are associated with low risks for both mother and child when obstetrical guidelines are followed.

Another study51 based in a centre for low risk women was a retrospective case review over a five year period of 1355 births in water.

When compared with land births over a corresponding period, women who gave birth in water had significantly fewer episiotomies with no evidence of a corresponding rise in lacerations, a reduction in the length of the first stage of labour, no increase in the risk of acquired infection or aspiration pneumonia and considerably lower levels of analgesia use.

Neonatal condition assessed by arterial cord blood pH, base excess and birth weight showed no differences.The authors conclude that this represents a realistic option for women at low risk of complications.

Many reports about water use are case series1,20,52-62 and focus on perceived benefits of water use for the mother, her baby and birth attendant.

These include shorter labour52, less use of pharmacological analgesics46,53, less intervention by care givers19, lower rate of perineal trauma60-62, and increased satisfaction with the experience of labour and birth54.

By contrast, some case reports have highlighted serious problems such as fetal overheating33,34, neonatal sepsis28, near drowning63 or death64.

Overall, reviews of the evidence21,23,65,66 conclude that appropriately large-scale research is still required to evaluate rigorously the physiological effects13, clinical outcomes, and economic impact of water use.

What we don’t know

The current evidence about water use remains quite heavily dependent on case series and comparison studies that include varying sized samples.

Therefore, reliable evidence about efficacy and effectiveness is still equivocal67.

  • Outstanding issues which require evaluation include:
  •  is water use causally associated with an increase in perinatal mortality or serious perinatal morbidity?
  •  at what dilatation should a woman be advised to begin water use?
  •  does the size or shape of the water container affect outcomes?
  •  if water has an effect on important physical/psychological outcomes for mothers or babies, are there particular women who should avoid using water during labour?
  •  to what extent immersion in water affects the length of labour?

Implications for maternity

Water use during the first stage of labour is offered by the majority of maternity care provider units in the UK and most offer support for water birth8.

Introduction of, and sustained suppor t for, water use may have considerable implications for service governance68.

However, not all costs fall to providers of care; a substantial cost burden is likely to be borne by labouring women themselves during informal use in domestic baths and showers or by hiring specially designed pools for use in their home or in a maternity unit.

Most maternity units have installed a water pool for use in labour8 and although installation and maintenance of a specially designed pool in a maternity unit involves obvious financial cost, this may be offset if there is a reduction in analgesia and anaesthetic use44.

There is evidence that formal water use means that at least one midwife will be in constant attendance during the first stage of labour and that at least two will be in attendance for birth7.

This level of staffing may be difficult to sustain and may have implications for equity of care for women who do not use water22.

Clear strategies for the training, preparation and support of staff who offer use of water during labour are recognised as essential7,25,31,37,44.

Key components of these include clarification of the roles of different maternity health professionals, multi-disciplinary development of local protocols, development of guidelines for clinical practice, and short-term secondment of midwives to learn alongside practitioners skilled and experienced in water use.

Implications for practice

Women may choose to use immersion in water during labour and/or birth. Midwives and other maternity care workers should therefore be knowledgeable about the evidence in terms of potential advantages and disadvantages.

Given the current quality of reliable evidence, effective practice is likely to be informed and influenced substantially by shared experience and personal observation.

Disproportionate weight may therefore be placed on perceived disadvantages or advantages and credibility given to outcomes which may not be associated causally with water use.

Practitioners should be alert to the evolving evidence base which underpins the use of water.

  •  Immersion in water during childbirth is a care option women may wish to choose and which health professionals have a responsibility to discuss and support using clear and balanced information.
  •  As with any labour or birth, it is essential to maintain systematic, contemporaneous records and to monitor and record routine observations about the well-being of the mother and the fetus. These data should be used to audit care and gather information about outcomes.
  •  Water temperature should be measured regularly using a thermometer and recorded.The water temperature should be comfortable for the woman and should be not more than 37°C during the first stage of labour and between 36-37°C in the second stage.
  •  Maternal faeces, meconium and blood clots should be removed from the water using a sieve, and effective cleaning of pools before/after use should be carried out to minimise risk of infection or cross-infection.
  •  Birth in water: the baby should be born fully submerged and be brought gently and without delay to the surface so that he/she can make their first respiratory efforts in air.
  •  Comprehensive, large scale research is required to address questions about the safety and effectiveness of using water during labour and/or birth.

Reproduced from Midirs 2005, last revised Jan 2005, review date Jan 2007. Informed Choice is supported by the Royal College of Midwives and the National Childbirth Trust.

References

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  9. Schorn MN, McAllister JL, Blanco JD.Water immersion and the effect on labor. J Nurse Midwifery 
1993;38:336-42.
  10. Cammu H, Clasen K,Van Wettere L et al.‘To bathe or not to bathe’ during the first stage of labor. 
Acta Obstet Gynecol Scand 1994;73:468-72.
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surveillance study and postal survey. BMJ 1999;319:483-7.
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controlled trial. Birth 2001;28:84-93.
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BJOG 2004;111:537-45.
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  23. Johnson P. Birth under water – to breathe or not to breathe. Br J Obstet Gynaecol 1996;103:202-8.
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  28. Hawkins S.Water vs conventional births:infection rates compared.NursTimes 1995;91(11):38-40.
  29. TrustdemandsHIVtestforpoolbirths.NursTimes1996;92(2):9.
  30. HIVtransmissioninbirthingpools.London:TerrenceHigginsTrust,1996.
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  32. Schulster L, Chinn RYW. Guidelines for environmental infection control in health care facilities. Morbidity and Mortality Weekly Report 2003;52/RR-10:20-1.
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  40. Cluett ER, Pickering RM, Getliffe K et al. Randomised controlled trial of labouring in water compared with standard of augmentation for management of dystocia in first stage of labour. BMJ 2004;328:314-318.
  41. CluettER,NikodemVC,McCandlishREetal.Immersioninwaterinpregnancy,labourandbirth. The Cochrane database of Systematic Reviews 2004, issue 1.
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The benefits of labouring in water for overweight and obese mothers

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.

Birth under water – Michel Odent

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.

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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.

 

Diving in: a dip in the water for labour and birth policy debate

Megan Cooper RM, BHSc (Honours), Jane Warland RM, PhD Helen McCutcheon RM, PhD.

Abstract

Water immersion for labour and birth is becoming an increasingly attractive option for women.

However, with what has been described as a paucity of research, water immersion policies appear to lack the evidence to ensure confidence in their use, safety in their implementation and importantly, acknowledgement of women’s autonomy to utilise water for labour and birth irrespective of their perceived ‘risk’.

In touching on the difficulties experienced by maternity care providers working within a system largely dominated by a ‘risk adverse’ paradigm, the following paper will highlight the shortfalls of research surrounding water immersion for labour and birth and the difficulties of utilising policies informed almost entirely by this research.

The current paucity of rigorous evidence and the difficulties faced by maternity care providers facilitating the option, highlights that greater emphasis needs to be placed on gaining a substantial evidence-base to inform future water immersion polices with more weight given to both observational data and anecdotal experience.

Future research should focus on both quantitative and qualitative aspects of water use for labour and birth to ensure that policies incorporate the required risk/benefit analysis, the opportunity for shared and informed decision-making and ultimately, the facilitation of woman-centred care.

Should we throw out the bath water?

For many women water immersion (WI) during labour and birth is an attractive and sought after option of care.

