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High BMI Waterbirth – time for trusts to take the plunge?

AIMS Journal Volume 31 No. 2 2019

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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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

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.

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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.

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