Despite the availability of literature surrounding WI for labour and birth many argue that high quality research with which to measure risks and benefits is still lacking.

As the option has become increasingly available, the development of policy to guide and inform care providers in the safe practice of WI for labour and birth has become necessary.

Consequently, policies appear to have been derived from what some describe as a less than substantive evidence-base (Cluett and Burns, 2009).

This has elicited debate as to whether the practice itself and therefore the policies currently informing the practice reflect the required foundational evidence to fulfill the ideal of evidence-based practice.

In touching on the current difficulties experienced by care providers working within in a ‘risk averse’ system the following paper will briefly explore WI for labour and birth, highlight the perceived shortfalls of research pertaining to its practice and discuss some of the difficulties of undertaking research at the level that many believe is required.

The role of qualitative research in informing the practice of labour and birth in water will also be examined with particular reference to the goal of woman-centred care and the need for policy that is reflective of a holistic evidence-base and supportive of women’s experience, satisfaction and choice.

The practice of water immersion for labour and birth

Despite common belief, WI for labour and birth is not a new phenomenon, with history dating back to the Egyptian Pharaohs and the Minoans of Crete (Mackey, 2001). In the 1960’s, Igor Charkovsky, a Russian midwife, began experimenting with the use of water for labour and birth after realising the positive physical and physiological effects of WI (Houston, 2010).

The 1980s saw Michel Odent, a well-known French Obstetrician and arguably the pioneer of modern water birth, establish the first birthing unit allowing women access to baths during labour, many of whom also went on to birth in water

(Houston, 2010). His observations and documented accounts of witnessing women immerse themselves in warm water allowed him to become a major influential figure in the global water birth movement and in the education of practitioners who facilitate the option of WI.

The advantages and benefits of WI during labour and birth have for the most part, not been thoroughly investigated through rigorous research.

Documented benefits include reductions in pharmacological pain relief (Eberhard et al., 2005, Otigbah et al., 2000, Benfield et al., 2001, Cluett and Burns, 2009), reduced blood loss and perineal trauma (Cluett and Burns, 2009) as well as facilitation of dysfunctional labour (Benfield et al., 2010, Cluett et al., 2004).

It has long been held that water immersion facilitates ‘normal’ birth and the latest prospective and descriptive cross sectional research findings provide support for this belief (Burns et al., 2012, Dahlen et al., 2012).

Burns et al. (2012) found that there was a higher frequency of spontaneous birth in nulliparas and greater rates of normal birth in both nulliparous and multiparous women when water was used during labour and/or birth. More specifically, of the 8924 participants almost 90 percent had a spontaneous birth and of these 5192 (58.3%) of women birthed in water.

Further support for benefits of water use come from Dahlen et al. (2012). They found in their Australian descriptive cross sectional study that women birthing in water had lower rates of major perineal trauma and PPH ≥ 500 milliliters when compared with those who used a birth stool on land.

Improved APGAR scores at five minutes were also noted for babies born into water compared to those whose mothers birthed in a semi-recumbent position on land although the authors note that they are unsure as to whether a semi- recumbent position was favoured by practitioners when there were fetal concerns, thereby potentially impacting on the results.

However, what is perhaps most important in terms of these findings is that there were no documented increased adverse outcomes for mothers who utiliszed water during labour and birth nor were there statistically significant increases in unfavourable outcomes for babies born into water.

Anecdotal experience supports these benefits further, with women suggesting greater levels of satisfaction, sense of autonomy and care providers observing less use of pharmacological pain relief and the facilitation of the fourth stage of labour, particularly in the initiation of breastfeeding.

Qualitative researchers have also found that women who birth in water feel protected, safe, relaxed and in control (Benfield et al., 2010, Maude and Foureur, 2007, Benfield, 2002).

For example, one New Zealand interpretive study, conducted by Maude and Foureur (2007), highlighted that WI provided a ‘sanctuary’ or environment whereby women felt protected and sheltered from intervention and interference. Participants also voiced a reduction in the fear of the birthing process and pain.

For many maternity care providers, water use for labour and birth is viewed as a method of providing women an alternative method of pain relief, ease of position changes and relaxation (Gilbert and Tookey, 1999, Meyer et al., 2010, Maude and Foureur, 2007, Woodward and Kelly, 2004, Stark and Miller, 2009).

Although evident throughout the literature, the observation and experience of maternity care providers is often challenged against minimal scientific proof, which to date, is still not entirely definitive.

Conversely, many continue to challenge the use of water for labour and birth claiming that it is neither normal nor natural for land living mammals to birth into water and that there exist too many associated ‘risks’ and adverse outcomes to mother and infant (Kassim et al., 2005, Mammas and Thiagarajan, 2009, Carpenter and Weston, 2011, Pinette et al., 2004).

The most recent published adverse outcomes pertaining to the use of water immersion during labour and birth come from Soileau et al. (2013) and Menakaya et al. (2012). Soileau et al. (2013) documents a neonatal infection and subsequent neonatal demise post a home water birth attributed to a maternal diarrheal infection in the week prior to birth. The infection believed to have been transmitted to the neonate after the mother defecated in the bath during labour.

This provides justification and support for the use of policy and/or guidelines in guiding practitioners in the facilitation of the option. Furthermore, its draws attention to the knowledge and understanding practitioners must attain in order to make decisions that ensure both maternal and neonatal wellbeing and safety when water is used.

Although Menakaya et al. (2012) did not assess maternal or neonatal infections in their retrospective design of 216 Australian women birthing in water, they noted that babies born into water showed a statistically significant difference in APGAR scores less than or equal to seven at one minute and as well as admission to Special Care Nursery (SCN) post birth in the water birth group.

Interestingly, three of the neonates transferred to SCN were admitted for feeding difficulties, issues which cannot be definitely linked to water immersion, one was admitted post a mild shoulder dystocia which presumably required the woman to be evacuated from the bath prior to birth and one for meconium aspiration, suggesting the presence of meconium which is commonly cited contraindication to birthing in water.

The remaining infants were admitted for resuscitation and an apneic event, which are also not unique to infants born in water.

One infant in the control group was admitted to the SCN and was transferred for respiratory distress requiring the longest stay of all infants admitted to the SCN. These findings are dissimilar to those of Mollamahmutoglu et al. (2012) who found no instance of neonatal infection and no significant difference in admission to the Neonatal Intensive Care Unit (NICU) when comparing infants who were born in water with those who were not. These findings are indicative of the inconsistent and contradictory findings pertaining to the use of water for labour and birth across the literature.

As a result, empirical research has failed to provide a definitive risk/benefit analysis relating to WI for labour and birth particularly in terms of maternal and neonatal infection, neonatal SCN/NICU admission, perineal trauma and the incidence of neonatal drowning and water embolism, as examples.

Furthermore, the ongoing reference to ‘potential’, ‘possible’ and ‘theoretical’ risks throughout the literature as well as throughout policy and guideline documents creates difficulty and uncertainty as to what actually constitutes risk and what is deemed as safe when WI is utilised for labour and/or birth (Kvach and Martonffy, 2012, Mackey, 2001, Pinette et al., 2004).

Watering down practice

Maternity care providers aim as far as possible, to deliver care which is women- centered (Carolan and Hodnett, 2007). Woman-centered care (WCC) incorporates the requirement of a woman making informed choices about all aspects of her care through the sharing of information (Leap, 2009).

Maternity care providers hold information that is vital to the woman but given the need to work within protocols and guidelines, may at times provide information to meet institutional and personal expectations and commitments resulting in what Carolan and Hodnett (2007) describe as “rule following and avoidance of responsibility”.

Although not necessarily a deliberate attempt to limit the information and options available to women, difficulties can arise as maternity care providers walk the fine line between meeting obligations as the woman’s advocate and the demands of institutional policies, guidelines and regulations.

Consequently care providers may forsake their role as the woman’s advocate, and instead support an environment that fosters informed compliance (Carolan and Hodnett, 2007).

Unfortunately the ideal of woman-centredness is often relinquished particularly as birth has become viewed a process that requires management and medical influence (Kitzinger, 2006, Davis-Floyd, 2001).

The burden of ‘proof’ and necessity of evidence to support or refute ‘alternative’ options irrespective of women’s requests and subjective knowingness that they work (Klein et al., 2006) has been significant in the debate surrounding water immersion for labour and birth.

Many of the benefits that water provides the labouring and birthing woman are also what may deter care providers from offering it as an option. Women and care providers alike, have suggested that water provides safety, sanctuary and distance from the rest of world allowing women a sense of control and ownership over their labour and birth (Maude and Foureur, 2007). However, this protection from intervention and intrusion

ultimately means that the contemporary methods of monitoring and gauging progress are no longer as accessible or practical. For many practitioners the inability to monitor and assess women as they normally would results in fear, not only of litigation and ‘what if’s’ (Garland, 1919), but also of the practice itself.

Combatting fear and anxiety could be as easy as encouraging care providers to witness women using water during labour and birth, but opinion and bias in disfavour of water immersion demands the current ‘gap’ in research be bridged.

Furthermore, ethical practice calls for practitioners to dissociate personal bias and views from their practice to ensure women’s autonomy and ability to exercise choice are not downplayed or absent in the facilitation of care (ANMC, 2008, ANMC et al., 2008).

This issue is further complicated by the political climate within which maternity care now exists. Despite many care providers supporting the implementation and practice of WI for labour and birth and having the capacity and accreditation to facilitate the practice, they may be restricted by the lack of institutional resources and support (Garland, 2011) and most commonly, policy that is derived from an aversion of risk and research that has yet to determine with any certainty the safety of using water for labour and birth.

WI for labour and birth, despite putting what feels like an ‘alternative’ slant on care, has the potential as a practice and option of care, to assist care providers such as midwives to re-recognize normal physiological birth and subsequently work towards fulfilling the ultimate goal of woman-centred care.

A drought of evidence?

Water birth, in particular, is frequently associated with perceived risks and dangers and for this reason its use continues to be challenged relative to safety implications for mother and infant as has previously been discussed (Pinette et al., 2004, Kvach and Martonffy, 2012).

The conundrum is yet to be resolved particularly given the perceived paucity of definitive evidence. Yet the option is becoming increasingly demanded and therefore available and as a result, policies are in place to guide care providers in its facilitation, which are probably based (at least in part) on this limited evidence.

Although a number of attempts have been made to undertake research at the ‘gold’ standard, randomised controlled trials (RCTs) examining WI for labour and birth have suffered from less than optimal sample sizes, selection bias or poorly controlled confounding factors in groups of low risk women who are usually highly passionate and motivated (Woodward and Kelly, 2004, Schroeter, 2004, Cluett and Burns, 2009).

This is evident in the latest Cochrane review that included only 12 suitable studies, and of these, only three examined the use of water during second stage of labour (Cluett and Burns, 2009). Further to this there is currently no population level data being collected anywhere in the world about outcomes of WI nor even how many women choose to use WI in labour and/or birth in water (Pinette et al., 2004).

Undertaking the recommended research on WI and birth particularly such as the RCT suggested by Davies (2010) is complicated given that randomising for such a study brings about ethical and moral concerns.

Hendrix et al. (2009) found this to be the case in their Dutch questionnaire-based study assessing women’s reasons for not participating in an RCT investigating home birth versus hospital birth. Eighty-four women indicated that they did not participate due to a concern that they would be randomised to the ‘wrong’ group.

Woodward and Kelly (2004) attempted to overcome women’s reluctance to participate in their pilot RCT comparing water birth with land birth by including a ‘preference arm’. Their results indicated there were no significant difference noted between women who were randomised and those who chose the ‘preference arm’ and therefore concluded that women would be happy to be randomised in future and similar trials.

However, criticism of this RCT highlights that their sample size was too small and therefore underpowered to determine safety, particularly given that only 10 women birthed in water. Further to this, Keirse (2005) challenges the validity and generalisability given the ‘preference arm’ and the bias that meant only 20 of the 60 women who had a strong preference for one of the two options, were allocated to their preferred option.

Subsequently, randomisation of women to options of care, which elicit both emotive and somewhat passionate views, such as the use of WI in labour and birth, is not ethically or practically feasible particularly where recruitment of large numbers would be required to determine with any certainty the morbidity and mortality of the intervention.

The proposed undertaking of this type of randomised research is further complicated by inconsistency across institutional policies in addition to funding, necessary infrastructure and available accredited staff (Garland, 2011).

Not only does this make it difficult to allow for the option and implementation of WI for labour and birth but it also inadvertently contributes to the lack of evidence in that accessibility is limited and therefore data on resulting outcomes, scarce. Furthermore, where it is consistently highlighted that high quality evidence is deficient, the question must be asked: who or what is informing the policies already in existence?

Initiating a wave of change

It is consistently highlighted that there is insufficient data to inform the practice of labour and birth in water, but is this really the case? It is clear that there is a paucity of evidence in terms of empirical investigation however volumes of anecdotal experience and observational data are available suggesting that water has significant and undeniable benefits to the women, and arguably to the baby.

Despite its availability, little weight is given to this valuable information, information that could be informing the movement forward and providing direction for future investigation of WI for labour and birth.

There is no denying that greater high level research would be advantageous to providing a definitive set of benefits and risks and therefore, greater insight into the relative safety of WI for labour and birth. However, is a RCT the right option?

The suggestion that rigorous evidence is needed to inform policies and guidelines with confidence and reliability could be attributed to what has been termed the ‘medicalisation’ of pregnancy and birth (Brubaker and Dillaway, 2009, Benoit et al., 2010) particularly where the measure of risk is at the forefront of maternity care facilitation.

However, in a risk-averse climate, adverse events whether recognised through well-constructed studies, auditing or anecdotal accounts, are generally the first to be documented so as to prompt review of practice.

Despite this, a search of the literature surrounding WI for labour and birth highlights very few documented adverse outcomes at any level of evidence and of those that are documented; the outcomes cannot always be definitively attributed to the use of water (Pinette et al., 2004, Cluett and Burns, 2009, Byard and Zuccollo, 2010).

What are readily available are anecdotal and observational accounts that suggest that WI has extensive benefits, not only to the woman but also to birth outcomes. It could therefore be argued that quantitative research alone is insufficient to provide answers to myriad of complexities, questions and queries relating to the practice of WI for labour and birth and therefore, insufficient when informing policies particularly where women choose to exercise self-determination and choice irrespective of their perceived risk.

Freeman and Griew (2007) touch on this in their review of one WI policy and its development. Their findings suggest that policy could further be enhanced by placing weight on the views and experiences of consumers and addressing the importance of informed and shared decision making.

This calls for attitudinal change not only to facilitate care that is woman-centred but also to ensure that women’s autonomy is factored into the development and implementation of policies underpinning practice.

The significance and value of qualitative evidence is slowly being realised, particularly in maternity care where WCC is the ideal. Despite this, empirical evidence is still commonly viewed as more rigorous and therefore more reliable.

This is none too clear in the hierarchies of evidence that fail to give weight to qualitative investigation (Spiby and Munro, 2009). However, as health care moves towards patient-centred models, or woman-centredness (Leap, 2009), as is the case in maternity care, there is the need for increasing weight to be also placed on experience and opinion particularly surrounding policy formation and care facilitation.

In light of this, a multi-faceted evidence-based approach to policy development and implementation of WI for labour and birth is likely to be advantageous.

However, before recommendations can be made, a critical analysis of existing policies and their development should occur in order to highlight whether the so-called scarcity of evidence poses difficulties for those involved in WI policy formation and to what extent policy facilitates and/or restricts water use practice and more importantly, women’s autonomy.

Pooling for the future

This paper has touched on the many shortfalls of WI research to date as well as foreseeable difficulties of future research surrounding WI for labour and birth. Future research requires greater emphasis on both the quantitative and qualitative aspects of water use for labour and birth to ensure that policies incorporate both the risk/benefit analysis as well as the opportunity for shared and informed decision-making.

This includes greater exploration of the experiences and perceptions of women and importantly, an examination of current WI policies to determine how they are informed and developed and to what extent they facilitate the practice and support women’s autonomy.

Not only is there the potential for this all-encompassing research to assist maternity care providers in working with autonomy as practitioners and ensuring their ability to advocate for women but there is also the potential for the use of water for labour and birth to have positive outcomes in a system that has an ever increasing rate of intervention and deviation from what can be both a normal and natural process.

References

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CARPENTER, L. & WESTON, P. 2011. Neonatal respiratory consequences from water birth. J Paediatr Child Health.
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DAHLEN, H. G., DOWLING, H., TRACY, M., SCHMIED, V. & TRACY, S. 2012. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery.
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DAVIS-FLOYD, R. 2001. The technocratic, humanistic, and holistic paradigms of childbirth. International Journal of Gynecology & Obstetrics, 75, S5-S23.
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Sheila Kitzinger – Birth in Water: Just a Fad?

Originally published December 11, 2014

World-renowned social anthropologist and birth activist Sheila Kitzinger (1929-2015) was a strong advocate for birth in water, known as waterbirth.

A voice for the ability for every woman to choose, Sheila believed that waterbirth should be an option in mainstream maternity care.

May0042569. Daily Telegraph. Childbirth Guru Sheila Kitzinger for DT Weekend. Picture shows Sheila Kitzinger MBE, she is an author and social anthropologist specialising in pregnancy, childbirth and the parenting of babies and young children. Picture taken in her bedroom, she does most of her writing in her four poster bed. Location Standlake, Oxfordshire. Picture date 27/09/2012

In this piece for Birth Institute, Sheila outlined some of the myths surrounding the birth method, and provides evidence that, in fact, waterbirth is a safe, effective and empowering birthing option.

Learn how to support women through labor and delivery in water. Become a midwife!

Waterbirth is often discussed as if it were a novelty – and a dangerous one at that. It has been assumed to be something that “dropouts” and “weirdoes” choose, or that it is just a recent, passing phenomenon.

In truth, birthing in water is a safe and widespread practice among hospitals in the UK and Western Europe – including Switzerland, Italy, Spain, Portugal, Malta, Denmark, Norway and Finland.

Furthermore, most practices aren’t as new as we think (the Ostend Aquanatal Centre in Belgium has been going strong since the late 80s), and waterbirth practices are here to stay.

Birth in water is safe and effective

Swiss study reveals that when using a pool women require less analgesia, have a lower incidence of perineal trauma, and reduced blood loss at delivery.

NICE (National Institute for Health and Care Excellence) concludes that waterbirth ‘provides the safest form of pain relief’.

There is evidence that being in water improves uterine contractility and speeds dilatation.  So, awoman giving birth in water is less exposed to interventions, including artificial augmentation of uterine activity, and is more likely to feel happy about her birth experience afterwards.

Yet that may not only be due to the water.  Labouring women who give birth in water have more one-to-one care from a midwife they have come to know.

This, combined with a relaxed environment in which the pool is used, contributes to the positive results. More first time mothers have spontaneous births in a freestanding midwifery center or at home than those in hospital.

In the UK, the NHS (National Health Service) states that women should be able to use a pool if they wish, and recommends one be available for every thousand women.

This option has become part of mainstream maternity care, and approximately 75% of all hospitals in the UK have installed birthing tubs.

Many community midwives are eager to raise the homebirth rate, and portable pools, designed to be used by just one woman (to avoid cross-infection), are selling well.

Complicated waterbirthing pools are not necessary.

Chairs, stools and other contraptions restrict movement, and when a woman is immobilized she is more likely to need obstetric intervention.

Francoise Freedman of Birthlight in Cambridge suggests using a pool at home to explore yoga movements during pregnancy.

These include hip-openers, kneeling stretches, and those to prevent and ease back pain, and others for ribcage expansion and pelvic floor toning.

The warm water acting as a cushion also makes a comfortable space to practice perineal massage.

Waterbirth is here to stay

Midwives keen on home birth and waterbirth were once seen as dissidents and mavericks.

This has changed now – so much that in the UK, it is common to encourage women to choose to labour, and perhaps give birth, in water and in their own home.  Pregnant women and midwives are being empowered now.

Every midwife-run and staffed birth center for low risk women offers pools, and midwives are beginning to develop the skills to use them. There is a feast of research from which midwives can learn more.

Ethel Burns, Waterbirth Practitioner, Research Midwife and Midwifery Teacher, and I have drawn up recommendations for practice in a paper available from Oxford Brookes University (read it here).

Sheila Kitzinger (1929-2015) was a social anthropologist of birth and an advocate of home births.  She believed that women have the right to decide the place of birth and kind of care they prefer, and to make an informed choice, based on research and their own values.

Women suffering post-traumatic stress after birth would ring her for help, seeking the confidence to deal with it.  For years she worked with mothers and babies in prison and asylum centers.  She lectured all over the world and her books are published in 23 languages.

Exploring movements in Water

Sheila was a keen proponent of water birth.

Her wonderful article gives us examples of the type and range of movements natural to labour and birth that mothers explore in water.

 

The pool in the photos is an original Oval Portable Water Birth Pool circa 1987  – to my knowledge the first specially designed portable water birth pool ever produced.

Please click here for a copy of Exploring movements in water:

The benefits of using water for labour and birth are well known…

The benefits of using water for labour and birth are well known…

Here are the facts…

  1. Relaxing in a deep pool of warm water can be a wonderful aid in labour. It’s worth having a pool mainly for this reason.
  2. Using a birth pool helps mothers to manage pain in labour and considerably reduces the need for medical pain relief.
  3. The buoyancy of the water supports the mothers body weight allowing her to relax more easily and deeply. They can cope better with contractions and also rest more comfortably in between them.
  4. It’s easier to use upright or squatting positions and move freely from one position to another, than it is on land.
  5. Being in a birth pool gives mothers an increased feeling of privacy and security. This enhances the secretion of hormones which stimulate uterine contractions and act as natural pain killers and relaxants.
  6. Studies show that labours tend to be shorter overall when a woman enters the pool at around 5cms. dilation.
  7. Fewer women need the help of obstetric interventions.

Women who receive less medical intervention generally stay in hospital for a shorter period of time.

The combination of an intervention free birth – with a short hospital stay result in a better experience for mother and baby.

Hospital staff and resources can be employed more efficiently.

Importantly – this results in significant financial savings!

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

 

 

 

The case for the wide-spread development of water birth facilities

In light of the publication of recent articles that report the growing demand from women around the world who want to have a natural, drug free, non-medicalised birth (Weiss 2014 and Gilbert 2015) we need to look at ways to help them have this experience.

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If they are not going be reliant on analgesia for pain relief they need options to help them cope with the pain to allow a physiological labor to unfold.

Immersion in warm water has been unequivocally proven to be of great benefit both physiologically and psychologically.

It is not important if the baby is born in water.

In fact, water birth should be de-emphasised as it is a controversial issue in many parts of the world.

The key point and main benefit that needs to be made and focused on is how women who enter a warm pool of water in established labour with strong contractions find that they are able to cope with the pain and have a natural birth.

Women have a greater sense of fulfillment and accomplishment and babies experience a non-traumatic birth.

Aside from the obvious benefits to mothers and babies, midwives experience greater job satisfaction and hospitals save money and optimise resources from the reduced use of analgesia, medical intervention and shorter hospital stays.

Nearly a third of women benefited from the use of a water birth pool in the UK in 2014 (National Maternity Survey 2014).

With up to 60% of mothers open to natural birth now is the time for midwives, obstetricians and hospitals to consider making this safe, low cost option available.

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Studies have shown that upright labour positions are associated with a reduced second stage, fewer episiotomies or instrumental intervention in contrast to mothers labouring on their backs. (Gupta, Hofmeyr and Shehmar 2012 and Gupta and Nikodem 2000).

Many women also feel empowered in an upright position, and experience a sense of control over their labour (Balaskas 2001).

On land women need to contend with the force of gravity that limits their ability to assume upright postures especially as labour progresses and they feel tired.

Many women do not have the fitness or stamina to maintain upright postures for lengths of time. (Gupta JK, Hofmeyr GJ, Smyth R 2007).

The transition from the land to water helps revive and energise the mother giving her a new lease on life and sense of purpose.

The buoyancy of water supports the mother reducing her relative weight by approx. 33% (Archimedes Principle) allowing her to easily explore the full range of beneficial upright positions in comfort and move in ways that were not possible on land.

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The calming, relaxing effect of the warm water promotes the flow of oxytocin, a powerful hormone that plays a huge role in childbirth, causing the uterus to contract and triggering the ‘fetal ejection reflex’.

Michel Odent has expounded upon the beneficial physiological effect that immersion in water during labour has on hormone secretion, including observations that women entering warm water experience oxytocin surges which can advance dilation and stimulate contractions (Odent 2014).

The economic impact

Studies have shown that women who are supported during labour need to have fewer painkillers, experience fewer interventions and give birth to stronger  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 unit  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 interventionist approaches in particular for younger mothers post-partum.

The experience of hospitals that have birth pools demonstrates the savings  achieved through reduced use of medical methods of pain relief and shorter hospital stays.

 

An economic evaluation of water birth

The cost-effectiveness of mother well-being

Abstract: Purpose To assess the cost-effectiveness of water compared with normal land delivery.

Methods; A retrospective controlled study was conducted over a two-year period in a Northern Italian hospital. The cohort included all the 110 women who completed a water birth and 110 women who had a land birth during the same period. The two groups were compared with respect to labour duration, perineal tear and newborn’s health status. The economic evaluation adopted a cost-effectiveness approach in relation to presence/absence of perineal tears.

Results: In the water delivery group 58 women (52.7%) experienced at least one perineal tear versus 80 (72.7%) in the traditional delivery group. The mean duration of labour was similar in the two groups. Neonatal well-being, expressed as Apgar score, did not differ significantly among the two groups at the first minute (9.48 vs. 9.28) and was slightly higher at 5 minutes in the water delivery group (9.95 vs. 9.84; P = 0.0269). Water delivery was found to be both more costly [ΔC = €279; 95% confidence interval (CI): 262–296] and more effective in terms of avoided perineal tears. The incremental health care cost per avoided perineal tear because of water delivery was estimated of €1395.7 (95% CI: 1049.2–3608.5).

Conclusion: Water birth, as compared with traditional delivery, allows for an increase in maternal well-being and is cost-effective.

Making Waves Improving access to water immersion in maternity units: Dr. Claire Feely

Water immersion for labour and/or birth can be a supportive low-cost, low-tech intervention that enhances women’s experiences of their labour and with positive outcome benefits.

In a previous article,1 we highlighted the current evidence in favour of water immersion that demonstrated the positive impact upon women’s and birthing people’s physical and psychological outcomes, including; reducing pain perception, epidural use, labour duration and hospital transfers; enhancing mobility, freedom of movement, feelings of safety, privacy and positive experiences of labour and birth.

Overall, water immersion enhances the neuroendocrinology of a normal physiological labour2 and is a helpful option for pain relief.3 

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Waterbirth basics from newborn breathing to hospital protocols

Barbara Harper 2000

Waterbirth is simple.

Within the simplicity of water labor and birth lies a complexity of questions, choices, opinions, research data, women’s experience and practitioner observations.

Over the past five years, as more hospitals within the United States examined waterbirth and created programs to support the use of water for labor and birth, newspaper reporters latched onto the sensationalism of this simple option and published stories of successful waterbirths in local publications.

Reporters do their best to simplify waterbirth and at the same time answer the most common questions. Each story shows a happy, beaming mother, a quiet, peaceful baby and a proud father, who usually successfully sets up a portable birth pool.

The surprise headlines like “Watery Birth” or “Baby’s Birth Goes Swimmingly” or “Junior Makes a Splashy Entrance” are countered with the simple stories of couples who have made this decision for themselves and are proud of it.

The first and foremost question in everyone’s mind and the lead in all these newspaper accounts is simple: How does the baby breathe during a waterbirth?

Inhibitory Factors

Several factors prevent a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns. The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his/her intercostal muscles and diaphragm in a regular and rhythmic pattern from about ten weeks gestation on.

The lung fluids that are present are produced in the lungs and are similar chemically to gastric fluids. These fluids come up into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero.

Twenty-four to forty-eight hours before the onset of spontaneous labor, the fetus experiences a notable increase in the prostaglandin E2 levels from the placenta which causes a slowing down or stopping of the fetal breathing movements (FBM).1 With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain.

You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about 40 percent of the time. When the baby is born and the prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response.

A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built-in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping.

If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs.2 If the baby were in trouble during the labor, there would be wide variabilities noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby’s birth.

The temperature differential is another factor thought by many to inhibit the newborn from initiating the breathing response while in water. The temperature of the water is so close to maternal temperature that it prevents any detection of change within the newborn.

This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature, yet babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed.

One more factor that most people do not consider but which is vital to the whole waterbirth and aspiration issue is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. Even if water were to travel in past the larynx, it could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

The last important inhibitory factor—the dive reflex—is associated with the larynx. The larynx is covered all over with chemoreceptors, or taste buds. In fact, the larynx has five times as many taste buds as the whole surface of the tongue.

When a solution hits the back of the throat and crosses the larynx, the taste buds interpret what substance it is and the glottis automatically closes; the solution is then swallowed, not inhaled.3

God built this autonomic reflex into all newborns to help them breastfeed, and it is present until about the age of six to eight months when it mysteriously disappears. The newborn is very intelligent and can detect what substance is in its throat.

It can differentiate between amniotic fluid, water, cow’s milk or human milk. The human infant will swallow and breathe differently when feeding on cow’s milk or breastmilk due to the dive reflex.

All these factors combine to prevent a newborn who is born into water from taking a breath until he is lifted up into the air.

Baby’s First Breath

What initiates the breath in the newborn? As soon as the newborn senses a change in the environment from the water into the air, a complex chain of chemical, hormonal and physical responses initiate the baby’s first breath.

Water born babies are slower to initiate this response because their whole body is exposed to the air at the same time, not just the caput or head as in a dry birth. Many midwives report that water babies stay a little bit bluer longer, but their tone and alertness are just fine. It has even been suggested that water born babies be given the first APGAR scoring at one minute thirty seconds, not at one minute, because of this adjustment.

Several things happen all at once in the baby. The shunts in the heart are closed; fetal circulation turns to newborn circulation; the lungs experience oxygen for the first time; and the umbilical cord is stretched causing the umbilical arteries to close down.

Nursing and medical schools taught their students for years that the first breath was dependent on the pressure of the passage through the birth canal, and then a reflexive opening of the compressed chest creating a vacuum.

That action has no bearing on newborn breathing whatsoever. There is no vacuum created. The newborn born into water is protected by all the inhibitory mechanisms mentioned above and is suspended and waiting to be lifted out of the water and into mother’s waiting arms.

All the fluids present in the lung alveoli are automatically pushed out into the vascular system from the pressure of pulmonary circulation, thus increasing blood volume for the newborn by one-fifth (or 20 percent).

The lymphatic system absorbs the rest of the fluids through the interstitial spaces in the lung tissue. The increase of blood volume is vital for the baby’s health. It takes about six hours for all the lung fluids to disappear.4

Outcomes and Concerns

When we look back at the analysis of the statistics of babies born in water it proves that these inhibitory factors are more than theories. A study conducted in England between 1994 and 1996 and published in 1999 reports on the outcomes of 4,032 births in water. Perinatal mortality was 1.2 per 1,000, but no deaths were attributed to birth in the water. Two babies were admitted to special care for possible water aspiration.5

It is estimated that there have been well over 150,000 waterbirths worldwide between 1985 and 1999. There are no valid reports of infant deaths due to water aspiration or inhalation. In the early days of waterbirth a baby was reported to have died from being born in the water.

This particular newborn death was caused not by aspiration, but by asphyxiation because the baby was left under the water for more than fifteen minutes after the full body was born. At some point the placenta detached from the wall of the uterus and stopped the flow of oxygen to the baby.

When the baby was taken out of the water, it did not begin breathing and could not be revived. On autopsy the baby was reported to have no water in the lungs and its death was attributed to asphyxia.6

This is the reason we bring babies up out of the water within the first few moments after birth. Some people have commented on the long time that some babies remain in the water in the film “Water Babies: The Aquanatal Experience in Ostend.” Videotape is deceiving, but so are our senses. When timed, the film sequence is only forty-seven seconds, but when viewers are asked to judge how long the sequence of immersion for the baby really is, reports range anywhere from one minute to five minutes.

Bringing a baby out of the water too quickly can be just as traumatic, but it can also lead to either torn or broken cords. This has been reported by a number of midwives and doctors.7 If the practitioner does not look for a torn cord the possibility of the baby needing a transfusion increases.

Torn or broken cords can be avoided by bringing baby out of the water slowly and gently. Mothers who want to pick up their own babies need to be reminded not to do it too quickly either.

The inability to accurately assess blood loss in the water is a reason given by some midwives for either not “allowing” the birth to take place in the water or asking mother to get out right away after the baby is born. But blood loss is easy to judge after a few births.

Garland and Jones report in a review of waterbirths at Maidstone Hospital in Kent, England, that midwives are much better at judging and reporting blood loss in the water after experiencing over 500 births.8 A useful way to identify the extent of postpartum hemorrhage is how dark the water is getting.

Can you still assess skin color of the mother’s thighs even though there is blood in the water? A few drops of blood in a birth pool diffuse and cause the water to change color. A waterproof flashlight comes in handy at this point.

Dropping a flashlight onto the bottom of the birth pool allows you to look for bleeding as well as meconium during the birth. It also helps you spot floating debris so it can be removed.

This brings us to the second most frequently asked question among hospital nurses and newspaper reporters: Won’t the mother get an infection?

Some hospitals still restrict a woman from laboring in the water if her membranes are ruptured. Based on the current and past literature, this is absurd. No evidence exists of increased infectious morbidity with or without ruptured membranes for women who labor and/or birth in water. 9 ,10

The oldest reference that researches the possibility of infection during a bath is mentioned in a 1960 American Journal of OB/GYN.

Dr. Siegel posed the question, “Does bath water enter the vagina?” In his experiment he placed sterile cotton tampons into thirty women and then asked them to bathe in iodinated water for a minimum of fifteen minutes.

In all cases when the tampons were removed, there was no iodine present.11 His conclusion states, “We can now stop restricting women from bathing in the later stages of pregnancy and labor.”

Laboring mothers have an advantage when the baby is descending and moving out—nothing is moving up and in. Things that we put into laboring vaginas may cause infections, such as probes, fingers, AmnihooksTM, scalp hooks and so on. Janet Rush, RN, and her Canadian group of investigators have conducted the only randomized controlled trial of the effects of water labor.

They reported that there were no differences noted in the low rates of maternal and newborn signs of infection in women with ruptured membranes.12

Infection control, especially in a hospital setting, requires diligence and the attention to strict protocols between and during births. Cleaning and maintaining all equipment used for a waterbirth will prevent the spread of infection.

In a random study conducted at the Oregon Health Science University Hospital in 1999, cultures were done from the portable jetted birth pool before, during and after birth, as well as from the fill hose and water tap source.

In all instances no bacteria was cultured from the birth pool but the water tap did culture Pseudomonas.13 In a British study of 541 water labors, no serious infections were reported during the three-year period of data gathering.

Again, Pseudomonas aeruginosa was the only persistent bacteria discovered in two babies who tested positive from ear swabs. No treatment was necessary.14

Some parents are concerned about mother-to-mother infections or contamination from viruses such as HIV or hepatitis. There is no reason to restrict an HIV-positive mother from laboring or giving birth in water.

All evidence indicates that the HIV virus is susceptible to the warm water and cannot live in that environment.15 Universal precautions still need to be adhered to and proper cleaning of all the equipment after the birth needs to be carried out.

Using disposable liners has become the norm for use with portable birth pools, but attention must also be paid to proper cleaning of drain pumps, hoses, filter nets, taps and any other items that are reused from one birth to the next. The issue of cleaning the jets of permanently installed baths has generated some concern and discussion over the past few years.

Many hospitals remodeled their labor units in the late eighties or early nineties, installing Jacuzzi-type whirlpool baths. These baths are great for women in labor, but often are not deep enough or are situated within very small bathroom spaces, boxed in and making birth in them difficult in all respects.

The protocol for cleaning jetted tubs is simply to completely clean the tub with a quaternary ammonium solution, refill with water and add some kind of brominating agent to circulate through the jet system for a minimum of ten minutes.16

A number of hospitals report that they use a half cup of powdered dish-washing crystals such as Cascade, and it works fine. Lynn Springer, RN, the perinatal coordinator for St. Elizabeth Hospital in Red Bluff, California, chose to install a beautiful corner Jacuzzi brand jetted bath on her unit in 1995.

They have routinely performed monthly cultures of the bath and the jets throughout the past five years of their waterbirth program without any significant bacterial growth. They follow the above-mentioned cleaning protocol and report over 1,000 water labors and 400 births in water.17

When to Enter the Bath

One issue that is repeated in the literature and voiced in the concern of mothers and their midwives is: When should the mother enter the bath?

Many hospitals use the five-centimeter rule, only allowing mothers to enter the bath when they are in active labor and dilated to more than five centimeters.

Some physiological data supports this rule, but each and every situation must be evaluated and then judged. Some mothers find a bath in early labor useful for its calming effect and to determine if labor has actually started.18

The water sometimes slows or stops labor if used too early. On the other hand, if contractions are strong and regular with either a small amount of dilation or none at all, a bath might be in order to help the mother relax enough to facilitate the dilation.

It has been suggested that the bath be used in a “trial of water” for at least one hour, allowing the mother to judge its effectiveness. Women report that often the contractions seem to space out or become less effective if they enter the bath too soon, thus requiring them to leave the bath.

Then again, midwives report that some women can go from one centimeter to complete dilation within the first hour or two of immersion.

Deep immersion seems to be a key factor. If the pool or bath is not deep enough, at least providing water up to breast level and completely covering the belly, then the benefits of the bath may be less noticeable.

The warm water will still provide comfort and the mother will benefit from being upright, in control and drug free, but full immersion promotes more physiological responses, the most notable being a redistribution of blood volume, which stimulates the release of oxytocin and vasopressin.19

Vasopressin can also work to increase the levels of oxytocin.20 The immediate pain reduction felt upon entering the bath is quite noticeable. It is what I refer to as “the ahh effect.”

The smile, the sound and the inner peace that mothers display are unmistakable. This response can happen at any point in the labor, but most notably when contractions are long and strong and close together.

Some midwives who assume there is little or no progress in dilation because the mother is not displaying any outward signs of discomfort are often surprised to find rapid dilation in the first hour of immersion. Having experienced a waterbirth myself, I can verify the incredible difference in perception of pain from the room to the water.

When I am with a woman in labor I generally assess her pain on a scale of one to ten before she enters the bath. Most report at least a six or greater. Then after no less than half an hour, I will make another assessment.

The second subjective answer of course varies from person to person, but the typical response is two to four. The mother is experiencing more than the sum of her physiological responses to warm water immersion. Most women feel inherently safe in the water.

The water creates a wonderful barrier to the outside world. It becomes the woman’s nest, her cave, her own “womb with a view.” If the pool is large enough to include her partner or husband, it then becomes an intimate place for the two of them to labor together and experience the love dance of birth.

If the midwife or physician wants to do a vaginal examination while the mother is in the water, it is much easier for the mother to refuse. Her mobility allows her to move quickly to the other side of the pool. Vaginal exams can be easily done in the water, but to maintain universal precautions, long shoulder-length gloves need to be worn.

The control that women gain by being able to move freely in the water often helps them assess their own progress either by feeling the baby’s movements more intensively or actually being able to examine themselves internally.

Women report that the water intensifies the connection with the baby at the same time that it reduces the pain. They can feel the baby move, descend and push through the birth canal.

The prospect of the midwife becoming an active observer increases as mothers have the ease of mobility in the water and assume more and more responsibility for the birth.

For many reasons, including reducing the risk of infection for the provider, many midwives suggest a hands-off birth for the mother. The water slows the crowning and offers its own perineal support.21 This “minimal-touch” approach also gives the mother a greater sense of controlling her own birth.

Perineal trauma is reported to be generally less severe, with more intact perineums for multips, but in some of the literature about the same frequency of tears for primips in or out of the water.22 23 One of the best benefits of waterbirth is the zero episiotomy rate that is reported throughout the literature.

Rosenthal mentions that episiotomies can be done, but no one else offers this suggestion.7

The combination of being upright, having the mother in a good physiological position to birth her baby, giving her the freedom of control and not telling her to push when her body is not indicating it, all contribute to better perineal outcomes.

The Midwife’s Influence

Midwives have a great deal of influence over the outcome of a birth, from the suggestions they make to a laboring mother to how they handle potential complications. An interesting phenomenon within the waterbirth movement deserves some discussion.

When a mother is laboring undisturbed—about which Odent has written and lectured—she will find her own place and time of birth, whether that place is the bathroom floor, under the piano, on the bed or in the bath.

If practitioners remain silent observers to the process, the baby is born wherever it happens. But when the mother has stated her intentions for a waterbirth and the necessary arrangements have been made to have water available, if then the midwife reminds her as second stage approaches or in the middle of second stage that the bath is ready and waiting if she wants to get back in— is the midwife influencing the mother?

In observing the statistics on waterbirth that Waterbirth International gathers from midwives and doctors, it is hard not to notice the variance from practice to practice.

Those midwives who report an 80 to 90 percent waterbirth rate are usually set up with either a birth center facility that uses easily accessible bathtubs, or every single one of their homebirth clients rent or use portable birth pools.

When the mother is in the midst of her subconscious birth responses and someone tells her that the bath is ready and waiting, she often will immediately dash for the pool and climb in, even in the pushing stage. On occasion she simply states that nothing in heaven and earth can move her beyond where she is.

A midwife’s or physician’s hesitancy for using water for birth can also be felt by the mother and she often acquiesces just to make her practitioner feel more comfortable, instead of following her own instincts and staying in the water. Many women in hospitals get out of the pool because they don’t want to get their midwives “in trouble” by insisting on giving birth in water.

And in the reverse, midwives often must insist that mother get out of the pool because protocols have not been set up for birth or the practitioner is just not comfortable with the process.

The decision to birth in the water should be left up to the mother, but based on sound advice and assessment of fetal well-being by the practitioner. The mother who presents prenatally and insists she is going to have a waterbirth no matter what is usually destined to birth anywhere but the birth pool.

I seriously counsel women who are taking on the system to evaluate their reasons for wanting to birth in water. If they are seeking only to avoid pain, that is a serious red flag and needs to be addressed on many different levels.

If they have experienced one birth already and know what to expect and are looking for a better birth experience, then they are usually open to using the water to be in greater control, and then seeing how they feel at the time of birth.

Flexibility is always required in birth, but especially for those women who add the element of water. In my own case, I wanted to birth in water the first time because I felt it was the best thing I could do for my baby. I hear many women say this, and I consider it a reasonable motivation.

But it is better to focus on the mother and what she needs; the benefit that women derive from being in the water and gaining control over their experience is passed on to the baby. For my second waterbirth, no one could keep me out of the water. I was completely focused on my experience and not the baby’s.

Fathers will often call our office and make all the arrangements for the birth pool rental. On occasion that is because the dad wants his baby to be born in water and no other place, not taking into account what the mother really wants. Usually it all works out just fine, but occasionally it can influence the outcome of the labor.

Protocols

Protocols differ from place to place, but as more experience with waterbirth emerges, we find that some previous reasons for asking a woman to leave the bath prior to birth are no longer hard and fast.

The prescence of meconium used to mean that the mother would have to leave the pool to birth her baby on the bed to facilitate immediate suctioning. This requirement has relaxed a bit as it has been seen that meconium washes off the face of the baby and even comes out of the nares and mouth while the baby is still under the water. DeLee suctioning can still be accomplished as soon as the baby is up in mother’s arms.

Tight nuchal cords were a reason to ask mother to stand for the birth so that the practitioner could cut the cord and then deliver the baby. Now the universal practice is to not even feel for a cord in a waterbirth, unless there has been a very slow second stage and you are afraid of cord compression.

No attempt is made to clamp and cut the cord. The body is birthed and then the cord unwrapped. It is amazing to watch a baby somersault and begin to unwrap its own cord in the expanse of the birth pool.

Breech position was definitely a reason for a more controlled birth or even an automatic cesarean section. But there are practitioners throughout the world who recognize increased safety for the baby if it is born in water.

The most experienced doctor we know is Herman Ponette, an obstetrician who practices at H. Serruys Hospital in Ostend, Belgium. He has attended well over 2,000 waterbirths including breeches and twins.

He uses a frank breech position as an indication for a water birth.24 There are other reports of a few hospitals in the United States attending breech waterbirths, and approximately fifty reported breech births in water at home.25

Shoulder dystocia is considered an obstetric or midwifery emergency by most practitioners. Protocols require mothers who are anticipating large babies to leave the bath. Now there is a growing body of experience that suggests shoulder dystocia can be managed easier in the pool.

Canadian birth attendant Gloria Lemay has written a protocol for management of shoulder dystocia in the water. It appears that tight shoulders happen more often because of practitioners or moms trying to push before the baby fully rotates.

There is no harm in waiting for a few contractions to allow baby to rotate, especially since the baby is not going to be taking a breath. Position changes in the water are so much easier to effect and the mother doesn’t panic but remains calm.

A quick switch to hands and knees or even to standing up with one foot on the edge of the pool if shoulders are really tight can help maneuver baby out.

Prematurity has always been considered a reason for a controlled and monitored bed birth. Some doctors who have experienced the great results of waterbirth for babies born from thirty-six weeks gestation on are now questioning whether waterbirth might be good for some babies who are less than thirty-six weeks gestation.

With the advances for waterproof fetal monitoring there are fewer reasons to require a woman to leave the pool, especially if her baby is tolerating the labor well.

A few cases of waterbirth for thirty-three, thirty-four and thirty-five-week-old babies have been reported.

The Waterbirth Choice

Once a woman has experienced a waterbirth she will more than likely want to repeat the experience. To that end, Waterbirth International gets some pretty interesting referral requests from women all over the world.

If circumstances have changed and the mother is no longer living in a place where waterbirth facilities or practitioners are readily available, she will go to almost any length to recreate the opportunity to give birth in water.

A research project that Waterbirth International has been conducting for ten years is a survey of women who have given birth in water.

One question on the survey form asks: “Would you consider giving birth again in water?” With over 1,500 surveys collected, only one woman answered no to that question.

On her particular survey she emphatically stated no in bold print with two exclamation points and then drew an arrow down to the bottom of the page where in very small print she wrote, “This is number seven, I’m done!”

It is hard to think of another “method” of childbirth that receives such praise from women and practitioners alike. Dr. Lisa Stolper is an obstetrician practicing in the quaint New England town of Keene, New Hampshire.

She began offering waterbirth to her clients at Cheshire Medical Center in October 1998. One year later she reported an overall waterbirth rate of 37 percent for all vaginal births and 33 percent for all births, including cesarean sections.

Her hospital has purchased just one portable jetted birth pool, but they use it for the labor of almost 50 percent of their clients.

They are now considering installing permanent pools to make them available for more women. Her comment about her job as an obstetrician was, “Waterbirth just makes my job so much easier.”

One of the final questions that newspaper reporters pose and birthing couples ask is, why aren’t more hospitals in the United States offering waterbirth?

Hospitals in the United States have made incredible advances in the waterbirth movement in the past five years. Monadnock Community Hospital in Peterborough, New Hampshire, was the first hospital in the country to embrace waterbirth and install a permanent birth pool; the pool was imported from England.

They still offer this option to women and can now look back on almost ten years of great outcomes and lots of satisfied families. The rest of the country has taken some time, with certain areas of the country making greater strides than others.

In almost all cases where there are successful waterbirth programs, certified nurse-midwives have started them. Midwives are more open to exploring the issue with their clients and doing the research necessary to get protocols accepted in hospitals.

Some midwives have even purchased portable birth pool equipment with their own funds in hopes that it would pay for itself by generating more business. In most instances, that investment has paid off.

The whole U.S. movement is at least five years behind the European movement in acceptance in hospital environments, but homebirth midwives in the United States have been offering waterbirth longer than most of their European counterparts.26

The United Kingdom has had the benefit of government-sponsored research and data reporting as well as the Cumberledge Report.27 The House of Commons Health Committee recommended that all hospitals should provide women with the option of a birthing pool.

The underlying philosophy of the Changing Childbirth report recognized that women have the right to choose how and where they wish to give birth. In a 1994 statement, the UKCC stated, “ . . . waterbirth is preferred by some women as their chosen method for delivery of babies.

Waterbirth should therefore be viewed as an alternate method of care and management in labour and one which falls within the midwife’s sphere of practice.”28

The states that have made the most progress for hospital waterbirth are New York, Maine, New Hampshire, Illinois, Ohio, North Carolina and Massachusetts. Obviously, the East Coast is changing faster than the West Coast.

It is surprising to some people when they find out that the whole state of California only has a handful of hospitals that provide waterbirth services. More than two thirds of the birth centers in the United States offer waterbirth as an available option.

Mothers who call Waterbirth International wanting advice on how to get their particular hospital to allow them to have a waterbirth are advised that it takes three ingredients to make policy changes within a hospital setting:

1) a motivated mother;

2) an open and supportive practitioner;

3) a compassionate nurse manager or perinatal coordinator who is willing to take on the training of staff and the creation of new policy.

Waterbirth International will supply the necessary research studies, the sample protocols, the pool kits, the videos and the experience to help couples get policy changed, but without these first three components some hospitals will continue to deny the request. Time is the other factor. The more advance notice a hospital is given the better chances there are for change.

There are so many areas of waterbirth to explore. Waterbirth is more a philosophy of nonintervention than a method or way to give birth. Waterbirth combines psychology, physiology, technology, humanity and science.

Waterbirth is ancient and yet new at the same time.

Waterbirth embodies a spiritual aspect of birth that is hard to express. Cynthia, who gave birth in water, said it better: “The water made me so completely connected to my body and my baby.

The water held me and cradled me so that I could surrender more completely to this amazing and wonderful grace that was happening to me. This is the way that God intended childbirth to be.” 29

 

Optimising Physiology: Labouring in Water and Waterbirth

Water immersion during labour and waterbirth is a low-tech but complex intervention that optimises the normal physiological processes of labour and birth.

We call for midwives and maternity professionals to familiarise themselves with labour and birth care in a birthing pool to ensure more women have access to its benefits.

Pain management is a key element of respectful and dignified maternity care, in which we advocate birthing pools should be as available as pharmacological options.

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